Dentistry Uncensored with Howard Farran
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1073 Dental Legislation with Rob Roda, DDS, MS : Dentistry Uncensored with Howard Farran

1073 Dental Legislation with Rob Roda, DDS, MS : Dentistry Uncensored with Howard Farran

6/27/2018 9:09:35 AM   |   Comments: 0   |   Views: 268

1073 Dental Legislation with Rob Roda, DDS, MS : Dentistry Uncensored with Howard Farran

Dr. Roda graduated from the Faculty of Dentistry at Dalhousie University in Halifax, Canada in 1981 and maintained a full-time private general practice in Dartmouth, Nova Scotia for ten years. He returned to school at Baylor College of Dentistry in Dallas Texas, and received his Masters of Science (Oral Biology) and Certificate in Endodontics in 1993. He became a Diplomate of the American Board of Endodontics in 1998. Dr. Roda has published and lectured internationally, most recently co-authoring the chapter on non-surgical retreatment in the 11th edition of Pathways of the Pulp. He is a Visiting Lecturer at the Arizona School of Dentistry and Oral Health, Past President of the American Association of Endodontists, Current President of the Arizona Dental Association, and is an active member the American Dental Association. Dr. Roda is an Associate Editor of the Journal of Endodontics, and is an Endodontic Consultant to the Arizona State Board of Dental Examiners. He maintains a private practice limited to Endodontics in Scottsdale, Arizona.

https://www.endoaz.com/



VIDEO - DUwHF #1073 - Rob Roda





AUDIO - DUwHF #1073 - Rob Roda


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1073 Dental Legislation with Rob Roda, DDS, MS : Dentistry Uncensored with Howard Farran


Howard: It is just a huge, huge honor for me today to be a podcaster interviewing Rob Roda. This is the endodontist local here in Arizona. The number one selling root canal book in the world of all time was Pathways of the Pulp by Stephen Cohen. And we had Stephen Cohen on our earlier issue. Rob actually co-wrote Chapter Eight with Brad Gettleman, who we had on the show too. It's just such a huge honor to have the third endodontist from the number one selling endodontic book in the history of dental textbooks. That's a fact. And also if you look at the numbers, the only book that is in the same space with us in volume of sales worldwide was Carl Misch's book on implantology. So, you guys are up here and if you cut the cells of this in five ways, that one-fifth wouldn't even be a close second.


So, congratulations on that. And I know that's a lot of work and you've done everything. Right now, you're the president of the Arizona Dental Association. You've taught at a local dental school, A.T. Still. You've lectured - I've seen your name on lectures all over. My gosh, how do you get twenty-eight hours out of a day?


Rob: It's really a kind of an interesting thing. I cheat a lot. Actually, I've always had a wonderful support system around me from my staff in the office, my partners - who helped me out and I bounce everything off them - and great friends, great colleagues. And I don't have a life so I just really enjoy what I do. 


Howard: (inaudible 01:53) Let me read your bio: "Dr. Roda graduated from the Faculty of Dentistry at Dalhousie University in Halifax, Canada...." Is that French?


Rob: No, it's an English part of Canada, which is way out East Nova Scotia. It's the farthest east you get until Newfoundland and then you've got Europe.


Howard: "... He maintained a full-time private general practice and Dartmouth Nova Scotia for 10 years. He returned to school at Baylor College of Dentistry in Dallas, Texas. He received his Masters of Science Oral Biology and Certificate in Endodontics in 1993. He became a Diplomate of the American Board of Endodontics in '98. Dr. Rhoda has published and lectured internationally, most recently co-authoring the chapter on Nonsurgical Retreatment in the 11th edition of Pathways of the Pulp. He is a visiting lecturer at the Arizona School of Dentistry and Oral Health, past president of the American Association Endodontist, current president of the Arizona Dental Association and an active member of the American Dental Association. Dr. Rhoda is an associate editor of the Journal of Endodontics and is endodontic consultant to the Arizona State Board of Dental Examiners. He maintains a private practice to endodontics in Scottsdale, Arizona."


My God, you have an impeccable resume! Seriously, thank you so much for driving from the rich part of Scottsdale down to where the poor people live in Phoenix to talk to us guys born in a barn. I want to start. There's so many things I want to talk to you about, but I'm going to start with older guys like us read books and the younger kids are on YouTube and podcast, so it's very skewed. Whenever I ever get e-mails, 25% of them are still in dental school, 5% are still an undergrad, all the rest are over thirty. And thank you so much. As about once a week, someone emails me at howard@dentaltown.com and says, "Dude, I'm as old as you." 

Do tell us where you're from. I love the stories. We had one this morning from a dentist from Tokyo, Japan. That was so romantic. Anyway, they're coming out of school... Just five, ten years ago they were coming out of eighty still in midwestern maybe two-fifty in debt, now they're coming out four hundred in debt. Because those private schools realize that every time they raised the tuition $10,000 a year, they still fill up the class, so now they're up to like a hundred thousand a year and they're dumping two hundred and seventeen dental graduates a year. They got to pay off these student loans and they feel like I need to do Endo but half the class comes out and says, "Honestly, I hate Endo. I don't ever want to do Endo." And then they want to pay off their student loans with a bunch of white bleaching, bonding, fluffy stuff. Can you come out of school five or $400,00 of debt and pay it off with bleaching, bonding, veneers and Invisalign, and never have to learn to endo?


Rob: I think the quick answer to that is No. I think that the biggest problem with the student debt, it's a bomb. It's going to blow up at some point or rather, there's going to be a large collapse and because it's just unsustainable.


Howard: It just went past one and a half trillion. 


Rob: Well, did you hear about the guy in Wall Street Journal? Wall Street Journal just wrote that article about the orthodontist in California. I guess that has a million dollars in student loan debt. 


Howard: He was a Mormon Dentist in Utah. One million in debt.


Rob: Yeah. And what was interesting was they said in the article that he was one of over one hundred and ten people who had over a million dollars in student debt. And I don't know how you finance that because you are a really successful dentist and I think I'm a pretty successful endodontist. I have no idea how you finance that. 


But getting back to your question, I think you cannot do the sort of standard little bread-and-butter dental procedures for two reasons: one is that just financially it's not as good as doing more complex things but the other thing is that now we've got the rise of the others, which is the competition that's happening from non-dentists doing what traditionally have been dental things. 


Howard: I love that. 'The rise of the others.'


Rob: I plagiarized that. There was a book. Now, I'm not going to say who wrote it because I don't recall. It was a book about fifteen to twenty years ago talking about how the United States was having a challenge because of the rise of all the other countries. And obviously, we're living in that world right now. 


But the same thing is happening in dentistry. So, we've got a in the state of North Carolina, the dental board published a cease and desist letter for a corporate group that was having no dentist at all. They were bleaching people's teeth and there was not a single dentist involved in the entire process. It was just a commercial enterprise. And the board said, "No, that's dentistry. You can't do that." And that company sued them. And the whole thing went to the Supreme Court of the United States who found in favor of the company and said that the dental board were a bunch of dentists who were trying to control their own marketplace and that has unleashed a floodgate of things. Now we've got all this DIY stuff that you see everywhere, which is amazing. And the biggest challenge to current we've got right now in Arizona is dealing with the advent of the dental therapists. So, watch out. 


Howard: Let's stay with those court cases because... DIY for international guests is do it yourself. There was another place. I forgot where it was. Was it North Carolina and South Carolina? SmileDirectClub. Who owns Invisalign? Align Technology owns Invisalign and now they bought 17% of SmileDirectClub. And they are opening malls were beauticians are orally scanning, sending the x-ray to Costa Rica, and they're doing Invisalign without an orthodontist. So, my question is, do you think an orthodontist ever has to look? Or dentist? Do you think that lady doing mani-pedis can do your Invisalign? 


Rob: No, absolutely not. I think that I think that one of the big faults with our capitalist system is this concept that somehow capitalism works in every single circumstance. And we see it doesn't work in our prison system. It doesn't work in a whole lot of other areas of the economy. But healthcare is difficult because the way capitalism works is when the person who is the consumer has the ability to say, "No. I don't want to do that." And there are certain parts of dentistry where you can get away with that and cosmetics is one of them. But most of the time, healthcare consumers, which is the patients of the world don't have the option to say, "I don't want to do that." I don't want to buy a TV so TV manufacturers up their game. But when someone says, "My teeth are really crooked and I need to fix it, and I really don't have the money to pay an orthodontist. I want to go and do this." They don't have a way to say No.  


