Dentistry Uncensored with Howard Farran

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

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Howard Farran:

It is a huge honor today to be podcast interviewing my buddy for probably 30 years, Richard Litt. How are you doing, Richard?

Richard Litt:

I’m doing fine, Howard. Thanks.

Howard Farran:

All right.

Richard Litt:

I was looking back in preparation for talking with you. I pulled out one of your early Farran Reports, where you interviewed me. It was 1995. You’re looking at 30 years.

Howard Farran:

My gosh, that was. That was a long time ago. That was funny. We started that newsletter in ’94.

Richard Litt:

Yeah.

Howard Farran:

… not knowing the internet was going to come out. Then in ’98, the internet came out. I said it’s no longer me sending you a letter. Now, it’s interacted, so I took my name off the Farran Report, made it Dentaltown.

Richard Litt:

Sure.

Howard Farran:

Now, who would have guessed that the internet would have jumped into the phone and then podcast come out. Now, I’m podcasting you on Skype, and they’re watching it in Katmandu. How cool is that?

Richard Litt:

That’s cool. Here we are 30 years later and I’m still looking at that report. Everything we talked about at that time unfortunately is still true. We’ll talk about that during podcast.

Howard Farran:

You’re the most beautiful, bald dentist out there.

Richard Litt:

You’re the most beautiful, bald interviewer I’ve ever interviewed with.

Howard Farran:

You know it’s funny, when I got on, he said, “You forgot to shave.” The only reason I stopped shaving is because I shaved my whole head every morning for so many years. I was just curious what the hell I was shaving off, so I haven’t shaved for two weeks. That’s why I have this facial fungus. Just in case, there’s one person in Schengen who doesn’t who you are, I’ll read your bio. Dr. Richard Litt received his D.D.S. Degree from University of Detroit in 1965, and his Master Degree and certificate in Orthodontics from Northwestern University in ’69.

Dr. Litt was Professor and Chairman of Department of Orthodontics at the University of Detroit from ’69 to 1980, and Clinical Professor and Director of Post-doctoral Orthodontics at the University of California, San Francisco from ’80 to ’86. Dr. Litt is a member of the American Association of Orthodontics as well as many other groups. He has published numerous articles. He is recognized one of the most dynamic educators in orthodontics today. He was a member of the European Orthodontics Society, the Societe D'Orthopedie Dentofaciale in France, the Edward Angle Society of Orthodontists. He was the Orthodontic Consultant to the Cleft Palate Center at Children’s Hospital of Michigan, and the Director of Orthodontics for Pediatric Dental Residency Program.

Dr. Litt started FORCE in 1985. FORCE is the first and only extended continuing education program in orthodontics patterned after a graduate school education, and presented by a qualified, credentialed specialist for both clinical and university experience. FORCE was assigned to educate the practitioners who want to add orthodontics to his or her practice, or expand their present orthodontics service to the next level. You are the most world’s [inaudible 00:02:53] orthodontic educator period. I don’t know who would be second. It’s just you. You run the Ortho department for two different universities in San Fran and Detroit. I took your course back in the ‘80s and I think I took it again in the ‘90s. I set a bunch of my friends your way. You’re just the man, Richard. How are you doing?

Richard Litt:

Well, thank you Howard. Thanks for that. Every one of us has a place. I decided a long time ago, that if I was going to be man that you call it or above, it would be my place, it was going to be in the area of orthodontic education for the general practitioner. That’s really pretty much the most unique part of my professional life. Once I left the university in 1987, I left to see San Francisco and I just said that somebody needed to teach the general practitioners in the pediatric dentist orthodontics the way an orthodontist does it.

I’ve spent the last 37 years of my career doing that. As you said, we did couple of courses in Phoenix. You did send a lot of people to me, and hopefully they’re all doing well and enjoying the things they learn, and making a good living and serving their patients well. That’s really where I pointed my interest. After I left the academia and left the university in 1986, I spent most of my career trying to educate some pediatric dentist to a standard of care that orthodontic education deserves.

Howard Farran:

Richard, I call my program, “Dentistry Uncensored,” because it just is, and I like to talk about the 4,000 elephant in the room. I want to start with something that everybody gets mad at me when I talk about, but I just want to just throw it out there. It seems like there’s nine specialties in dentistry and eight of them … Say, the orthodontist, he’ll help you do anything you want to ask him and all, because he knows you’re going to do the incisors, and you’re not going to retreat molars. Neurosurgeon will help you do anything with extraction, because he knows you’re going to send them [inaudible 00:04:46]. It seems like the orthodontist do not want to help any general dental dentist. They just say, “You just send it all to me and I’m not going to help you from Invisalign to a class one molar.” Am I just sensing that or do you sense that too?

Richard Litt:

No. I think it’s changed a lot in the last 30 years, but nowhere near to where it should be, and no 100% agreement, that’s one of the reasons I decided to do what I was doing. As long as you raised that question, it is the elephant in the room. For the first, probably 15 years that I was doing this, I was in … Frankly, [inaudible 00:05:19] I love the orthodontist. They still didn’t believe that orthodontist-

Howard Farran:

Dude, you are black bald.

Richard Litt:

Yeah. That’s a good way of putting it. They didn’t believe that an orthodontist from within the fraternity should be out there teaching general dentist. People would come to me actually. They wouldn’t come to me. They bump into me accidentally, because I literally remember walking down the street and seeing friends who used to be my friends, whom I golf with and was on the faculty, but then they crossed over the other side of the street, because I was teaching General Dentist Orthodontics. That was a personal thing.

The reality of it was that someone says to me, “We are teaching general dentist orthodontics,” and they did it with a … it didn’t have a nice tone to it, it was a critical tone, my answer was, “Who do you think I was teaching at the university?” Those were general dentist. They’re just 10 of them at a time. Now, the difference is I’m teaching 50 at a time. The idea of teaching general dentist is okay in the orthodontist mind, as long as we maintain a small number of people that were training, and putting out there in a competitive environment. I understand the business side of it, but when I started doing this Howard, I took some surveys at first, because I knew I was going to be criticized, and if you want ostracized.

I started evaluating the referral patterns to general dentist head before they took my course. To make a long story short, what I found after the first five or six, seven years of doing this that the general dentist, that I had the opportunity to train were doing a lot of orthodontics. They were doing it to the standard of care that an orthodontist does it. They were referring 400% of the number of patients they were referring before they took the course. Some orthodontists bought that and really actually started getting calls more from orthodontist saying, “Thanks. You’re doing a great job. My referrals are much more educated now. I’m actually seeing more referrals.”

By at large, the major part of the orthodontic community still feels what you just described that we shouldn’t be teaching the general dentist orthodontics. I can give you some reasons and some of them are valid, unless they get the proper kind of education. You mentioned that eight of the nine specialties have no pause with teaching general dentist orthodontics. Let me tell you two reasons, not two reasons, two aspects to that same question. Why isn’t orthodontics taught at the undergraduate level in the dental school? Then extending that, why don’t we teach or why aren’t orthodontists comfortable teaching general dentist orthodontics outside the university?

Orthodontics is different. That doesn’t mean it’s better, it’s worst. It’s different. Mean difference is a unit of crown and bridge or a unit of endo treatment can be measured in matter of hours, maybe days if you have to wait for the lab work. Therefore you can do it on a repeatable basis over and over and over again while you’re in dental school. You can’t teach a general dentist effectively how to do orthodontics or crown and bridge by doing 100 restorations. One unit of orthodontics takes two to three years to complete and then another two to three years if it worked and to what extent it worked, and to what extent it’s going to change.

The nature of the treatment is much more longitudinal therefore … from my management standpoint, much harder to do in dental school. I understand that. It doesn’t mean it can’t be done or shouldn’t have been done, but that was possibly a legitimate part of the argument about [inaudible 00:08:26].  Again, I can show you how to do an upper root canal. In a matter of an hour, you can do 50 of them and you’re pretty good at it. You can’t do that with orthodontics. The other aspect of it that orthodontist try to use as why they shouldn’t be teaching general dentist is that it’s based on totally different principles, and then what we learned in dental school. In dental school, we don’t understand, we don’t study.