This group in particular, Smile Direct... Again, because I'm an endodontist and not an orthodontist, I'm not intimately familiar with the details. But I see that there's this idea that expertise doesn't matter anymore and that seems to be a trend in our society. And you can go on YouTube and look at the end of the, what do they call it, the priest class, because that's what we are. We're the priests. Well, now, we don't need the priest class anymore. I would challenge that assumption and say, "Yes, we do." And I think that anybody who thinks they're going to be able to go in and have someone who isn't familiar with dentistry scan their teeth, send it to somewhere else to get Invisalign trays made, send them back to the patient and there's no dentist there looking to say, "Well did that scanner pick up that oral cancer on their palette? Did they see that? Or are we certain that this malocclusion that they've got is something that's treatable with removable trays? Maybe you need fixed braces." So, I personally think that expertise is greatly maligned nowadays. And this is just another example of it. 


Howard: Of all the orthodontists we polled and surveyed on Orthotown, they can only treat 20% of their ortho cases with Invisalign. So, 80%, they're not even using Invisalign. I think it was bizarre from the courts because when they start- You've worked with the Arizona State Board of Dental Examiners. That's confusing to the international people. The Arizona State Board of Dental Examiners, that's the government agency of dentistry. The Arizona Dental Association, that's a non-profit volunteer mechanism.


But when they set up the state boards, the original courts that I learned in reading the Paul Starr's Pulitzer prize-winning book, “The Rise of the American Healthcare System”, he said that the reason the government stepped in with healthcare is because the asymmetry of the information was so skewed. I know what bottled water is, I know what coffee is, I know what a book is, I know what phone is, but I don't know if that lotion or potion is going to cure my disease. When we get called for the board, you are guilty until proven innocent, unlike all the other B to C consumer courts, you're innocent until proven guilty. So, when they call you up at the board, your X-rays, exam and diagnosis and treatment are guilty until you prove they're not. And then now the courts are saying that you don't need to be a doctor... What I'm trying to get to, it's not a transparent transaction. When I go buy my readers, I put them on and stand in front of the mirror, but when I go do-it-yourself Invisalign at Smile Direct. I don't know if I have a long face, open bite. I don't know if I have a (unclear 00:11:57). I don't know any of this stuff.


Rob: And therein is the other shoe to drop in this thing is that people don't know what's going on, but we all have short memories and there's actually a large cohort of people in the political world, not the judicial legal world, but in the political world who really have this belief system that we should not have regulation of any kind and these are the pure capitalists so to speak. For example, I believe it was Senator Ted Cruz, a few months ago, who introduced the bill into the Senate to try to reduce the amount of regulation of boards at the state level too. I guess urging states to do that. I haven't read the legislation itself but-


Howard: Urging state boards to what?


Rob: All the boards. It's not just in healthcare, it's everything. There's boards of contractors. There's boards of cosmetology and all these different types. There's a school of thought that says that these boards are there to help the state protect the consumer and the public, but there's an opposite school of thought that says these are run by the very people who are being governed and it's actually protecting the turf of those. And so, they say that, for example, a licensure examination is something that isn't to test the knowledge of the person. It's this group, this board under the auspices of the state government, that is actually preventing the new people from coming in and becoming competition for them by forcing them to take this exam. I think that's ludicrous. Personally, I think that if you haven't shown that you know what's going on, then you haven't shown what's going on.


A certain amount of expertise and knowledge needs to be demonstrated and I think a lot of people think that by forcing them to do that, we're somehow protecting our turf and keeping the competition out, which absolutely, in this state as you said, is completely untrue. In Arizona especially because we have non-dentist owners of dental practices. We have one of the most competitive environments in dentistry that exists in the United States. And does it help the consumer? No. Maybe in some cases, it can. I think that overall what it does is it makes it so that people have a great incentive to try to work smarter. But the reality is that there's only so much you can do to cut your cost and then you start cutting corners. That's what I don't like when I see that.


Howard: Right. I just want to stand up for Ludacris. I don't know why he had to bring in my favorite rapper and say that Ted Cruz was Ludacris. Ludacris, you rock buddy! I'm sorry Rob Roda just threw you in the same bus with Ted Cruz. I want to go back to Ted Cruz because he's from Texas, isn't he?


Rob: I believe so, yes.


Howard: Texas had that Supreme Court ruling where someone was a Diplomate of the American Association of Oral Implantology and was advertising that he was a specialist. The Texas Dental Society - which you're the president of the Arizona Dental Society - sued him and said, "You can't call yourself a specialist."


Rob: Actually, that was the dental board. That was the state organization. It wasn't the Texas Dental Association. It was the State Board of Dental Examiners of Texas. And they basically went after him under their advertising guidelines saying, "Hey, you're violating guidelines because you're not a specialist. because you're not a member of one of the nine recognized specialties of the ADA." This went all the way to the superior court in Texas who found that the board's reliance on the ADA as the sole arbiter of who's a specialist and who isn't is a process that is wrong because the ADH process could be biased. 


This law suit happened a couple of years after the ADA refused to certify a dental anesthesiology as a specialty. And Dental anesthesiology... They were bonafide specialty. They've got training programs, residency programs. They've got journals. They've got their own knowledge. They've got a board. They have all these things that matter in becoming a specialty. In 2012 was the last application. The commission on dental education and licensure of the ADA, who are the group that supervises the apparatus. The apparatus said, "Yes. They did it." They've accomplished it after a couple of failed attempts now they are good enough to be a specialty. But the final vote went to the house of delegates because of political lobbying, ended up voting it down. 


And that was it. The anesthesiologists weren't having it so they joined with the American Academy of Implant Dentistry that's been trying to sue their way into specialty status for a long time. And also, I believe the American Academy of Orofacial Pain and the fourth group is the oral medicine group. Either their name escapes me right now... They formed a group called the American Board of Dental Specialties (ABDS). The ABDS has now set themselves up as a competing board for discussion or for deciding who's a specialist or not. So, the Texas State Court said you are not allowed to just rely on the ADA. All the states are revamping their advertising guidelines now in light of this lawsuit to try to maintain high standards of specialty, but at the same time not get caught in a vulnerable position for lawsuits because nobody wants to get sued. 


Howard: Oh wow. I'm sorry. My walnut brain thought that was started by the Texas... You just threw so many hot buns out there I want to start going through. When you bring up dental anesthesiology... Hey, I've been practicing here thirty years since '87. My dental office, when you drove in at forty, is right next to safe way, Chase Bank (inaudible 18:10). It's exactly three point zero miles. Yeah. It's just awesome except my cars get really old because my car is a 2004 and it still adds one hundred forty thousand miles on it. Those are, have to. So, it'll probably…


Rob: For all of our viewers under northeast, one hundred thousand miles is something that means low mileage here in a country like Arizona where there's no rust. 


Howard: My God, I have no reason to buy a new car.... 


But every time someone dies in the dental office that I've been here, it's always sedation-related.  We've had two in Yuma, three years apart. So, a lot of kids listened to you. A lot of them think, "Well, I'm going to go learn IV sedation at the Holiday Inn" and start offering that. But I always think people don't die from a filling. They don't die from a loose-fitting denture. They die from a sedation. I told them I wouldn't touch that with a 10-foot pole because what confuses me is in Arizona - in any of these hospitals, amazing hospitals - you're not allowed to do the sedation and the surgery. The only place that you see that is in oral surgeons, general dentist. And that deal about the dental anesthesiology, thought that I'm never going to. You couldn't, you couldn't beat me with a crowbar and make me start putting people to sleep because if something goes wrong... And I also notice, there's only three publicly traded dental offices in the world, two of them are in` Australia (1300 smiles and Pacific smiles) and one in Singapore (Q and M). When their Wall Street lawyers looked at all that, they said, "Well, you can't do any sedation on anyone under sixteen, over sixty-five because that's where all the desks are. And all the desk in Arizona, they're all two and three-year-old and four-year-old kids. And that's why some of the Arizona pediatric dentists like Jeanette Maclain is really big in SDF because it scares her - putting a two-year-old under... What do you think about this anesthesia do? 


Rob: It's tragic. I can tell you that, that my choice in my practice is that if anyone needs to be sedated or put to sleep, I'm always going to have an anesthesiologist there because I believe - and that was my training when I was in the dental school, was you can't be an anesthesiologist and a surgeon at the same time. The other thing: just a quick a correction, yes, when deaths happen in dentistry, a lot of times they have to do with anesthesia. But the other thing is that a lot of times it has to do with young children that are small. And the dentist is trying to do a whole bunch of quadrants at once so they don't have to keep bringing the kid back. And unfortunately, if they're not careful with their calculating, they can overdose the child. And that has happened a couple of times here in the state too. But the sedation is... you're putting them a little closer to death than they are when they're walking around the street.