Any of us don’t study bone muscle interaction. We don’t study craniofacial growth and development. We don’t study genetics. We don’t study foreign function relationships. The fundamental basis of orthodontics is very different from the things that dentist learn in dental school. I think back to when I first started looking at this and I have this … I run two departments. Let’s go back to the University of Detroit. In 1970, I became the Chairman there. I spent the next 11 years trying to integrate an orthodontic program into the general dental curriculum. I had 10 hours in the curriculum during the four years. Our crowns and bridge department at the University of Detroit at 900 hours.

The offices was obviously on crown and bridge, because those were the powers that run the dental school, but just as important that when a young man or a woman gets out of a dental school, there’s really nothing on the state boards that has required any information about orthodontics. The students were looking what they had to complete, and what they had to learn to get out of dental school, and then secondarily to pass their boards. The faculty was primarily interested in teaching graduate students. The gap just went unfilled. The problem for me is not only that … you just used the black bald or ostracizing people who try to teach general dentist, it lead to a bunch of short courses, misinformation and inappropriate education that was finally to become available for the general practitioner outside of school. People from within the community, like myself, were not willing to do it. What they got was others fulfilling the void. I’ve spent probably 20 years in my career trying to undo some of the misinformation that was spread out, that was given to general dentist by unqualified educators if you will.

Howard Farran:

You want to call any out or any camp site out or any …

Richard Litt:

No. I don’t want to call any camp site. I would tell you that there-

Howard Farran:

It is Dentistry Uncensored, and no one will argue with two old, bald guys.

Richard Litt:

No. It’s okay. It’s not a personal thing. It usually is-

Howard Farran:

No. I know it’s not personal, but I’ve always told these dentists, you’re going to these short term Ortho courses, whether it be Six Month Smiles, Six Month Brace whatever. I always say, first, get your foundation. Go see Richard and learn classic orthodontics that your orthodontist does. That’s the base of the pyramid. Then you can go up and learn something, aligners and things like short term. Do you agree with that assessment or not?

Richard Litt:

Not only do I agree with that, I’d pay you to keep saying it. I couldn’t say it any better. It’s exactly what I say-

Howard Farran:

Why don’t do you add editorial about that for Dentaltown magazine? Why don’t you write an opinion piece on that? That if you want to do short term Ortho, Six Month Smile, Six Months Braces, power [inaudible 00:11:30], titanium aligners. There’s multiple cams. First, build out the base of the pyramid with a classical ortho.

Richard Litt:

Well, that’s actually what I leave. How to get that-

Howard Farran:

Well, it’s true. It’s just absolutely true. It’s not something you believe. It’s math. It’s physics.

Richard Litt:

No. I agree with that. It’s not you can name all those in fast braces, high-speed braces, Six Month Smiles, all of things. All of those are aimed at showing the dentist how, and how to do it and how to do it quickly, and how to make money, but nobody talks about the when, the why, and the underlying principles about it.

Howard Farran:

The diagnosis and treatment plan.

Richard Litt:

Yeah. That takes time and that takes effort. That takes energy. Six Month Smiles, for example, or high speed braces or fast braces, all of that is the first three to four to five or six months of orthodontics. After that, if you don’t care about finishing the case or establishing occlusion, or making sure the CO and CR are in harmony and all the other fundamental things that we need to think about, you can do six months brace. Somebody finishes my program. They can do Six Month Smiles. Just stop after you line up the six upper and lower of your teeth. That’s what I call, “Half Halfs orthodontics,” rather than high speed braces. If you want to do that, you can. You talked about Invisalign.

Most of those programs are selling appliances or a technique. They’re not selling an orthodontic education. Invisalign is a classic example of outstanding marketing, selling a relatively straightforward, simple appliance. It’s a product. People say, “I’m an Invisalign orthodontist.” I ask them, “Have you ever gone out telling everybody you’re a 557 [inaudible 00:13:10] dentist?” That’s what it is. Invisalign is a tool that some people use. It has a significant limitation. It has a certain place especially in our adult [inaudible 00:13:21] population, where is that a conscious, even to use Invisalign.

A year ago, I was asked by the people who were started Invisalign before and to all these other large corporation and stuff. Would I be interested in teaching some courses? When I said, “Yes.” My premise was, “The appliance is great, but before you start using Invisalign or any other quick treatment protocol, you need to understand as you just said, diagnosis, treatment planning, bone-muscle interaction, long term stability, instability issues in orthodontics. You need to understand all of orthodontic diagnostic modalities in order to make appropriate diagnosis, and then decide which tool that you want to use to solve the problem.

The problem then is if all you have is that one tool, everything looks like a perfect case for that tool. That old saying, “If all you had was a hammer, everything looks like a nail.” If all you had was Invisalign, everything looks like a non-extraction, simple alignment case. Unfortunately, that’s not true. It is a very effective tool and a very limited number of patients. I don’t have any problem with the tool. I have a problem with the people using it who don’t have any education to understand what they’re doing.

Howard Farran:

That Invisalign, that’s been a hell of a stock, hasn’t it? Five year-

Richard Litt:

It sure have.

Howard Farran:

Twenty to sixty. What a stock that thing’s been.

Richard Litt:

From a business standpoint, it was a genius marketing plan.

Howard Farran:

Yeah. Now, is it true that the patents are coming to an end and there’ll be more competition with the … What is it?

Richard Litt:

Yeah. That has happened. I don’t follow that very closely, but from what I understand, that happened a number of years ago. You have other corporations that have all added a series of numbers of now. There’s Clear Correct and there’s half a dozen other. Actually, you raised a really good point and we can talk about it right now. I was doing a presentation at the San Diego Dental Society meeting not that long ago, and someone asked me about Invisalign. I just happened to have seen that day before an advertisement that showed, “You can now order your trays … You, the patient, can bypass the dentist now and order trays and a paper work that you can design your own treatment, and send it to a company that will send you back the trays. Do you remember the company called, “Sharper Image”?

Howard Farran:

Yes.

Richard Litt:

And the Catalog. Well, they used to have to an ad where you could buy this box. Inside that box was a kind of impression material. You can stand up, put your foot in that box, taking impression of your foot, and send it the lab that make orthotic and we don’t need the podiatrist anymore. Well, they’re doing that now with clear aligners, so-

Howard Farran:

Who’s doing it?

Richard Litt:

Not only has a patent gone and companies like Clear Correct and so many other big corporations are selling clear aligners, every orthotics applied company has a division selling clear aligners now, but you don’t even need the dentist anymore. You can go right to the patient. You can buy impression material and send it the lab.

Howard Farran:

You know the name of that company?

Richard Litt:

Smile something. I don’t know off the top of my head, but I can get it to you at a later point.

Howard Farran:

Okay, yeah. Send it to me. That’s amazing. Hey, speaking of … you said ortho takes two or three years not to get off topic, but we see advertisings for things that accelerate ortho.

Richard Litt:

Yeah.

Howard Farran:

Propel, things like that.

Richard Litt:

Sure.

Howard Farran:

Has any of that got your attention?

Richard Litt:

Yeah. It’s got my attention, and I would be very excited to see it happen. The only one of all those things that’s showing any evidence that it actually has some degree of speeding up or a tooth not moving is the controlled trauma. It started with the Wilks brothers doing their surgical procedures, bario and ortho combination, where they lay a flap and do quarter academies in between all the teeth, and then you line the teeth. The traumatic injury increases cell turnover rate and therefore, speed up a tooth moving. It’s a rather aggressive and a major surgical intervention and it’s really expensive.

Then somebody got a good idea of, “Maybe we can do interproximal micro traumas.” Similar to Propel and so many of these ideas. They’re trying to do that by changing cell turnover rate to speeding up tooth moving. Wonderful biologically sound concept. Not a shred of scientific evidence available yet, anywhere in any publication that it is, any clinical significant  effect of speeding of treatment. Is there hope? Yes. There’s hope in terms of injectables. There’s hope in terms of controlling things like injecting prostaglandins into the periodontal ligament.

It is actually yet a really good question. That is really probably the forefront of orthodontic research at most of the universities today. A number of years ago, the functional appliance has worked. Then it went to mechanical things and technical things. Now, it seems to be that the research that I’ve seen is in the area you just asked about. What are the possible ways in which we can speed up treatment? You know Howard, all of that has been triggered by one thing.

Howard Farran:

Money is the answer. What’s the question?

Richard Litt:

That wasn’t what I was thinking. The bottom line of that too what has been triggered by is the same thing that triggered Invisalign. It’s the same thing that triggered Clear appliances. The same thing that triggered all these authentic appliances and the wires and all that, adults seeking orthodontic treatment. The only reason adults are seeking orthodontic treatment, is because we have made orthodontics so efficient now that the orthodontist can handle. The trained orthodontist can handle 500, 600, 700, 1,000 cases a year in his or her office.

When my predecessors started two generations ago, if they were lucky, they started 50 to 90 cases a year, and they do everything by hand. We can deliver orthodontics much more seriously. We’ve had zero population growth over the last couple of generations. We have far more people practicing orthodontics. All of a sudden, orthodontics became available to the adults. We need more patients. That’s why adults are now seeking orthodontics. Once that happened, we started looking at how we satisfy the adults. One of those things is speeding up treatment, because they would come in to the office and say, “Okay. Can I do this without braces? Okay. Can we do this in six months instead of two years?” That’s the trigger.

Money, yes, of course. Money is the underlying basis for all that, but still it’s the adults entering orthodontics that has changed the nature of all those things today. When I got out of graduate school, if I saw two adults in a year, it was a lot. Today, 30 to 40% of patients in orthotic practice are non-going adults over the age 18. Many of them are in their 50’s, 60’s and 70’s. It’s a different world today. The speeding up, the treatment is a very hot commodity. I think there will be some enhancements and improvements in it, but until we see the evidence, I think it’s just another marketing report.

Howard Farran:

Now that it’s gone for two adults a year to 30 to 40% of orthodontics practice, is that changing the open bay concept? Does a 50-year-old man want to be sitting in an open bay with two 12-year-olds on each side of him?

Richard Litt:

No. That’s absolutely true. The design of offices is changing. Most orthodontics offices, they used to have a quiet room, where you have a management, usually, the pediatric dentist. Now, they have adult rooms. Many of those still have an open bay, but there’s at least a couple of [inaudible 00:20:30] maybe more in every practice, because adults don’t want to be sitting with six other kids around the mini circle and somebody’s crying or somebody’s vomiting with an impression tray in their mouth. It’s very different from a physical development standpoint in terms of ostracize.

Howard Farran:

That was the first market read that I learned to get tino orthos when adults are coming to me and saying, “I want to get ortho, but I don’t want to go in there with … sit on my briefcase and be next to five kids open bay. They say that orthodontics only does kids. That’s where I saw the first opening for general dentist to get involved. I want to start back to the very beginning.

Richard Litt:

Okay.

Howard Farran:

The thing that always was my beef about Ortho education is that these dentists, they’re always the first to tell you they graduated 300,000 students on. They never know their math to the fact that the taxpayer picked up half the tab of that dental school. When you graduate from law school, med school or dental school, the lady working at the waffle house, her tax is paid for half a year education. In some cases, it might be 75% of your education. Then they send these kids back to 19,022 towns in America, half of which don’t have any specials. They don’t have an endodontist, orthodontist. They send these kids back and train.

Then that kid is coming into the dentist every six months with some facial problem that could have been fixed intercepted, and the dentist is asleep behind the wheel, because they don’t understand what’s going on. By the time everybody figures out, this girl’s going to smile with her upper gums showing or doesn’t have a chin or something like that, then they need orthognathic surgery. I always thought that was the true crime that the rural kids get intercepted treatment. That’s why I always thought that every single general dentist has to be completed classically trained in orthodontics just for diagnosing and treatment planning.

If you just sit there and say, “Oh, your daughter’s six. She should see an orthodontist.” That’s not how you sell. You could only sell with passion. It’s when you’re looking at mom and dad saying, “The orthodontist can fix this right now in 12 months.” If she finishes growing, the only they’re going to fix this is with an oral surgeon. You have to go in there now. That passion, that feeling that really get mom and dad to go to the orthodontics that the general dentist has to be highly educated on the diagnosing and treatment planning.

Richard Litt:

I couldn’t agree more. You remember what I just said a minute ago, is that what I saw after five or six years of teaching general dentist is they were all doing orthodontics, but they were sending four times as many patients in orthodontist.

Howard Farran:

I know.

Richard Litt:

Simply because they recognize it. I actually did start giving, as I said, some positive feedback from orthodontist saying, “There are some positive benefits. Yeah. At first, we thought you were taking money out of our mouths,” but we are seeing more patients and they’re better educated patients. There’s no doubt about that Howard. You and I are singing the same song. I believe-

Howard Farran:

It was the same thing when I got out of school, god this is going back to different mindset. When I got out of school, University of Missouri can see everybody in that building, the two guys that were placing implants, behind their back, they were all called, “Butchers, crazy man, sticking titanium, bars, ramus.” They were presented as nut balls. When I got out, I never diagnosed and treatment planned an implant for a sinus lift. I totally bought into that. You’d have to be a nut to be doing implants.

It wasn’t until I flew all the way to the University of Pittsburgh and went to the Misch Institute and was telling Misch what I was thinking. Some of those early implantologists literally had their license. The first case that failed, the state board would take their license away. Now, there’s 275 companies selling implants. People don’t realize that 2016, go back to 1980, and you are a quack doing that stuff. God, it’s amazing how everything’s changed.

Richard Litt:

It sure has. That’s a good example too. Yeah. It’s basically the same issue. If you don’t have the skill to diagnose the problem, you don’t see the problem, then nobody’s going to get that treatment. That’s the biggest problem in not educating general dentist in dental school. You just said the number of implants companies that have crapped up. Why do you think that general dentist, all these courses have crapped up; Six Month Smiles, high speed braces, Invisalign, Clear correct? Why have they crapped up? Because there was a void that marketers and businessmen saw that they could sell to the general dentist. General dentist been educated the way they should have been in dental school, those instance wouldn’t exist. People would see the dentist, would see the flaws in them, and be looking for a better education. No question about it.

Howard Farran:

How do my homeys, how do they learn orthodontics right now? What’s your website?

Richard Litt:

The website is FORCEINT.com.

Howard Farran:

FORCEINT.

Richard Litt:

FORCE International.

Howard Farran:

F-O-R-C-E-I-N-T. FORCE stands for Faculty for Orthodontic Research and Continuing Education. FORCEINT.com. How is it? All lecture? Can you do it online?

Richard Litt:

That’s a good question. I’m still doing a number of seminars, in person seminars. I am, because of what you said the first few minutes we were talking here, the [inaudible 00:25:46] online education and for example, what we’re using right now, Skype and JoinMe and so many other available technologies that are online. I am moving in that direction, but I still offer my comprehensive orthodontic course in a number of cities across the US and Canada. I want to come back to the Canada thing in a minute, because relative to the other question you were talking about kids in small town is not getting access to orthodontics.

Howard Farran:

Why would you do ortho in Canada? They’re just going to get their teeth knocked out the hockey puck.

Richard Litt:

Yeah. If they’re wearing retainers, I believe they’ll all stay in the same place when they get it with the puck. We’ll come back to your question in a minute about the education courses available and then how we deliver it. Let me talk about Canada for a minute. Canada became a very successful educational environment for me, because there were a limited number of orthodontist and there were thousands of kids in small towns. Some of them way up north, far away from an orthodontist. Their parents would have to take them four, five hours in a car to get to an orthodontist.

The generalist and the pediatric dentist in Canada had to learn how to do orthodontics. There was nobody available to do it. My product was very appealing to them. Therefore, it was well accepted all across Canada. I gave courses from Halifax to Victoria for years. I still do. I’m going next week. I’m on my way up to Vancouver to do another comprehensive course. I still do courses in Vancouver, in Toronto. We did them in Ottawa, all across Canada. Now, I’ve done it in two major centers; Toronto and Vancouver and the Canadians will try to go to those places.