 

I've always been - I don't want to just say respectful - I've been terrified of that. The first time I did my first ever rotation as a senior in dental school through their children's hospital. We had a child that was put down under general anesthesia to do ear-to-ear crowns and all that stuff all at once. And after the procedure is over, everything went really well and this is with an anesthesiologist. And I noted that there was an anesthesia resident there too, plus the surgeons and everyone else. Surgeons back off... anesthesia, pulls out the tube, does all this stuff. And then there's like, "Okay, wake up. wake up." They're trying to wake this kid up and this kid wasn't waking up and I'm standing there...I'm a dumb dental student so I don't get to do anything.  I just sit back in the background. I'm looking at this thing and thinking I'm going to see a kid die. This kid turned blue. He turned the cover of this book and I was terrified. I've never been so terrified in my life at any moment.  Then all of a sudden, they were rubbing his chest and doing all this stuff, trying to get him to wake up. All of a sudden big gasp, and within moments, his color went from blue back to pink and then he was fine and they're like, "Oh, yeah, that was all fine." But I could tell looking at those, the anesthesiologist and the surgeon - they were all terrified themselves.  And so, I think that the idea of sedating children, unless it's absolutely necessary, it's something that needs to be carefully done. You always have to look at the idea of maybe I should get an anesthesiologist in there because their training, their expertise is above and beyond. And it's a specialty.


Howard: Yeah. And I wouldn't do it - I just wouldn't do it. I can't think of anything that would be more... I know a dentist that lost a patient and they were depressed the rest of their life till they died. We had another one in our backyard where the hygienist could numb - so she went up and again, they're trying to do it all in one appointment - hygienist totally numbed up the kid but that didn't get communicated to the dentist. He came in, he numbed up the kid and the kid were like three and they died. These are tragic. These are things that happens in the kiosk. It's not a big deal, but I'm going to alter my questions with the hot topics that you're dropping. You said Arizona is one of the few states where a non-dentist can own a dental office. We have fifty states. How uncommon is that? 


Rob: I'm not the right person to ask this too, but I recall my executive director saying that there was like five. 


Howard: What are the pros and cons? What are the trade-offs? Are you a proponent of a non-dentist only dental office or anything? 


Rob: I think that there are pros and cons to it. Obviously, if non-dentists are not allowed to own a dental office... I shouldn't say that. The way it generally works is they say that a dentist has to be an owner of the dental office, but it doesn't usually say the proportion. So just because there's only a few states that have a non-dentist, able to own the practice outright, it doesn't mean that you don't have a corporate dentistry in all fifty states because we do. But what happens is they have to have a dentist who is a part-owner of some kind. It doesn't pose a certain amount of control on the part of the dentist, but I think that the reality is that as long as it's properly controlled by State Board of Dental Examiners, I don't see there's any problem with it. 


Our board, for example, here in Arizona, we have a law that was passed shortly after they legalized the non-dentist ownership that said that all non-dentists entities that own a dental practice have to get a license to practice from the dental board. And so that was the work of the Dental Association pushing that through. So that now they're held to the same standard as a dentist. I'm not sure that I see a huge difference except that now, people that are not dentists - dental hygienists, for example - there's practices in the state that owned by dental hygienists and they hire dentists to work.


Howard: One owns like ten.


Rob: Yeah, but then there was that one a couple of weeks ago where the dentist quit and the two hygienists started doing the work and then they got arrested for it. It's a class six felony doing dentistry without a license in this-


Howard: In Phoenix or-


Rob: And that was on the news. That was on USA Today.


Howard: Last week?


Rob: No, I'm going to say probably a month ago now. But there were two hygienists...


Howard: I'll try to find that story and we have another huge issue because Arizona, California, New Mexico and Texas have like a two-thousand-mile border with Mexico. Okay, let's be honest. I've been here thirty years. I’ve had a yard crew, a maid crew for thirty years, and anytime I ever went to my gardener, I said, "Do you know of any dentists from Mexico that are not American-trained practicing?” And, they could always give you five names. And the first time I found out about this, one time I was talking to my yard guy and he said, "Are you alright?" I didn't feel good or had allergies. And he goes, "Because I got a bunch of prescriptions in my car." And I go, "Why is that?" And he goes, "Well, I always go to the pharmacy in Guadalupe and it's so cheap, I always buy a bunch of stuff in case I ever get sick. I have all this stuff." But, anyway, you and I both know that in California, Arizona and Texas, there's a lot of dental offices ran by non-English-speaking dentists. So, have you seen that issue in Arizona?


Rob: Well, I'm not sure that I have a problem with a non-English-speaking dentist working here as long as they're licensed.


Howard: But they’re not.


Rob: But if they're not licensed, then that is a problem. There was an incident actually in Mesa a couple of years ago where there was an unlicensed dentist. This does happen not just in the Hispanic population, but it also happens in any immigrant population because immigrants tend to feel, especially when they don't speak English very well, they're not that familiar with the culture because they're new arrivals, they feel much more comfortable with people from their own culture doing the dentistry. And unfortunately, it does exist that some of these people that are doing that are not licensed. And like any person who's not a licensed dentist, there's no way that we have any kind of control over that so they can basically do anything and nobody really knows what they're doing. And, like you say, maybe having a trunk full of pills that you give out, that may not be the safest thing in the world, especially nowadays with this opiate epidemic and everybody concerned about taking painkillers. So, obviously, as a dental association, we're really concerned about that when people are not practicing dentistry with a license. 


Howard: You keep dropping these bombs. I'm trying to ask you my questions. When you talked about opiate epidemic- So, when I went to school thirty years ago, the media- We were the bad guy, physicians and dentists, because Grandma's got cancer. She's in pain. You won't give her morphine. You're being skimpy. And all these people are suffering. So, the very conservative physicians and dentists from the eighties and seventies, sixties, they broke open their prescription pad and said, "Okay, we're growing opiates." So now the pendulum swings and now we're the bad guy because we gave out all this Vicodin and hydrocodone. You’re an endodontist. That's the most painful part of dentistry. It's not from fillings and cleanings and exams. It's molar endo. You wrote chapter eight of this book. If you did a hundred molar root canals, what percent of those would get an opioid? 


Rob: Well, I can actually tell you that - the exact number - because now in the last two years, the Board of Pharmacy has this prescription monitoring program that we have to all sign up for. And in 2017, I've prescribed opioids twice. 


Howard: In 2017. And, you did three root canals that year?


Rob: That's right. Yeah.


Howard: So, two out of three?


Rob: No, I just prescribed to two. Twice. That was all. Because what's happened is that among other things, I am not only concerned for opioid prescribing, which obviously every practitioner has, but in terms of purity with endodontics, there've been several studies recently out of a couple of universities that showed that if you stagger six hundred milligrams of Ibuprofen with about seven hundred or eight hundred milligrams of Tylenol- Give the Ibuprofen, two hours later give the Tylenol, two hours later give Ibuprofen, two hours later give the Tylenol... That absolutely is as good as a Vicodin (inaudible 00:30:04).


Howard: Actually, they do that study. It's better. It's better every single time. But, come on, this is Dentistry Uncensored. What percent of our homies out there? Every single molar root canal, they give him Pen VK five hundred milligrams and twenty tabs of Vicodin. Seriously, what percent does your gut feeling say for the United States of America? 


Rob: I don't have any statistics to go on that are official, but my gut would tell me probably about half. 


Howard: Yeah. So, then we're also getting all kinds of trouble about superbugs.  I've been seeing a lot of bizarre research showing that America is 5% of the planet, but we take half the prescriptions. And they'll take identical twins. One girl, when she was three, had a prescription for an ear infection, and the twin sister didn't. Now the one that had one round of antibiotics is putting on more weight and obesity. So, they're saying the antibiotic starts throwing up all of her gut flora. Bugs are getting immune to it. What would you say to a dentist that ... Every single root canal, he just writes a Pen VK and 20 tabs of Vicodin?


Rob: I would say stop now. Don't do it. People get penicillin or amoxicillin or if they're allergic to that, Clindamycin. And those are the three. I see a lot of Keflex out there, no bueno. Those are the big three. You do that if someone has a necrotic pulp, if they have swelling, fever, lymphadenopathy. You don't do it if they have a cold-sensitive tooth because cold sensitivity is not helped with antibiotics. You don't do it with irreversible pulpitis that's not helped with antibiotics. And so, if you're using it judiciously - and of course the best thing, even better than antibiotics, is actually get in there and do something. Open up the tooth to clean it out. Or if you're going to extract it, extract the tooth." - just local measures, incision and drainage, all these things. I hardly ever write prescriptions for antibiotics and to be honest, I did.  I used to. Back in the in the eighties, when I was a general dentist especially, but even as I got out of out of graduate program, I would prescribe more, but I'm finding that I'm doing less and less and less and less now.