To go back to what you were asking me where someone can learn orthodontics. Our courses are offered live in a number of cities. Right now, Vancouver, Toronto, Detroit. We’re starting a course in San Diego, California. I’m also doing one in next December and January in San Juan, Puerto Rico. The primary areas are Detroit, Toronto and Vancouver and San Diego. Also, about 10 year ago, we put our entire program online. Someone could take the FORCE program by going to our website and taking the comprehensive course online.

When I do it live, it is essentially seven and a half to eight days of lecture, three and a half days in each of two segments one, one month, one the following month. When we do it online, there’s 20 hours of lecture, me standing in front of a video camera and doing the exact same program. Then we had a lot of supplemental issues. We have a lot of clinical videos. We have hands on technique videos. We have basically all the tools that you need to learn orthodontics can be done online by looking at the FORCE online program.

Howard Farran:

If I were to learn ortho from A-Z online, it’s 20 hours long at FORCEINT.com?

Richard Litt:

Yeah.

Howard Farran:

Twenty hours?

Richard Litt:

Yes, but that’s only the lecture series. Now, there are clinical videos. There are technique videos. I’ve always said, not just the FORCE online or the FORCE lecture series, the comprehensive course, that’s just the beginning. I’m not foolish enough to believe that I can take any general dentist no matter how smart they are, and teach them how to do good, effective clinical orthodontics in eight days. It’s not possible. I can teach you how to get started. I can teach you how to think like an orthodontist, but we have ongoing study groups that meet in multiple cities across that US and Canada on a regular basis. I, for example, I go to Vancouver, Calgary, Toronto, Ottawa, San Juan, Puerto Rico, Detroit, several cities in the Midwest. We meet three to four times a year with the participants who’s graduated from the course. They bring their records and their cases. It’s a study group. You learn from each other. I’m just the man who facilitates it-

Howard Farran:

Can I be your luggage bellman in San Juan, Puerto Rico?

Richard Litt:

Absolutely. I’ll share my frequent fly miles with you.

Howard Farran:

Oh my god. That is the coolest place on earth.

Richard Litt:

Howard, that is the reason we started online program, because the traveling is difficult. I’ve had people take my course in Dubai. I’ve had people in japan take the course-

Howard Farran:

How much is your online course?

Richard Litt:

Well, let me back up. The course in person is $8,995 for both sessions.

Howard Farran:

Two lessons. How many days?

Richard Litt:

That’s three and a half days each session. Thursday, Friday, Saturday and Sunday half a day. Then the online course, if you take the course online, there are certain things that you’re not getting. First of all, you don’t have the opportunity to talk and ask me questions, because it’s just video clips. You watch the whole thing from start to finish. It’s interactive. You can play at any point, go back and use it any way you want. You don’t have the opportunity to ask questions. The tuition for the online course is 4,995. If then, and we’d had a number of people do this, if after you’ve taken the online course and now you have the basis and the fundamental starting point, now you can come back and take the live course and that 4,995 is applied to the $8,995 tuition.

Howard Farran:

That is so cool.

Richard Litt:

For the $4,000 balance, you can retake the entire course live. The live course also has a hands on clinical program that obviously you can’t do online. The last day and a half is working on [inaudible 00:30:52].

Howard Farran:

Dude, you know what your best marketing in the world would be?

Richard Litt:

You.

Howard Farran:

Your best marketing in the world be that 20 hours online, take the first hour or two or whatever and make an online … put it up on Dentaltown for free, and then they get to see you. There’s 210,000 dentists on Dentaltown, and 40,000 downloaded the app on the phone, which you can take the online CE on the android phone and the iPhone. Then they get to see you for an hour and anybody that sees you for an hour is going to fall in love with you, and know that you mastered the concept. You have really high likeability factor. At the very end of the video and say, “You just completed one hour, two hours. If you want the remaining 18 hours, log on to FORCE International and give me your credit card and finish it.”

Richard Litt:

Well, we did. We started that with you. You have one of our courses online. You have the sweeping away, the missed fact versus fiction courses.

Howard Farran:

Well, what year was that though?

Richard Litt:

That was a couple three years ago.

Howard Farran:

Yeah.

Richard Litt:

That was intended to do that, to just what you said, to give people the opportunity … Before, I don’t care who you are, whether John Croisser or Frank [inaudible 00:32:01] or anybody. Before you’re going to dump that money into taking a course, you want to see who that person is and how do they project themselves, and do they legitimately have the information and the ability to teach me. We offered that course. My hope was that they have interest in people contacting us and taking the online course, or taking the live course.

Doing this podcast with you is the same intentions. I’m sure it does for you as well as for me, hoping that will give people the opportunity to hear what we do, see what we’re doing, and then follow through by either taking it live or online. There are probably some other things that we can talk about I might be able to do in conjunction with you in terms of the ortho town or your video programs available. I’m certainly amenable to online marketing and to video marketing. The whole idea. I’m still going strong. My whole idea is to still get as many people into the room as I can, because it’s in my personal best interest. Obviously, it’s a business fan, but it’s also in the best interest of dentistry and the best interest of patients seeking orthodontics.

Howard Farran:

A lot of my very close friends took your course. They all just loved it. They love you and the course.

Richard Litt:

Thank you. I still remember Mike Detolla and some other people that you-

Howard Farran:

Bob Savage, Tim Taylor, Tom, all of them.

Richard Litt:

Sure.

Howard Farran:

It was just amazing. This is Dentistry Uncensored. What are the controversies in orthodontics? Back in the day, one of the reasons that I started in ortho, back in ’87 and learning from you is the fact if I sent 100 cases to the orthodontist, 100 out of 100 had four bicuspid extraction. It seemed like they were doing the ortho in eight to 12 months and spending a year trying to close that space over the … That’s really faded away a lot. What are the big controversies today?

Richard Litt:

That’s probably still the single biggest controversy. Even though all the data is in, the issue of extraction versus non extraction is still one of the major controversies in orthodontics. There are people today, not too many orthodontists, but a lot of other general dentist gurus that are selling the idea, and even some orthodontists selling the idea that we don’t take out teeth anymore. That is actually Ludacris. There’s still some really supposedly intelligent people in making those statements. There is still a battle.

There are people who I have great respect for and unfortunately been scoped, actually is one who passed away recently who was constantly trying to defend, like I do, the issue of orthodontics needs bicuspid extractions in a certain percentages of our cases. Let me take your statement and say 100%, 100 out of 100, probably a little bit of an exaggeration. I know you’re not all [inaudible 00:34:39] exaggeration, but that’s probably a little bit of an exaggeration. I have a slide in my presentation that shows the history of extractions in orthodontics. If you go back to 1909 when orthodontics became the first specialty, Edward Hartley Angle was the father of orthodontics.

He never believed that extractions were necessary out of ignorance. He didn’t have any idea. We had not research. We had no history of success, no history of instability or stability after treatment. For the first 20 years in orthodontics, there were zero extractions done. What happened then was someone, his students who became world renowned figures, Charles Tweed right there in Tucson, Arizona and Calvin Case, and other who were students of Angle, treated patients non-extraction for years. It took them about 10 years before they realize all these expansion stuff collapsed when you let go of it sooner or later. The pendulum swung the other way. In 1940’s, 70% of patients went to an orthodontic office, received bicuspid extractions. The reason, because of-

Howard Farran:

1940, it was 40%?

Richard Litt:

No. It was zero percent until about 1930. Then by the 1940, it was up to 70%. That was because Calvin Case and Charles Tweed had shown that while they listen to Angle to get their education, they tried what he told them to treat everybody non extraction, and a significant percentages, their cases were collapsing back to where they were before. Every case that they try to expand the arches on, specially the lower arch would rebound back. The crowding would come back completely. They turned around then and decided to extract four bicuspids. They overdid it. They overreacted.

The incident of extraction stayed high in the ‘40s and the early ‘50s. Then we gradually began to see that we were over retracting teeth. We were getting too flat of facial profile. We had a specialty. We were extracting cases that probably what we call, “Borderline,” today, but we’re being treated with extractions. The incidents gradually went down. Went down to maybe, instead of 70%, went down to 40%. When I got out of graduate school, it was about 40%. That was 1969. Then something else changed dramatically.

Early treatment became a fad. As we did early treatment, and I’m not talking about 6:30 in the morning. I’m talking about seven, eight, nine, 10-year-old kids. When we started doing early treatment, we realized something that has changed the facial reaction on non-extraction issues. That is we saved the leeway space. It’s two most important appliances I own or a lingual arch and transpalatal bar. I can save the leeway space. I can significantly reduce the incidents of extractions. Tony Gianelli of Boston University a number of years ago in the ‘70s did a beautiful study, a simple one. He looked at 100 consecutive kids who came into the clinic, there in the ortho department, and 77% of them had 4mm or less of crowding. Another 7% of them, now we’re up to 84% had 6mm of crowding or less.

Only 15% or 16% of the kids had enough crowding to require extractions. Why are we extracting teeth in 40% of the cases? Because we weren’t saving the leeway space. In addition to that, there are other reasons that require extractions. For example, by maxillary proteus infections, who have a soft tissue proteusal problem and it can’t be resolved without taking out teeth. The incidents of extractions went down in orthodontic practices. Again now after the 1980’s until the 1990’s to about 20, 25%. Maybe in some practices where you see only adults or older patients. You don’t have the opportunity to save the leeway space. Maybe it would be down to 20, 25%. In young pediatric oriented practice, it might be down to 15%. Then there are other-

Howard Farran:

Explain the leeway space. Some kid might not get that.

Richard Litt:

Okay. The leeway space is a difference between the size of the erupting cuspid and first and second bisuspids compared to this media distal diameters of primary canine, primary first molar, primary second molar. In the lower arch, adults or parents don’t understand this either, when you tell them, “I’m putting the space maintainer, because the permanent teeth are smaller than the baby teeth.” They look at you funny. If you look at the wisp the three, the four and the five, that’s the lower cuspid, first bi and second bi, compared to the C, the D and the E, that’s the primary canine, first molar and second molar. There’s 2 ½ mm of difference on each side.

If you save the leeway space in the lower arch by putting in a lingual arch, I have five extra millimeters of space to unravel the 5mm of crowding into the anterior. There’s 2mm in the upper arch. By saving the leeway space, we can significantly decrease the incidents of extractions, but it isn’t going to zero, because there are people who are proteuses. There are people who are hyper divergent or have long faces, and they tend to crowd up overtime. There are aesthetic issues or people who are only slightly protrusive, don’t like it. Therefore they prefer to have their teeth moved back. There’s all kinds of variables.

If you look at the data today, our journal suggest that if you interview every orthodontist in the US and Canada, you’d find it somewhere between 15 and 25% of the patients into office require extractions. Maybe a guy who believes in a lot of interproximal stripping, who does a lot of early treatment, who does palatal expansion and some other procedures that we can use to decrease the incidents of extraction, maybe you might this little as 15%. When I hear people stand in front of an audience and say, “I haven’t seen an extraction case in 10,000 cases.” That’s 15 years of my practice. I believe that 20% of those patients are being treated with no practice. I’ve said-

Howard Farran:

That’s just part of the human condition. If you’re an extremist … [Inaudible 00:40:01 ] dentist say, “I’m metal free in my practice.” Really, you’ve never seen in one incident that amalgam would be better? You don’t even have, but then they’re … and they go, “I’m metal free.” Do you fly metal free airplanes? Do you drive metal free cars? Really? When someone says that they don’t do any extractions, that’s just a red flag that they can’t think. They’ll normally think everything’s black, white, left, right, up, down. You’re just not smart if you’re an extremist.

Richard Litt:

Absolutely true, but you’d be surprised at how many people … Certainly, it’s been taught to the general dentist. Let me tell you why. Let’s look at the economics of it. When I do an extraction case, and I’m going to give you the figures relative to Metropolitan Detroit or the midsternal region, having an extraction case, four bicuspid extraction case takes about 20 to 22 months of treatment time. It takes probably somewhere between two and a half and three and a half hours of chair time, not all of that is the orthodontist doing it, that’s the staff too. Average fee in Metropolitan Detroit area, somewhere between, let’s say, 5,500 and $6,500 for a four biscuspid extraction case.

Now, a non-extraction case takes about 30% of the chair time, because as you just pointed out a minute ago, the significant amount of time is taken by trying to translate teeth through bone to closing extraction site. The average treatment time for a non-extraction case is probably 40% less than an extraction case. The mechanics are simple. The side effects are fewer. It is infinitely easier to treat a patient non extraction that is extraction. It’s infinitely easier to treat a patient with cancer with aspirin than it is with chemotherapy too.

Just unfortunately, it doesn’t work. What we’ve been doing is, we still do, we charge the patients who get non extraction treatment a higher fee than they should be charged relative to the fact that those patients next to them is having four bisucpids extracted and paying almost the same fee. The range in fees in 10%. The range in effort and time and risk is about 40%. Therefore, wouldn’t you be smart from a business standpoint to treat everybody non extraction? It make a lot more money.

Howard Farran:

Let’s keep going with the non-extraction. The one thing I’ve also noticed in the 30 years of being a dentist is that some countries like Germany, I’ve realized that … Americans pull your four wisdom teeth, because they exist. A lot of people believe I’m pulling these four wisdoms, could you see on the panel, these impacted wisdom teeth, then you see the lower anterior is crowding. You’ll say these two wisdom teeth are pushing all these teeth and the incisor collapsing. That’s a huge … More dentist in Germany are more likely to say, “No. The erupting wisdom teeth do not cause mandibular anterior crowding than in America.” American does-

Richard Litt:

Yeah, that’s probably true, but … The ones who have listened to me will know that there’s no relationship. The one’s who are-

Howard Farran:

Well, talk about that, because I firmly believe half the dentist and I’d say to believe that those impacted wisdom teeth are causing-

Richard Litt:

Hey, I did too, because when I got out of dental school, the old surgery department told me that when the wisdom teeth come in, they cause lower incisor crowding. Then we have a number of studies done, which side of Toronto a number of years ago, did a beautiful study, “The Burlington Growth Centre,”v outside of Toronto, where they had a number of … I think they were 25 in each of three samples. Then one sample, they had a group of children that had no wisdom teeth, congenitally missing. Another sample, exact sample, same number of boys and number of girls, same average age, et cetera. The only agreeable was the presence or absence of the wisdom teeth.

On one sample, they had no wisdom teeth. Another sample, they had erupted wisdom teeth in position. Then the third sample, they had [inaudible 00:43:32] impacted up with the wisdom teeth. There was no difference in the incidents of crowding whatsoever. None. It’s got nothing to do with wisdom teeth. The reason that their surgery blamed it, because it’s circumstantial evidence. We get lower incisor crowding even people who have none when they were 12, 13, 14, 15. No crowding. We’ll start to get some lower incisor crowding between the ages of 18 and 30, when your wisdom teeth come in, 20, 21, sometimes 18.

The wisdom teeth are coming in coincidentally about the same time we begin to see lower incisor crowding. Therefore, it got the blame partly out of ignorance and partly out of … It serves my purpose, because now I can get people to send all these kids to the surgeons now, can get people to send the cases for extraction. The reality of that is, the same percentage of people will have the same amount of crowding if they have no wisdom teeth, if they have impacted wisdom teeth, if they have that fully erupted wisdom teeth. The reason we get crowding is the late increments of mandibular growth driving the contained mandibular dentition into the maxillary arch where the sutures in the midface fuse at 14 and 15, but their growth continues for many years after that.