Rob: It's not as little as the opioids, but I'm absolutely positively the over-prescription of antibiotics is causing the rise of the superbugs Clostridium Difficile-Associated Disease, which is CDAD, or antibiotic related colitis. We used to call it pseudomembranous colitis. We didn't know what it was. It's caused because you've got bacteria that can live through the antibiotics that wipe out rest of the gut flora. And this clostridium bug grows, creates two toxins that destroy the colon. And it's a horrible, horrible way to go. And the new version of it, the NAP1 strain, that came out in 2003, now has a mortality rate. From 20% of the people over the age of 65 that get clostridium disease are going to die.  And again, you talk about, you know, what happens when you're a dentist and one of your patients dies and they can die from that - from anesthesia overdose - but they can also die from a lot of things including clostridium disease. So, don't overprescribe antibiotics and I mean, you. 


Howard: Okay. Well, name the three that you said. You said Pen VK...


Rob: Pen VK and clindamycin for people who are allergic. And then, the Pen VK, I put slash Amoxicillin. I think that they're both (inaudible 33:25).


Howard: But you specifically said No Bueno on Keflex. Why did you say that?


Rob: Yeah. Probably Keflex because it doesn't have a spectrum that covers all the bugs that are used for dental infections. And you'll find even in books like this, the only time you use Keflex is when for some reason you can't use that one, that one or that one. And, even then, I would probably go with something more like a Z-pak or something like that as opposed to Keflex. It's not that effective. And when I see patients that come in and their dentist and they did have an infection and the dentist put them on amoxicillin, penicillin, clindamycin, they come into see me and they've gotten some relief from that. With Keflex, it's a real crapshoot. Sometimes, they do, sometimes, they don't.


Howard: Alright, I'm not letting you out of here until you autograph my book and not on a piece of paper. You got to write it on the heart on the hard part. Well, the one thing I want to tell the kids is the one thing that's bizarre in their Endo training is that it seems like every time they want to learn something about Endo, they at least got to go to Sky Harbor, fly across the country, drop several thousand on a course. You need to be cheap. And, this book... Is there anything not covered in this Endo book?


Rob: Not much. It's pretty comprehensive.


Howard: And how much does this book cost?  


Rob: It's probably somewhere between one hundred fifty and two hundred probably.

 

Howard: And what would their plane ticket to the course cost? Three hundred? And then the course? There's endo courses in Santa Barbara that are three thousand a weekend. And I remember when I went and saw Misch the first time, all these people were asking all these questions. All your questions were in the first three chapters of his book. They're like, "Oh, I didn't read his book." Just like college, you read the book so then when you hear the lecture, then you can see if you guys straighten out, then ask the question. What does everybody else do? They didn't read the book. They're listening to these lectures and are asking all these stupid questions like: "What did he say?" And then, they would try to read the book the night before the test. And those were what we called the 49:50s - me and Dubkin and Paul (inaudible 35:30). Because back at Creighton, five thousand people would apply to that Creighton Dental School and they'd accept fifty. So, the 49:50 were the ones that wouldn't get in. We'd say, "That guy's a 49:50. He doesn't have a chance." But when you looked at the Paul (inaudible 35:52), Joe Dubkin's and things like that, you start with the damn book. You say you want to learn how to place implants, well, start by reading the other best-selling dental book in the history of dentist or dental textbooks, (inaudible)


Howard: Can you get me his last book - the implant book? It's laying on the side there. 


Rob: I read that book. That's an excellent book. 


Howard: Yeah. Which leads me to my next question because again, there's probably like one guy as old as us watching right now, and I'm going to have... In fact, my oldest have four boys. My oldest one's dropping his fourth boy any minute now. I mean not met. We almost saw it... As I said, "We're not going to cancel Rob." I said, "We're not. This is so rare. We'll just get there later. Plus, it's the fourth one. You get all excited about the first three but the fourth one, we'll just show up with a Whataburger? 


Misch is avoiding complications. We’re all intelligent. I mean, my guys, that adds a Bible look at these two bucks. I mean, you could take them to the gym just to work out with. That's how you get all the information for lowest price. But, again, 25% of our audience is still in school. One of the things that really confuse them, they don't know irreversible pulpitis first time (inaudible 37:08). Now, that's one thing but they don't know if they should retreat with this or pull the tooth out and go with implants. How would you guide a 25-year-old dentist in Glendale to retreat center to (inaudible 37:22) and retreat the root canal or center to you and retreat the root canal or center to the oral surgeon and extract it and fix it with titanium? 


Rob: There's a couple of ways to look at that. Number one: what are the outcomes of treatment? Outcomes of nonsurgical or surgical retreatment are extremely high. And in fact, one of the things that's interesting to...  


Howard: Say that again?


Rob: The outcomes of nonsurgical retreatment or surgical retreatment, which is commonly called the apicoectomy, are extremely high. And, what's interesting is it used to be with the older techniques of surgery that the nonsurgical retreatment was a much higher success rate. But, in the last twenty years, that has flip-flopped and now surgery actually has a higher success rate in four different meta-analysis that have come out over the last eight years than a nonsurgical retreatment. And, so, the options have never been better for trying to save a tooth. Now, I'm not saying that there's anything wrong with a dental implant. Dental implants are awesome.  So are bridges. So are removable partial denture and when you have to lose the tooth.  And that's a great idea, but if there's any way to save a tooth, it's usually better to try to do that even if you're only going to get a few more years out of it. Because as we're learning more and more about the long-term implications of dental implants with pericoronitis becoming rampant after fifteen or twenty years with these things, you start to say, I think a new philosophy is growing. You remember the days when they used to say that a natural tooth was simply a space maintainer for the future implant. Well, now, they're not saying that anymore - all the people. And it's funny because I learned that quite a few years ago from the real savvy oral surgeons and periodontists in Scottsdale who were really smart and they started seeing this.  "Oh. Wait, now, I'm seeing a lot of my stuff coming back and there's problems here."


And once that tooth's gone and you've got an implant and the implant has a problem, now you've really got some challenges. And so, they started redirecting to me to say, "Is there any way to fix this? Is there any way to say this?" And so, the new philosophy - I think that's coming out with the implants - is the same as the philosophy that doctors have had with knee joints and hip joints for a long time, which is wait as long as you can. Don't do it right away. Try to save teeth as long as you can. The problem is that the general public has this idea that somehow, we're making toasters or we’re building television sets. We're not. We're doing healthcare. We're applying the best knowledge and technology we have to an imperfectly understood system.  And sometimes even the best treatments don't work. And people want a guarantee. They want a warranty, they want to think- And that is not how healthcare works. Now they don't ask for a warranty from the guy who put the new hip joint in. But sure as heck for us, they get really angry when something goes wrong. Partly, that's our fault. Partly, it's because of the society just sort of kind of demeaning what dentists do compared to what their physicians do. And so, you get into this kind of a dichotomy. One of the things the public has to realize is that the human mouth is in a state of degeneration from the time the teeth erupt to the time that they die. And that degeneration never stops. It's relentless and it's ongoing. And the only thing we can do as dentists is to slow it down until… So that by the time that person dies, they've got a relatively full complement of healthy natural teeth. That is a successful course of dentistry over the lifetime of a human. 


And so, while we would love to think that everything we do lasts forever, we all know that it doesn't. And things are going to break down. The oral environment is so hostile. I tell people. They get mad at me. They say, "Well, my dentist put this bridge in and now it's got decay." And I said, "Well, when did they put the bridge in." "Thirty years ago, and I'm really angry that this thing failed." And I'm like, "What are you talking about?" You've got to be kidding me. If you took your Mercedes that you just paid $70,000 or $80,000 for and you put that in an environment where it's bathed in corrosive solutions and the temperature goes from the temperature of hot coffee to the temperature of ice cream back and forth at dessert for dinner, plus you're pounding it with sledgehammers to twelve hundred pounds of pressure per square inch or six hundred pounds of pressure per square inch, twelve hundred times a day, that car's not going to last that day.


I am proud of dentistry and I’m so proud of what we do because what we do last in this incredibly hostile environment and so what we want to do though, realizing that everything is degrading, is go from step A to step B to C to D, and if E is implants, go to E. Don't go from B right to E, go right through the thing. Now, what the young dentist - going back to your question - in Glendale is going to say is 'Well, I've got a root canal. It has post-treatment disease. How do I decide if it's fixable or not?" Well, you read the book. Lots of stuff in here that will help you with that.


Howard: And thanks for writing it. That was an awesome read.