You’re driving these lower teeth into this wage. That’s why we get lower incisor crowding. Everybody’s going to get it to some extent, 90% of the population is going to get to some extent, ir-respectable wisdom teeth. Why that’s in Germany? I don’t know. An interesting thought, I had a wonderful experience in graduate school. I went to Northwestern University. One of my teachers was a man by the name of Harry Fischer. I don’t know if you’ve heard that name before, but he was the world’s renowned bone biologist. He wrote a book with a man named Orinman, both German. Fischer was Austrian, but he came out of that area in the world. They wrote a book called, “Bone and Bones.” He was a genius. He was probably recognized as one of the early pioneers and the greatest contributors in the history of understanding bone physiology, bone facial growth, et cetera.

We had a class with him, which is one of the highlights of my career. He talked about wisdom teeth. He said, “Wisdom teeth, even if they did theoretically pushed against the posterior of the lower second molars, can you picture, what’s at the atypical end of an erupting wisdom tooth?” Self-proliferation, right, against medullary bone. Can you picture something that’s differently adding cells, pushing 12 teeth forward to crowding up lower 12 teeth made up of enamel, contacting each other, being driven together by an erupting molar pushing against soft bone?”

He likened it to the fact that you’re standing by the side of the road, and your feet are in mud, and you try to lift your car to put on a spare tire. Is the car going anywhere or your feet going into the mud? That is his analogy. I never forgot that. That wasn’t data. That was his explanation, his analogy to explain it. The data shows no relationship, whatsoever. Why it happens, as you said, in Germany? I don’t know. My guess is that’s probably a misunderstanding in a lot of countries around the world.

Howard Farran:

While we’re talking around the world, I can’t think of a greater orthodontic historian than you. Talk about, a lot of the older dentist, they used to hear back in the day that Americans would do four bicuspid extraction, and the Europeans would do four second molar extractions. Then there was another character out of Europe, Witzig who was a lot of that non extraction. Remember Witzig?

Richard Litt:

Yeah. He wasn’t out in Europe. Witzig was out in the world in Wisconsin, but he went to Europe.

Howard Farran:

His technique was out of Europe.

Richard Litt:

Yeah. He went to Europe and he spent two days in the office of orthodontist named Gerard Smooth in Bonn, West Germany, and he came back an expert on orthodontics. What he did was actually, unfortunately he passed away. I don’t have anything negative to say about the man as an individual, but what he did with his misrepresentation of information is creating an idea of everything should be treated non extraction. Again, we the specialty are just as responsible for what happened after that, because we had not educated the general dentist who are listening to Witzig to understand that what he was saying was an adulterated BS. It made no sense whatsoever.

If you have an uneducated audience and you’re a good speaker, and you’re selling what they want to hear, he’s preaching to the choir, he convinced them that orthodontist don’t know what they’re doing. Can you believe that? I don’t take that personally. Can you believe that dentist can sit in a room and listen to this man say that 9,000 orthodontists in the United States are stupid? I have the answer. He had two days of training in our office in Bonn, West Germany. They did, because they wanted to hear that. What he said was, “Orthodontic treatment causes temporary mandibular joint dysfunction, [inaudible 00:47:57] bicuspid extraction dishes in the face.”

It took us 10 years or more with significant study, lots of evidence to disprove all that information. The remnants of this still are around. Unfortunately, we are still fighting the battle of bicuspid extraction. I don’t want to do bicuspid extractionor the main reason I told you a minute ago. I make more money on a non-extraction case, but I can’t treat a patient who needs four bicuspid extractions non extraction. It’s malpractice. It’s not in their best interest.

Howard Farran:

You’re saying, about what percent of an orthodontist practice in America needs to be four bicuspids extraction? Well, again it’s-

Richard Litt:

Like I said a minute ago, [inaudible 00:48:34 ] my opinion and based on the data we see in the surveys done by German clinical orthodontist say we’re from 15 to 25%. If you have-

Howard Farran:

Okay, but-

Richard Litt:

Go ahead.

Howard Farran:

Then go around the world, because the one bizarre thing about United States and Canada, we’re a melting pot. You go to Vietnam. They’re pretty all Vietnamese. You go to Korea, they’re all Koreans. You go to Poland, they’re 98% Poland. Will you talk about the variants around the world? How is orthodontic different in a homogenous population like Japan or Korea or Poland versus United Kingdom or everybody’s from somewhere around the world? Americans are mostly all mutts, wouldn’t you say?

Richard Litt:

Yeah.

Howard Farran:

Even if an American tells you they’re Italian. With just follow-up questions, you’ll find out their dad’s German, and their mom’s …

Richard Litt:

Yeah. Their four generations that go they were Italian.

Howard Farran:

Yeah.

Richard Litt:

I understand it. I don’t think your ethnicity or the group that you evolved from whether it be Italian or Russian or Ukrainian or Korean, whatever, has a significant impact on the incidents of extractions. There are differences. For example, what we consider a bimaxillary protrusion or require extractions in a Caucasian population is perfectly normal for an African-American population or Hispanic population. You want to take out as many teeth to reduce protrusion in a sample of people, who are naturally protrusive by Caucasian standards. That same thing happens for example in Korea and Japan and any of the Asian countries. They have a much higher instance of skeletal class three pragmatic mandible.

Therefore, a lot of compensatory extractions have to be done. Because of the residue and the nature of their growth pattern and their skulls, the relationships, more extractions have to be done to solve underlying problem and avoid surgery. There are sudden reasons why you might find a higher or lower incidents of extractions in different ethnic groups. The biggest difference and the answer to your question, I believe is you can go to countries in Europe, not so much today, but 15, 20 years ago. Today, it’s different because almost all those countries have sent people to the United States and Canada to get educated.

I have some classmates from Switzerland and from England and they went back there, and they brought more of the American principles to the European countries. For example, I’ve spent many years, excuse me, teaching in France. When I started going there, nobody took out teeth. I went over there and talked about head gears and bicuspid extractions. They looked at me like I had horns. What are you talking about? The reason is, it goes back to one word you used a few times, money. There was no money for fixed appliance therapy in Europe. Those were socialized healthcare systems.

Orthodontics was paid for by the government, completely. You know what they paid? $50, $100. I was in England several times and I was stunned by what I saw and what I heard. Yes, our country covers orthodontic treatment for all of our population until they’re 12. Excuse me. Until your teeth come in, we’ll do orthodontics free. Then when you get all your teeth in, now, you have to go outside the system to the nurse health service for example or some of these other countries. The real difference between extractions in Europe, in England and other places, and here in North America is that they didn’t have availability of fixed appliances. All they have is removable appliances. We’ll go back to what I said earlier. If all you have a removable appliance, you can’t do extractions. You can’t brotherly move teeth or bone with removable appliances.

Same thing with Invisalign. Your inadequacy of techniques and skill and training dictated treatment plan. It was asked backwards. Now, that’s changed a lot, because people like me and many others that gone to Europe, given their courses, now, you’ll find that in France, there’s a significant percentage of people who treat orthodontic cases like the North Americans do. They’re doing extractions now. Before, they didn’t have the education. They didn’t have the tools. They didn’t have the ‘know how’. Everybody became a non-extraction case, which sounds where you go if you got Invisalign or Six Month Smiles or other that stuff, doesn’t it?

Howard Farran:

Yeah. Richard, I only got you for eight minutes left. I’m going to throw a barrage of questions at you.

Richard Litt:

Okay.

Howard Farran:

… and the most controversial. When you go downtown, occlusion is religion. You’re either Yahweh, Jesus, Allah, Buddha, Eta. There’s neuromuscular, there’s Hanky Dawson. I’m just going to throw things at you’re saying. A lot of dentist say, “well, you know what Richard, when people chew, their teeth don’t even touch.” Some people with orthodontics say, “Orthodontics all blow out their curve of speed, the curve of Wilson.” You have everything from a dogmatic religion and has to be neuromuscular. It has to be Hanky Dawson, then you got other people just say ‘occlusion.’ That doesn’t even matter. Teeth don’t even touch when you eat. Tell us your thoughts. You got 50 years of wisdom on occlusion. How much of this is voodoo and how much of this is science?