Rob: The whole book is an awesome read. There's a lot of other authors in there and every shred of it is good material.  But the other thing is that you can rely on your specialist and this is really what we tell people the most: if you're not really comfortable with it, honestly, get a specialist you trust and make sure that you trust that specialist, that they’re someone who's going to take care of you, take care of your patient, not throw you under the bus, and not just care about making money, but care about what's happening with your patient. And when you got that, you've got a friend. It's like that genie in Aladdin.


Howard: That's funny, Ryan. You Googled that there were the hygienists to do the dentistry and you pulled out and sent it to me. And this was just last week too. But this one last week was in Idaho. He was talking about one in- You said-


Rob: It was in Arizona.


Howard: It was in Arizona.


Rob: That was hilarious. And, Ryan was able to find one a week ago in Idaho. I was lecturing at the Dental Insurance Association...


Rob: By the way, you're an amazing lecturer. I've heard you speak. You're just awesome. Not that we're in a mutual admiration set here, but yeah... 


Howard: Well, I'm trying to do my hair like you. I'm trying to be Rob Roda.


Rob: And I’m trying to be (inaudible 00:43:26).


Howard: Actually, you'll find my name in this book too. I don't know if you knew that, but I opened up on a page and I just wrote my name in there and Ryan says I was disgracing property.  But anyway, I was lecturing down there and there was about three hundred insurance people there. Insurance people are weird. They'll go to lunch with you. They'll go to dinner with you. They'll stay in the barn till three in the morning, show you all their data and then I'll say, "Can I just have this chart and publish it in Dentaltown?" "No." Their older data is... 


Rob: Were you at the dental consultants meeting up here at Talking Stick? That was about a month ago. 


Howard: No, I did not do that one. God, I wish I would have gone to that. This one was in Florida. But they talked about it’s (unclear 00:44:13) science. So, after you network with ten or fifteen people, they were always showing me the same data because I asked him about molar endo a lot. They were saying when you have ten people look at a root canal and say that was successful, you might say, "Well, it's short." The insurance people, they're brutal. They're just like, “Is it too still in the mouth? If it's in the mouth, it's work.” They're showing that at five years, which is just sixty months, if an endodontist does the molar, 5% of them are extracted at sixty months. If a general dentist does it, 10% are extracted at sixty months. 


So, my question to you is, why do you think one out of twenty molar root canals are extracted in five years by an endodontist? And why do you think it's twice that rate for a general dentist? What do you think the endodontists are doing wrong to have 5% fail in five years? And what are the general dentists doing wrong to double that? 


Rob: Well, first of all, I think that a 5% failure rate over five years is not bad. That's actually pretty good. In fact, even 10% percent last that long, I believe...


Howard: Marriages don't last long. I believe one-third of marriage in the United States fail before five years. Is that your new warranty? This will last as long as your marriage.


Rob: Well, one of the big things is simple. It sounds so stupid, but just simple rubber dam use.  Endodontists always make a big deal out of rubber dams and because they are a big deal. It's the only way to keep the bacteria from the mouth, from getting into the tooth, from the saliva, from getting in the tooth. You can use various things. Even this - what's that thing called the with the battery life... Isolate. The Isolate manufacturers promote that as being useful for endodontics. But the trouble is that when people breathe, it aerosolizes the bacteria in their oral pharynx and some of them are going to land in the prep. And the only way to do that right now is with a rubber dam.


And yet, there was a study in 2015 or 2013 in the Journal of the American Dental Association that showed that only 44% of general dentists use a rubber dam all the time and when they're doing root canal. And the other 56% did not or used it sometimes but not always. Whereas with endodontist, it's 100%. Right there. You have a measurable reason why. And there have been subsequent studies that showed that if you didn't use a rubber dam, you will end up having a higher failure rate than if you did. It's not a huge amount, but the success rate drops by three to 10%, which seems to be in the range of what we're talking about. 


The other issue is that I saw this guy in New Zealand speaking... He was a risk management guy from London working for an insurance company in London that insured all the New Zealand dentist and he's doing a risk management presentation.  They have this great chart, and it was a pie chart. It had, like right here with stuff you know, and then there was a little bigger when it said 'stuff you know you don't know,' and then all the rest of the whole pie chart was stuff that you don't even know you don't know. 


Another big part of the problem is that when you and I were in school, dentistry was this big. Dentistry was the size of a basketball. There's some knowledge of all of dentistry the size of a basketball. Now that's some knowledge is about the size of a beach ball. And yet we still have four years for dental. They haven't made it five years. They haven't insisted on a GPR like they did in New York, but most states don't do that. And so, what happens is that people end up... They have to cut back somewhere. 


And unfortunately, endodontic education has been cut back in a lot of places. We did a survey at the AAE in 2012 and some huge percentage of our undergraduate educators, people that are in dental schools that train the general dentists of the future. I don't want to quote the exact numbers, but in my head, I almost want to say 75% of them agreed with the statement that their graduates were incapable of doing endodontic therapy to a competent level, or they weren't sure whether they were capable of doing endodontics to a competent level. And, that was incredibly disturbing for the Board of Directors at the AAE when we heard that survey result. It was like unbelievable. It was the biggest indictment we saw. Even our educators are saying that these kids aren't getting enough training on endodontics. 


And it's not going to get better because they have to get training in implants. When you and I were in school, implants weren't really taught - or cosmetic dentistry. They need all these things. So, something has to give. And so, they've cut back on endodontics and this really means that not only does that 25-year-old who's trying to make a decision in Glendale as to what to do with this tooth, not only do they have to maybe read a book, but they are going to have to do some courses. They're going to have to engage. And personally me, I'm a big promoter of study clubs. I think clubs are awesome. And I've been training (inaudible 49:08) up in Canada for 15 years.


Howard: Where were you born again? 


Rob: I was born in France. My Dad, my dad worked for {inaudible 49:15) so we were all over the place.  I was born in the American hospital in Paris.


Howard: So, you lived in three countries?


Rob: Actually, I went to high school in Frankfurt, Germany. 


Howard: That's probably why your wall... so open-minded and well-rounded.


Rob: I don't know about open-minded or well-rounded. I think that it gives me perspectives that are beyond what we would normally get if you lived in the same town your whole life. 


Howard: So, I think people who have been... today's the day, we just found of Anthony Bourdain took his own life. He committed suicide last night. But guys like that... He was a chef but he went all over the world...


Rob: Kate Spade...


Howard: ...who's from Arizona. David Spades from Arizona and the Spade family is from there.  But they get such an interesting perspective because if all you know is your little blue city, you need to see the red ones and the purple ones and the green ones. And I thought Anthony Bourdain was so intellectual because he cooked in a restaurant in every damn, near every country. 


Rob: The CDC just came out with a report in February that said that for the first time in history... First time since World War II, that the life expectancy in the United States has dropped. That happened in 2016. That was the first year ever since World War Two, that life expectancy in United States dropped. And last year, 2017, it dropped again. It's two years in a row. There hasn't been two years in a row and I don't know how long. They blame it on the suicide, which they just came out with a report yesterday in the MMWR from the CDC said the rates of suicide have jumped up 30% all over the United States, except in Nevada. It was flat. No one's killing themselves in Nevada. So, I guess the gambling must be good. 


The other was the opiate epidemic and the CDC named it in February... They said, "We are in the midst of an epidemic of despair." And hearing about Kate Spade and Anthony Bourdain... Now, I didn't know that. That's just awful. And so, you look at the opioid epidemic and you say to yourself, "All these people taking all these drugs. Why are they doing it?" And the CDC calls it despair. And that's what really bothers me the most when you said earlier that they're blaming the dentist for doing this and doing that. It's not the dentist's fault. This is a symptom of a bigger problem in society, a much bigger problem in society that unfortunately can't be fixed by you and I. Because if we could, I would fix it. And I know you would too. 


Howard: Staying on the subject of despair, let's go straight into the dental insurance. So, you lived in Paris, France.


Rob: Well, I was three when I left France, but I lived in Germany when I was in high school. 


Howard: Okay. So, I think, three of the greatest cities I've ever lectured in is Tokyo, Paris and London. And all three of those. We're talking about root canals, (inaudible 52:07) all three of those. I mean Tokyo, Paris, London. The government pays $100 from a root canal. Yeah. So, when we were podcasting dentists from Japan and Paris and London, they told you all of this at the bar while you're drinking beers. But as soon as the camera turned on, they all clammed up. But this is what they all told me and Ryan is my witness. They say, well, when someone comes in and gets a root canal, you Americans... What would you think the average general dentist gets for a molar root canal in Arizona and what would the endodontist get in Arizona? What would you guess here in Arizona? 


Well, I think the average endodontist probably gets about twelve to $1,500. I think the GP for a molar and the GP probably gets about nine hundred to eleven hundred. I got GPs that charge more than I do, but I get. 


Howard: Okay. So, could you, could you do, Rob, a root canal for 100 bucks? 


Rob: No. 


Howard: Okay. So that's what they tell you. They go... We're in Japan. Yeah. I mean it's very expensive. By the way, if you think you need a bigger office, go to Japan because when you go to civilizations like Tokyo, land is a million dollars a square meter. So, you could go into a dental office size of a dining room, they'd squeeze three operatories in there and the reception. I mean in this room. And so, they say, "Yeah, we need to pull it because the implant is not on the list." So, then they'll charge market rate is like $1,500 for the implant, a thousand dollars for a crown.


So, when you live in Tokyo where land's a million dollars a square meter. Paris France is (inaudible 53:44). London, crazy overhead. And the government - the NHS, say, "No, you only get $100 and you have to take this fee and you'll have to be a provider." So, we're seeing around the world molar endo plummeting and implants say enough simply because the third provider. And that's what I never understood with injuries. I mean I understand if it's a benefit and they say, "Hey, your government wants to help you get a motoric now. So, here's 100 bucks. Go or, if you want knock, yourself out." That's a subsidy helping you. But it's not a subsidy helping. It's controlling you when they say, "Oh, we'll give you $100. But all that dentists can't charge more than (inaudible 54:26). I see the same thing with so many things, like government housing. 


Then you go back to Johnson's great society. He didn't say, "Hey Rob, here's 100 bucks. When you go out to find a home, we're going to give you $100 a month." Maybe you want to buy a trailer, maybe you want a condo, maybe you want to live with your mom and pay your mom her dollars. "No, no, no, we don't do that. You have to live in our government housing project. You have to live in the projects." "Well, can I have some money for growth?" "No, you have to have stamps." and it's always about control. So, what would you say to dentists listening in Tokyo, Paris and London who are extracting perfectly treatable teeth because they are participants of the NHS?


Rob: You know, I first heard about this problem when I was at an implant course at the University of Frankfurt back in 2008 and the professor was teaching a group of endodontists from the United States. We were all very unfamiliar with how that system worked over there. He made the comment that apical surgery doesn't work and there were a couple of professors, from North Carolina in particular, that were going over the chairs. They were going to throttle this guy and it was hilarious and he was like, "No. no. no. It doesn't work here because we only get paid $100 to do an apical surgery and so we can't afford to use microscopes and ultrasonic and MTA and all these different things that make it work here." And so, in a way, he was right. When you have a situation like that I don't know what I would say to the members of the dental profession in these countries other than try to change the law. Try to change the rules because you're absolutely right. 


It's a control thing as opposed to a helpful thing. And, in Canada, I did live there for eighteen years. They have a government program. I was a general dentist and they had a government program that paid for dental care for kids. They get a fee guide. They are pre-scheduled and you had to accept their fees and you were not allowed to withdraw from the program. So, it wasn't like Medicaid here where if you didn't sign up, you didn't take Medicaid. Everybody had to take this plan. So, if you had a kid come in under the age of sixteen, you knew that you were getting $20 for that filling instead of the normal sixty-five that you'd bill out and that was in the 1980s. Don't go by those prices now and you just had to do it. But everybody's Canadians. And just say okay, and you just did it because it was good for society. There were a lot of people that grumbled and complained, but you just kind of did it. It really is a form of control where people are trying to control the world, whereas if you just gave them, like you said, some kind of a subsidy. And I think the fear is 'Oh, well, you know, if I give that guy $100, he's not going to give it to his mother for Randy's going to go and buy drugs.' And okay, figure out a way to prevent that from happening. But the thought that you somehow have to impose this much lower fee is in my mind, kind of ridiculous. Although there's a lot of people that feel that, you know, dentistry should be given away free. And I challenged them to then pay the taxes to pay for that because that's something that's not going to happen. 


Howard: Yeah. Like every time Bernie Sanders say free healthcare. I mean, what does that mean? Is he going to come arrest me and take me to my office? And Jamie's a janitor and work free for the rest of my life? And they're like 'Oh, no. We're just going to take other people's money.' Oh, so their money is free to you. Everything's free in Wally World? And when you do it in any other industry, like when New York imposed a decade of rent control, you can only charge this much grand. Guess what happened? Nobody built one new unit of a rental property. So, what did that do on supply and demand made rental properties more... it's off-topic...


But you said something very interesting. You keep stepping into all these minefields... A lot of your millennials come out of school and you say, well I got $250,000 student loans. 


I'm not joining the Arizona Dental Association. Dude, the insurance companies are lobbying your government every day? And Rob's best friend, besides the ADA, the Pew Organization... But you have all these interests. So, you committed eight, nine, ten years of college to be a doctor of dental surgery or a specialist. You got two to $300,000 in student loans. You don't think the insurance... Look at the rules. The insurance companies in Arizona... They can all compare their prices. But if I got all the dentists and I would (inaudible 59:03) to my house and compare prices, what would happen to me? 


Rob: That's a criminal event.


Howard: Yeah. The American Dental Association is like your mom and dad. I don't care if you like them or don't like them.  They're the only ones you got. My mom is officially batshit crazy. I'm the only normal one in our whole family. My two older sisters were nuns. How could they be normal? In fact, we started this deal. You said that the dentist or the high priest... my mom, ever since she was that tall, she just convinced me I had to be a priest. She always told me, "Howie, you're so smart. You can be the first American Pope." So, when people say, "Why do you want to be a dentist? Well, the alternative was a priest and dentistry look really good when you're not a priest. But the bottom line is they don't know what you do. What percent... what's going on state by state? What are you guys spending your time? They think you're just going out for dinner and having cigars and Martinis but tell them that if the American Dental Association and all those issues went away, we'd get ran over by the lobbyists for Insurance, TSOs.

 

My answer to the dentist in Japan is you got to draw the line in the sand. You can help and subsidize and say $100 (inaudible 01:00:27) account, but you can't draw the line and say that has to be the fee. And then the. And then the state could even put out a list and say, "Hey, here's all the dentists in Tokyo. Here's the ones that will accept $100 payment in full. And here's the ones that will just accept it as a subsidy." But when the government starts drawing a line, the dentists have to get politically organized, and you need to go back to the government of Japan, France and England. We need to do it in Arizona because again, that's where the abuse is. It's okay to say, "Howard, I will only pay a $100 benefit towards a MOD posterior composite." That's great. But when you say I have to do it for that. I either have to stop doing it or switched to amalgam. So, talk about what the political branch of the American doc because I've been a dues-paying member for 30 years because someone has to speak politically right for our profession. 


Rob: Well, the problem is that dentistry is a cottage industry. We are a group of small manufacturers and small businesses. And what the dental association does is it unifies everybody together and gives us a political voice. Now what that entails are activity at the federal level. But at the federal level, to be honest with you, the activity is important and it's effective. But it's not that often, it's something that the federal level affects you. It's at the state level where it really affects you. And so, for example, here in Arizona, several years ago, we found out by just checking the budgets of the state dental board that the dental board had millions of dollars sitting in their reserve and every organization, including our dental association and charities and all of these, they have a reserve fund.


It’s your rainy-day fund. What you take care of takes care of you if income goes down. And so, the board had one of these, they had millions of dollars in there. In fact, they had so much that they had enough. If they stopped charging for any kind of license fees at all, they had enough to run the associate, run the board for three or four years. And we were like "Wait, now that's ridiculous. You had all your money swept back in 2008 when the government stole all the money from the boards, which was an illegal tax on dentists by the way. But now all of a sudden, you've built it back up again and it's because they're overcharging the dentists and hygienists of this state. They're charging us for way more than it costs for them to run their little enterprise there. 

And so, the Dental Association went to them, went to the state legislature and we ended up after a quite a bit of negotiation having a law passed that has not only reduced the amount that we will be paying going forward for the next three triennial periods. In other words, until every dentist has re-licensed, there's going to be no dental board fee for you. You have no licensure fee for the next triennial period. That'll save you seven or eight hundred bucks right there. And it's these kinds of things that the dental association does in the state of California. Not necessarily a political thing, but a delta dental of California was... And I don't remember the exact thing that they're doing - Something that was absolutely outrageous. And the CDA, the California Dental Association sued them. And just $165,000,000, which is $5,500 per member of the CDA and they're all getting a check. 


That's great but not only that, but now Delta can't do this thing that they were doing. Now, we fortunately have a really good relationship with our delta here in the state. But in California, the CDA and that Delta, have a pretty adversarial relationship. Every state has their story of what they've done. And that's really where the rubber hits the road is the state dental associations. And so, I have people. They get angry. They say, "That, ADA. That's a terrible thing. It's a big monolithic green monster in Chicago... ADA definitely is the umbrella organization. They're the mothership, but it's the fifty state associations that you will miss the most if you're not going to want to join. And if anything, bad is going to happen to the ADA, It's the 50 state associations that you end up with that end. 