Richard Litt:

That’s a really good question. I’m not sure I could answer that in eight minutes, but let me tell you this-

Howard Farran:

No. Take your time. This is Saturday, man, take your time. I will talk to you to for you 40 days and 40 nights.

Richard Litt:

Very good point. I believe that that are certain fundamental principles of occlusion that have an impact functionally on us. I also believe that when you’re talking about TMD problem or myofacial pain or some of the other issues that have blamed on occlusion, there’s no relationship whatsoever. In some respects, there are the studies [inaudible 00:53:53] University of Michigan did a study to show that the incidents of TMD … Only 10% of the input has anything to do with teeth. Mostly comes from other issues altogether. I think occlusion has been overly blamed or not just blamed, but given credit for having significant more impact than it has.

I believe that since we have to have some target to make things fit together and we have some basic level of biology that there are certain fundamental principles you need. I go back to Demico’s theories about CO and CR should be in harmony. There’s an envelope of motion which self-describe that I have to be able to get into and out of CO and CR without major interferences. That’s a least a target for me. CO and CR in harmony, you have to be able to get into and out of it without balancing interferences or other interferences, but thousands and thousands of people don’t have CO and CR in harmony that function fine. Thousands and thousands of people have interferences between CO and CR and function fine. Then some people with 120 anatomical perfect context and a normal functioning joint have TMD.

I’m giving you a broad, secured answer to your answer to your question is I believe we have to follow some basic principles of occlusion, but I think that those who throw occlusion as the primary factor in this whole equation are way off base. I’ve taken a lot of occlusal courses. The person I listen to, who was probably the most common sense person that I ever heard was Peter Dawson. Peter Dawson was a prosthodontist. He was a lab technician before that. He was very articulate or oriented and he came at occlusion from a functional, but mechanical standpoint, but he thought and understood it like an orthodontist.

When you start talking to be about neuromuscular dentistry and Myomonitors and TENS units and all those other stuff, they have some place in physical therapy and stuff like that. I remember years ago, I sat in a class with one of the early pioneers in the Myomonitor. We had 25 or 30 people in the class. All of us were orthodontist. He put Myomonitors on all of us. Before we did this, he asked, “How many people in this room,” 25 or 30 people, “how many of you have TMD symptoms of any functional occlusal symptoms?” Maybe one or two people raised their hands. Probably some had other symptoms, but they didn’t even consider them symptoms.

Everybody was pretty normally functioning. He clipped this Myomonitors on everybody, and everybody’s [inaudible 00:56:18] came down and forward about a millimeter, a millimeter and a half, which was their neuromuscular determined forward position. Now, if you go to LDI, then you’re going to start treating people with that position. You’re taking 25 people who don’t have problem, you’re recreating a neuromuscular determined artificial position and calling that home. That’s a house of cards Howard that started to collapse already, but it’s a foolish way to approach orthodontics.

When people started selling neuromuscular dentistry, my eyes rolled back in my head and that’s witchcraft and voodoo to me. CO and CR must be in harmony. Again, I should say, ‘must be’. That’s a wrong of saying it. Should be in harmony, because you have to have some starting point. Again, there are lots of people who have interferences, who have balancing interferences, who don’t have harmony between the two and don’t have a functional problem. We should have some starting point to go towards.

I believe my goals, from an occlusal standpoint, our CO and CR in harmony, lack of interference between CO and CR, canine disclussion, and as close incisors guidance as I can get. I say that with respect for the restored dentist who has much better control of the size or length in the shape of teeth and we do in orthodontics. We can’t always get ideal incisor guidance just mechanically, it’s not possible. I strive for those things. Canine values, CO, CR in harmony, no interferences and incisor guidance were possible. That’s my theory.

Howard Farran:

Now, here’s a weird follow-up question.

Richard Litt:

Okay.

Howard Farran:

In America, what percent of orthodontics done today do you believe is really just cosmetics?

Richard Litt:

Well, I’m not sure what you mean in that question. Let me answer it in two ways. I say to people who take my course and I say to everybody personal that I met and they were talking with, and they asked me about orthodontics. 95% of what I do is cosmetic dentistry. When you talk about a cosmetic dentist, which obviously there is no such thing as a specialty … Oh, there’s a cat in your face.

Howard Farran:

It’s funny. Whenever I do a podcast and I’m not paying attention to my Mimi, she has to jump up on my desk to get my face. She’s basically saying-

Richard Litt:

I thought she wanted to hear what I had to say.

Howard Farran:

She’s basically saying, “Quite talking to that other ape and talk to your cat.”

Richard Litt:

When you hear the term, “cosmetic dentistry,” and to others, it’s very popular, even though it’s not an ADA recognized specialty. It’s a very popular group of people and they call themselves, “Cosmetic dentist.” I believe orthodontics is the ultimate in cosmetic dentistry, because basically that’s all it is. People can function fine without ideal occlusion. They come to orthodontics for aesthetic improvement. I am a cosmetic dentist. I don’t save lives. I don’t save TMD’s. I don’t save traumatic injury. I am a cosmetic dentist.

Now, if you give me certain things like functional shifts on little kids, we have clear evidence that an occlusion with a functional shift of little kid can lead to detrimental problems and joint bridge failure. Class two, class three opened by interferences, not of those things have shown any data that suggest that poor occlusion causes trauma, break down or pain. You have just as many people with TMD symptoms who have a perfect occlusion or a normal occlusion as you do with the malocclusion. That data is proven. I think I forgot your question-

Howard Farran:

If 95% is cosmetic dentist, but the other 5% is other things like this functional shift, spend a little more time explaining what a functional shift is in some way.

Richard Litt:

When a little kid bites together, if they have an interference and sometimes that interference can be a primary canine, or they had a finger habit and they caused some constriction on their maxillary arch, so when they close together, their teeth hit contact point to contact point on a cusp tip. It sends a message back to your brain that says, “Ouch. Don’t bite there.” They shift their jaw off to one side. They’ll get a cross bite on one side. The middle line moved over to one side, but the other side is in normal relationship.

They do that for comfort purposes, because the premature contact triggered a movement that would allow their teeth to get together without interference and discomfort. If you leave that alone long enough, you’ll get assymmetrical growth of candal, you actually can get facial asymmetry. You can get their studies to sow that of all the things we looked at, the nature of different occlusions, class one, class two, class three opened by cross bite, the only one that has increased risk of causing functional breakdown later is a functional shift done on cross bite, where a youngster will hit, slide off to one side and then one candal is down, out of the falls of the other, it’s in the falls of … and they make function fine. They’re not in major discomfort. If you leave that like that over a long enough period of time, they can get some pathologic side effects.

When I talk to patients, they ask me, I get this all the time. I have patient come in and say, and they’re wringing their hands. They’re concerned because their little kid has a couple of crooked teeth or cuspids blocked out or something. Their question always is, “Does my child need orthodontics?” What they’re really saying is, “Do I really have to spend $6,000 to fix that crooked tooth?” What they ask is, “Does my child need orthodontics?” My answer always is, “Nobody needs orthodontics. It is elective procedure. There are many benefits to it, but they’re mostly cosmetic. There are some small percentages of patients that may need ortho [inaudible 01:01:18 ] function standpoint, but mostly it’s elective process.

Howard Farran:

Help me answer another question I’m always asked. The balancing mental health from the banking or sucking of thumb versus dental health. I raise four kids. One of them was a thumb sucker and I never want to stop because he just loved it. He could be all stressed out. The moment he threw his thumb in his mouth, he was as happy as having a beer or something. When do we do got to stop comforting the mental health of sucking out of thumb or banking a pacifier and go to dental health?

Richard Litt:

Good point too. Sucking is a normal thing for infants. The suckling needs are there whether it’s their thumb or a breast or a finger or something else. Suckling is normal. Even thumb sucking is not a problem unless it starts to cause dental or dental or dentoalveolar or skeletal changes in the child. At that point in time, and it could be even on a five-year-old. If you start seeing on 11, 12-year-old … I see kids who suck their thumbs at 11, 12 years of age, and you would never know by looking in their mouth. They’re sucking your thumb and it’s the extreme degree of force that you put on your teeth, it’s individual resistance to deformation. There’s a lot of factors.