Howard: And by the time you're sixty-five, how many thousands of hours of those dentists volunteered their time? You're sitting there on the couch whining and not paying your check and they're down there after their long day. They got a wife and kids and family and they got stuff to do. How many, dental meetings have you gone to with no pay and your dental career? 


Rob: Thousands. 


Howard: It is vulgar. You either volunteer your time or you get out your damn checkbook and write the check. I mean it's your profession. But I got one beef with Delta and I've the guy. If you couldn't deliver him to come here and talk and because I always wanted... 


I understand gentlemen disagree. How would you like to go to every family dinner with your mom? Where you got two sisters that are Catholic nuns and a gay brother. Isn’t that nice? Isn't that nice? So, I understand that people can disagree. What I tell my sister nuns - Just leave them alone now because any day he's go to hell. So just be nice to them now because he's going to go to hell for eternity. So, while he's here, just be really nice though.


But here's what I don't understand... I'm not a lawyer, I'm a dentist. SO, price discrimination, if I charge Bill Gates a thousand dollars for a can of coke and you a dollar, Supreme Court says that's legal. You can't discriminate on price (inaudible 01:06:08). Number two: price discrimination is legal to volume. If you buy one can of coke, it's a dollar. But if Walmart or Fry's buys a hundred thousand cans of coke though, they're going to get a discount. And the Supreme Court says volume discount is legal, but you have to show your math because they want to be able to look into it and say, "Was there actually savings?" But number three, they say easy legal and that's geography and that's what Delta - in my humble opinion, non legal opinion - does that is take Arizona. So, they'll sell dental insurance to a company like say Intel or Motorola or something, a state agency and it's one fee per thousand or a hundred or ten thousand or whatever. Well, those people are coming from South Phoenix. They're coming from Scottsdale. And if I go to LA, if I go to Compton or Beverly Hills, or out here, I go from South Phoenix and Scottsdale and I buy a basket of goods, I go get a gallon of gas, a pack of Marlboro cigarettes, a gallon of milk, a loaf of bread, a basket of goods, they're the same price all in town. But in insurance, when that patient lives in Scottsdale and goes to the dentist, they'll pay a high fee, maybe seven, eight, $900 for a crown. But at Compton or South Phoenix, they only get $600 for a crown. We just saw that in response to... Pew wrote an article about something. They're always saying this stuff that just doesn't make sense and I've asked him to come on the show. Of course, they won't but this lady... it was a newspaper article about not enough dentists in rural Tennessee. And she says, "Well, you know what, I couldn't make it anymore because of the UCR. So, I moved 30 miles away to Memphis and now my insurance UCR is twice. If they would've gave me twice the money, I'd still be out in rural. 


So, then you even go to Arizona, you get a bypass. In Scottsdale, they'll give you a hundred thousand. Go get a bypass in Casa Grande, they'll give you sixty thousand. But the Supreme Court says that is illegal. Pharmaceutical companies do it. They sell a Viagra $10 a pill in America and they sell for fifty cents and India, Brazil and China. So internationally, they do it all day long. But our court say that's not legal, but that's all I see in healthcare. And, so, every time I meet a registered nurse, an orthopaedic surgeon, a lot of them say, "Well, I can't go rural because I can get twice the money for the same procedure if I moved to Tucson or Phoenix." Get your butt over to Scottsdale or Paradise Valley. Because once they find out, you're in a surprise. You're going to get a surprise when you open up a surprise.


Rob: I was not aware that they had this huge geographic difference. And so, I'm glad you told me that because that's not something I want to look into it


Howard: And if I'm wrong because I was wrong before, I always thought that was the Texas Dental Association that sued the implant guy. And you were talking it was the dental board. Yeah So, the government. So, I missed that one. I was wrong. I'm sorry for spreading misinformation.... Who's head of the Delta here?


Rob: I think the chairman of the board is Brian Harvey, who's a periodontist down in Tucson. 


Howard: I want him on the show. I've been trying to get him as long as (inaudible 01:09:51) you. Okay. See stubbornness pays off. 


And, the other thing, I've one other issue with Delta. The American Dental Association - I don't know how they did it - but they hired the greatest healthcare economists ever. He worked with the World Health Organization. He worked at the United Nations. What was the name... Marko Vujicic? The guy is the smartest guy. If the Ada fired him today, he'd get a job at the World Health Organization, CDC in Geneva, Switzerland. He'd go anywhere in the world...


Rob: But they aren’t firing him.


Howard: And he likes Chicago and he's a Canadian. Yeah. I think he went school in Canada. But he's been dying for years. Delta has all this insurance, like we just talked about the insurance claim. They show me at a bar if they're drunk, that at five years, 5% of your root canals have failed, endodontist, whereas, 10% of mine, general dentist but he wants access. He wants to hit it with basic algorithms and there's no transparency. 


Rob: Yeah, it's really hard. And we've tried for many years and every once in a while, they opened the books a little bit. And, so, you'll see a study. There was a big one done in southern California at USC using an insurance database to look at the overall survival rate of teeth that have root canals. Given that a million and a half root canals they could look at and see their success rate is, the insurance companies are sitting on the greatest goldmine of healthcare data that you can possibly imagine. 


And, it's interesting that you mentioned Marko. Well, because last year, I went to one of the most fascinating lectures ever went to was about big data and big data is the new big thing. And there's a guy in Oklahoma at Oklahoma State University who is a wonderful guy named William Paiva, and this guy has his office of health informatics, right between the medical school and the business college. His building's in the middle. This guy has so much data on medical health data because he had some company that just collects all this data. It's enterprise software, so it's like a Dentrix except for medical practices and medical hospitals and all this stuff. And, this one company - I'm sure there's others - but this one company has collected all this data. They anonymize it and they give it to this guy. So, this guy's there and he comes and does presentations. And mining that data produces so much astounding stuff. And, so, I told him just for fun because he was doing a presentation rendered on. He said, "Where does endodontics in the medical field interacts so I could maybe get some of this?" I said, "Emergency rooms. Someone's going to go into an emergency room with a toothache or swollen face and you can tell us how often that happened when these procedure codes." He says, "Oh, I know those codes. That's this, this, and this." I said, "Yeah, pull those out."


And that was two days before he comes to the lecture. So, it's two days later and his staff has pulled together this thing that shows through time because you've got sixteen years’ worth of data. The amount of people in hospitals for two (inaudible 01:12:48) of things kind of goes flat. And then all of a sudden 2008 hits and all of the state governments immediately start cutting back on their Medicaid. Here in Arizona, we cut back on the adult Medicaid dental benefit. And all of a sudden, whoop up hospitals like this. And then when they start putting it in, then it starts to level off when the economy gets better...


Howard: What was his name?


Rob: William Paiva. Oklahoma State University. It's somewhere in Oklahoma. This guy's awesome. Anyway, so, I put him together with Marko and now they're doing it. But Google goes to him to get medical data. 


Howard: Yeah. Because if you let our ADA amazing mind, Marko Vujicic... I mean just basic algorithm, not to mention machine learning, artificial intelligence... The reason I want it is because my homies believe stuff that is crazy. They might as well believe in the tooth fairy. You ask any dentists in Arizona after two beers: "How long do you think the average posterior composite last?" Mine last forever. Really. And how long do you think an amalgam can... 


Because whenever you find what limited research, there are... Every time I find research, it'll be on like 2017 or maybe a big study, one hundred and fifty molars. While Delta sitting out there with a hundred million claims. But what limited studies you do seem like the average amalgam is lasting fifteen years plus the average posterior composite six and a half years or less, and about 112% of all the dentists don't believe that. Because they say, "Well, that's because the dentist (inaudible 01:14:43) He's horrible. I am all this. Obviously, I walk on water. I mean I could never swim as a child because I couldn't go under the water. I could only walk on the water. And my composites last twenty-five years and Delta could come back and say, "Dude, not even 1% of the composites last twenty-five years. Yeah. 


I got my MBA from ASU. They always talked about the balanced scorecard. And they said it's so important to see the score because you start believing stuff. Man, I've gotten so over at them and I still got two more...


Are you okay on time? 


Rob: Yeah.


Howard: ...because I still got two big questions. So why do you want to quit being an endodontist and work for Pew. Why is that your favorite organization on earth? 


I would almost want to do that because they really need to hear other voices. I'm not sure whose voices they're listening to or why they're listening to those voices, but they've been pushing this dental therapy thing. Their thrust of why they want to do it changes from place to place. Here in Arizona, they had a really difficult political minefield to go because our legislature is mainly Conservative Republicans but with a significant amount of more liberal type Democrats. And what happens is, is that the idea of a dental therapist, a mid-level provider with minimal training who can go out into rural areas are poor places and do and decrease the cost of dentistry, which you and I know is ridiculous. They're going to go out there and that really appeals to people who have a feeling that they need to help socially there. There are people. 