My answer to your question is, if you start to see dental or dentoalveolar alterations that could cause functional shifts or interferences or aesthetic issues like an open bite, then maybe it’s time to intervene. We have data to show that there are lots of kids when you get them to stop sucking their thumb, they develop some other problem like bed wetting. There is a mental issue here that you have to deal with. It’s hard to say this to a patient, but maybe there, we ought to be involving a psychologist in dealing with this problem, because you can trigger other side effects by taking away the suckling side effects and they get from finger sucking.

Howard Farran:

One other thing, when I talk about need for … there’s a lot of people I see that they need … We were taught the BMW; the Biological minimum width. I’ve seen it for 30 years, where when adults only have half millimeter of bone in between their lower incisors, it just seems like thy have less or more prone to gum disease. When those lower anteriors are straight, it seems that there’s less gum disease. Is that science backed or is that just my-

Richard Litt:

No. It’s not science. In fact, the contrary exist. I hear that a lot when people say that and it seems to me, and I can’t argue with anybody that says, “It seems to me.” I used to hear somebody that say, “It seems to me that people with it get more TMD. Or it seems to me that people with crowding get periodontal disease. Or it’s hard to keep your teeth cleaned when you have crowding.” When you look at large and doing the logic studies to show large samples of people, people with crowding don’t have any greater incidents of periodontal disease and people without crowding. That’s not an issue.

It’s either bacterial or it’s systematic, or it’s some other incidents. Now, could there be a certain instances where people have crowding and they can’t get in there and they don’t floss and they can’t get it cleaned? Yeah. There could be local areas where maybe a localized periodontal problem is because you can’t get access to it, or there’s papilla that’s resorted or stuff like that. Generally speaking, look we go back in periodontics used to blame orthodontics for causing periodontal disease. That’s not true either. There’s no data to show.

Now, occlusion increases the risk of periodontal disease. Crowding doesn’t increase the risk of periodontal disease. Now, occlusion has an increased risk of TMD problems? No. It’s a separate, isolated entity. Now, occlusion itself isn’t even really a disease [inaudible 01:04:37] if you think about it. Its variations are normal. It’s not really considered pathology. My answer to your question is no, there is no correlation generally speaking between crowding and periodontal disease.

Howard Farran:

You’re talking about 8,000 dentists right now. The bottom line is for 4,995, you get your money back with one case.

Richard Litt:

Absolutely.

Howard Farran:

If you’re listening to this, how the hell could you not do one case?

Richard Litt:

I agree.

Howard Farran:

Richard Litt is a one-patient return on investment. You listen to his 20 hours and my god, you do one case and you made it back. Then if you want more and hands on, the guy is so amazing. He credits it all to the hands on course. Richard, you are so amazing. I loved all of you lectures, everything.

Richard Litt:

Thank you.

Howard Farran:

Also, the homeys might be thinking, if they take your course, like implants, or if you go to the cologne, there’s 275 companies selling titanium implants.

Richard Litt:

Sure.

Howard Farran:

When you do ortho, how many different companies sell ortho bands and brackets?

Richard Litt:

Yeah. There’s a lot of them. There’s probably 15 or 20 major companies, and maybe some smaller ones. You mentioned the 4,995 and you can get it back in one case. I don’t want to mislead anybody. The 4,995, if you want to do it, I think it’s an outstanding way to get started. You can take our online course online, FORCEINT. Now, after you take that course, you still need product. You’re going to have to spend several thousand dollars to have the products be able to deliver orthodontic treatment. You’re going to make a minimum of 8,000 to $10,000 investment, so it’s two cases. That’s why I’m trying to say rather than one. You get that back in the first two cases that you start.

Also, I’m not naïve enough to think that I can get you where you need to go by talking to you for 20 hours on the internet. We offer other opportunities like online study groups like local study groups in cities across the US and Canada. I have a consultation service over the internet, where I’ve done 15,000 cases over the internet, where people send me their records. I make a diagnosis and a treatment plan, and send them back their cases. I can teach you orthodontics without ever meeting you. As what you mentioned at the beginning of this podcast, technology. Let me read right this. Howard, let me make sure everybody understands this. If somebody’s looking for us, it’s www.FORCEINT.com.

Howard Farran:

By going along with the product, when they follow you, are you agnostic to any ortho system? Or is your course, you use like Onco or self-liking-

Richard Litt:

I primarily use Onco product. There are a lot of companies that will come after these people and try to sell them product, but I believe that most of the major supply companies have a quality product, but I’ve worked closely with Onco Corporation over the last 20 years-

Howard Farran:

Which is owned by-

Richard Litt:

You can’t get from one corporation. We have a supply in this that involves products from many different corporations. Again, you can do good orthodontics wherever you buy your product.

Howard Farran:

Can you email that list my son, Ryan, at dentaltown.com, and we’ll put that in the notes?

Richard Litt:

Okay. The list of people we work with, companies? Sure.

Howard Farran:

Yeah.

Richard Litt:

Yeah.

Howard Farran:

Do you like CBCTs for ortho? Or you’re still just a [inaudible 01:07:58] man? Do you think CBCTs are-

Richard Litt:

I love CBCTs. It’s a beautiful tool. Lionel Johnson wrote a classical article a number of years ago. It’s an incredible technology looking for a purpose. It’s awesome. It’s awesome in orthognatic surgery and implantology. We still haven’t a problem in any good uses for it in orthodontics. There are some, the major area is in the localization of impacted canine. You’d see how close that canine is to the lingual surface of upper laterals or centrals. It’s being sold. It’s being used. Orthodontics aren’t jumping on that damn leg very much, because we haven’t seen return on that investment. It doesn’t make a whole lot of difference yet in orthodontics. Will it in the future? Maybe so.

Howard Farran:

Damn dentist loved to raise their overhead. Anytime they get a chance to spend $100,000 on a shiny object, they just can’t resist.

Richard Litt:

Isn’t that truth?

Howard Farran:

I always tell them that the alternative was a Porsche, then buy your Porsche for your office. Nobody needs a Porsche. Nobody needs a Ferrari, but they just always believe they got to have a CAD/CAM, a CBCT, a laser, and then you give them a list of 1,000 [inaudible 01:09:10] dentist that don’t have any of those stuff and they’re confused.

Richard Litt:

Absolutely. I couldn’t agree more.

Howard Farran:

Okay, buddy. Seriously, I think you’re one of the legends of dentistry. If they had a dental hall of fame, I’d nominate you first. You’re just a hell of a guy. It was great seeing you last time for dinner when you’re in Phoenix. If you’re in town again, if you ever need a baggage man to send one in Puerto Rico, that is the coolest. Is that your favorite place to teach?

Richard Litt:

Yeah. One of my favorites. You need another job, for whenever I’m in Phoenix, I’m going to give you a holler, we’ll have a dinner again. Thank you.

Howard Farran:

if you had to pick between giving a lecture in San Juan Puerto Rico or Paris, France, which one would it be?

Richard Litt:

I’m going to Paris every time.

Howard Farran:

Yeah. That is the classiest-

Richard Litt:

I spent a lot of time. I’ve spent 10 years in France, four, five times a year in the 70’s and the 80’s, so I have a second home there. I’m bias, but Puerto Rico’s-

Howard Farran:

You have a second home there?

Richard Litt:

Not really literally. I don’t mean literally. I don’t own a home there. It feels like a second home to me.

Howard Farran:

Yeah.

Richard Litt:

I have a lot of friends over there and some of the best years of my life. It actually was a wonderful part of my own education, because I learned a lot about European dentistry and international attitudes about dentistry and orthodontics in particular. It makes you realize how lucky we are to live in this country.

Howard Farran:

That’s the mother of dentistry. That’s [inaudible 01:10:19] didn’t it all start in Paris?

Richard Litt:

Sure, yeah. Absolutely.

Howard Farran:

Okay. Well, hey, thank you so much for spending an hour with me today …