Actually, a Democratic congresswoman and one of the meetings down there asked me and she says, "You know, I'm from Tucson and I've got a lot of friends of mine that just can't afford dentistry and I think this is going to make dentistry cheaper." She says, "But if you decide that you don't want this to happen...." And she was really misinterpreting what we were trying to say. She says, "What do you tell my friends?" And the first thing I said to her is "Well. So, the first thing you can do is fluoridate the water in Tucson. That'll help them a lot more than these dental therapists well." You and I both know that - and that's what I loved about that podcast you did with Jeanette MacLean - because preventing dental disease is a complicated, multi-faceted effort that has to be undertaken diligently over long periods of time and unfortunately with more funding than the politicians want to pay for it. 


But if we did that, we would have a much better world. And, and so they throw this dental therapist things thinking that it's going to correct it. Well that appeals to a lot of the people on the - I don't want to use stereotypes - okay, the left side of the political spectrum. They liked that idea. On the right side of the political spectrum, all they want is what's going to make business get better. What's going to decrease the cost of dentistry and make business more profitable? So, Pew split their attack and they supported a lot of the left wing democratic sort of public health types. And over here, they use the Goldwater Institute and a couple of more conservative groups to push the idea that this is going to be the savior for the private practice of dentistry and that somehow this would really enhance the income of private practice dentist. 


Well, if you and I and every other dentist in the state was busy and we couldn't see another patient because we were so busy and we're booked out two months ahead and we just don't have any openings in our day. "And I'm sorry, I know you're in pain or your crown came off. I can't help you." You know what? Then therapists might help that. But why the heck would some 25-year-old kid in Glendale with a six-figure student loans sitting there with holes in their day? Why would they want to employ a dental therapist? It's ludicrous. Sorry I shouldn't use that word. Sorry...


Howard: ...At least throw Snoop Dogg under the bus. 


Rob: Okay. So, it's Snoop Dogg. 


No, but seriously, it's crazy. And it's not a manpower problem. And Pew believes it's a manpower problem and they have spent two... Well, between them and the Kellogg Foundation, the ADA estimates that they have spent $200,000,000 in the last 10 years to push this dental therapy concept in all the states where they're pushing it. That is a massive amount of money and when I think of how much $200,000,000 could have bought if simply we're giving it away to people. It's just astounding. And so, with that kind of money, I have to believe that they do believe their message. But their message is so flawed that I want to go down there and talk to them. I don't want to say, where do you get this message? Where does this come from? How does this jibe? Because both messages are flat. Your capitalists message on the Republican side is flat... is wrong. Your message on the Democratic side is wrong. 


You know, New Zealand is where they've had therapists for the longest. They've had them there for about ninety-five years. And the dental therapists in New Zealand, despite their efforts at doing whatever the work they do, the amount of kids that entered into hospitals for acute dental infections nearly tripled over the last fifteen years. And, so where's the dental therapists in preventing that? Therapy doesn't prevent anything. It's not a preventive... it's not a group that's going to do dental prevention or preventing dental disease. Because dental disease prevention is not by large a manpower issue.


You know, where it's a manpower issue? It's a manpower issue in Gabon. It's a manpower issue in Burkina Faso where there's one dentist for every fourteen million people. Yes, you've got a manpower problem there. This is not a manpower problem here. And the way that actually a good friend of mine up in Flagstaff just characterized it perfectly. He said a few months ago: It's like trying to cure the smoking epidemic by creating more lung surgeons. That's not how you get people to stop smoking. You get people to stop smoking by preventive efforts. And this is where this whole concept falls down and why Pew hasn't figured that out. They're going to spend $200,000,000, or maybe not them, part of it's from Kellogg, but these groups spend that kind of money on trying to push a concept that can't work versus using that kind of money to push preventive. 


Two hundred million bucks you could put a toothbrush in the hands of every single human being on earth with that. And there's kids in our towns in South Phoenix that I know for a fact don't know what a toothbrush and floss is because on first Give Kids A Smile Day down there fifteen years ago, these kids came in from the Washington School District and their mouths were terrible. They were full of problems. And logistically, we were bad. It was our first time we ever did it. We were trying hard. We are meaning well, but we weren't efficient. And so, I remember at the end of that day, having done eight or ten or fifteen molar root canals, whatever I did that there was a kid who had a swollen face ready to get back on the bus and go. And I said, "No, I'll see him again." They said, "No, he's back. He's gone." And I was like, Oh my God. I cried all the way home. 


So, the next year we had our act together and we really had it logistically. We were just a machine and Bam, Bam, Bam, Bam, Bam. And, we got three times more dental work done at that event than we did one year before all in the same place, all at the Boys and Girls Club on Sixteenth Avenue in Buckeye. The third year, the same kids coming in from the school district didn't have as much dentistry to do. They didn't. The fillings that were there were still there. And, the root canals that were there were good. The, they had some other things that weren't attacked last time. So, I did that. These kids... Their oral health was measurably better and it wasn't because of the dentist doing fillings and crowns. It wasn't because of me doing root canals. It was because we had an army of hygienists that taught these kids how to brush and how to floss. Just by doing that, these kids took care of themselves and two hundred million bucks buy an awful lot of toothbrushes. 


Howard: I just want to end on one note because you've gotten so into overtime...


Rob: I apologize for that. 


Howard: No, no, no. We're all great. But when he said two hundred million bucks, now remember this... So, in the United States, there is two hundred and eleven thousand Americans alive with an active license to practice dentistry, but reality only a hundred and fifty thousand are general dentists that do thirty-two hours a week or more and thirty thousand are specialists like Rob who's an endodontist... thirty-two hours a week or more. So that's a hundred and eight thousand. So, if you took Pew's two hundred million, divide that by a hundred and eight thousand dentists, general dentists and specialists working thirty-two hours a week or more in the United States of America, that's only eleven hundred bucks per person. What are the dues for the ADA for year? 


Rob: Eleven hundred bucks.


Howard: That's what I'm telling you because when you don't join, then they're going to run all over you and you already invested all those student loans, all those years and to come back and say, "Well, I'm not going to ever talk to my mom again because she doesn't know. She eats meat and I'm a Vegan." Oh, shut up. She's your mom and they're all volunteers. Your mom's a volunteer. When you're out of home... When Grandpa Howie takes your phone call. I'm a volunteer. The ADA... It's all volunteers. But that two hundred million, that's our dues. That's $1,100 a year per person. So, pay your damn dues and to shut up the antifluoridationist. They say, "I don't want to fluoridate the water." I say, "Okay, fine. I'll compromise. Just fluoridate the Mountain Dew" Will you pass a lot of that? Because it's equally as stupid. You don't want to fluoridate the water, then fluoridate the mountain dew. 


They come into my office with their baby crying, with a sixty-four-ounce thirst-buster Mountain Dew, pipetting Mountain Dew into the mouth while feeding them Funyuns. When they come back in my operatory, I said, "You can't bring a Mountain Dew." I said, "Do you take your bong to church?" You leave your bong at home when you go to church and you don't take Mountain Dew in the operatory. Because you've got to talk real with these people. You got to keep it in their language and they're just humans trying to get through life even if…


Howard: Anyway, I could talk to you for forty days and forty nights. It's been such an honor for you to come on the show today. Thanks for coming over. And if you could deliver the Delta Guy... I think they don't want to come because it's Dentistry Uncensored and they think I'm going to attack... I just have questions and gentlemen can disagree just like my sister has disagreed with my brother. I get it. But I sure like to talk about it. 


So, you're the godfather of Arizona and I mean that sincerely. Of all my friends, you're the godfather dentist of Arizona. I don't know who else be that role. I don't know who the hell else would be that person. So, if anybody that has a message, you know where I live, send them my way. Thanks for doing this at the end of the long week. Ryan, thanks for working. And, that was an awesome show. 


Rob: I guess really the biggest benefit that I didn't expect. I mean, I expected that there would be certain financial benefits. The advocacy. Of course, I expected that. The thing that I really did not expect to be welcomed the way I was. I was a stranger here. I moved here from another state when I finished my residency program and I didn't know anybody... And, the first place I came to was the dental association and I have made a network of wonderful people who I can ask questions of. I've been introduced to people in all specialties, all walks of life. The generalists, the hygienists... Everybody that's a member of this wonderful, wonderful family that we call the Arizona Dental Association. That's what I really didn't expect, and it was absolutely marvelous and I still, to this day, benefit from the contacts that I've made through this association.



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