Dentistry Uncensored with Howard Farran
Dentistry Uncensored with Howard Farran
How to perform dentistry faster, easier, higher in quality and lower in cost.

895 Treating the Cause of Disease with Dr. V. Kim Kutsch : Dentistry Uncensored with Howard Farran

895 Treating the Cause of Disease with Dr. V. Kim Kutsch : Dentistry Uncensored with Howard Farran

12/9/2017 10:53:04 AM   |   Comments: 0   |   Views: 79
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895 Treating the Cause of Disease with Dr. V. Kim Kutsch : Dentistry Uncensored with Howard Farran

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VIDEO - DUwHF #895 - Kim Kutsch

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AUDIO - DUwHF #895 - Kim Kutsch

Dr. V. Kim Kutsch received his undergraduate degree from Westminster College in Utah and then completed his DMD at University of Oregon School of Dentistry in 1979. He is an inventor holding numerous patents in dentistry, product consultant, internationally recognized speaker, is past president of the Academy of Laser Dentistry, and the World Congress of Minimally Invasive Dentistry. He also has served on the board of directors for the World Clinical Laser Institute and the American Academy of Cosmetic Dentistry. As an author, Dr. Kutsch has published over 100 articles and abstracts on minimally invasive dentistry, caries risk assessment, digital radiography and other technologies in both dental and medical journals and contributed chapters to numerous textbooks. He coauthored Balance, a textbook on dental decay with 100,000 copies in print, and wrote the Rough World series, a young adult science fiction trilogy. He acts as a reviewer for several journals including the Journal of the American Dental Association and Compendium. Dr. Kutsch also serves as CEO of Dental Alliance Holdings LLC, manufacturer of the Carifree system, and Remin Media. As a clinician he is a Graduate, Mentor and Scientific Advisor of Dental Caries at the prestigious Kois Center. Dr. Kutsch maintains a private practice in Albany Oregon.

Howard: It is just a huge honor for me today to be podcast interviewing my buddy for probably three decades, Dr Kim Kutsch. He received his undergraduate degree from Westminster College in Utah and then completed his DMD at university Oregon School of Dentistry in 1979. He is an inventor holding numerous patents in dentistry, product consultant, internationally recognized speaker, is past president of the American... The Academy of Laser Dentistry and the World Congress of Minimally Invasive Dentistry. He's also served on the board of directors for the World Clinical Laser Institute and the American Academy of Cosmetic Dentistry. As an author, Dr. Kutsch has published over a hundred articles and abstracts on minimally invasive dentistry, caries risk assessment, digital radiography and other technologies in both dental and medical journals and contributes chapters to numerous textbooks. He co authored 'Balance' a textbook on dental decay, with one hundred thousand copies in print, and wrote the 'Rough World' series, a young adult science fiction trilogy. He acts as a reviewer for several journals including the journal, American Dental Association and Compendium. Dr. Kutsch also serves as CEO of Dental Alliance Holdings LLC, manufacturer of the CariFree system, and Remnant Media. As a clinician he is a graduate mentor and scientific adviser of dental caries at the prestigious Kois Center. Dr. Kutsch maintains a private practice in Albany, Oregon.

My god, Kim! You are an amazing man! You have always been at the front of every parade. I mean any time I ever went to a parade you were always in the front. You're always on the leading edge. Between bleeding edge and leading edge just where you been your whole life.

Kim: Yeah, it's an interesting place to be at times, let me tell you.

Howard: So, I know you're passionate about dental caries and CAMBRA, the medical management model of diagnosing and treating dental caries. It seems...

Kim: Yeah.

Howard: It seems like the reality is, I don't want to throw my homies under a bus, but what percent of dentists just see a cavity and treat it like an engineer or a civil engineer and just mechanically remove the decay and re patch it with pavement?

Kim: Way too many.

Howard: Well, what percent would you say though?

Kim: Ah Golly. Probably 95%-96%. Somewhere in that ballpark.

Howard: Yeah, that's true.

Kim: Yeah.

Howard: And the same percent treat TMJ just by taking upper impression and making an (02:27 unclear).

Kim: Yeah, I mean it's... Howard, our profession is so focused on restorative and a surgical approach to care that it's just ingrained in us. And I think it all goes back to dental school. We were up there on the fourth floor being taught microbiology and then they take you down to the clinic floor and they put a drill in your hand and you sort of just cut. You understand where the disease is coming from, but the approach is just taught to us, we're just buried in this restorative model. And so I don't fault anybody, it's how... What we’re all trying; what I was trying to do. It's the way we're all trained. Although, that's changing in the Dental schools now. But it's just... It's like the treatment of periodontal disease, same thing. I mean, we all get so focused on that we forget to stop and go back and go, "wait a minute what causes disease in the first place and shouldn't we maybe think about treating that instead.

Howard: And a lot of it's driven by health insurance codes.  I mean, these hospitals will get a hundred thousand dollars to do a quadruple bypass from Medicaid and Medicare and then they'll get twenty five dollars to have a doctor exam.

Kim: Yeah I mean...

Howard: So basically, if you want to pay for the hospital every hospital administrator says if they don't do three major surgeries a day they can't pay any of their bills.

Kim: No, I mean a lot of it is driven by cost and so we've never been reimbursed as a profession for our diagnostic skills and our knowledge and we're only reimbursed [really on...  I think that's a major problem for us. It just goes back to that we get paid for doing the filling.  We don't get paid for teaching the patient how to floss. We don't get paid for doing nutrition counseling and what have you to help patients correct their health or get healthy. We just get paid for things that you can show that you did on an X-ray, that the insurance company can verify that you did something. Now that's a real challenge for us, the insurance side of that whole deal.

Howard:  So, talk about CAMBRA. What is it?

Kim: So, CAMBRA is just an acronym for the model, that philosophy, of treating dental caries. Starting with a risk assessment, trying to identify what caused the disease and then trying to manage and mitigate those risks for the patient, to get them back to a state of health.  It's as simple as that and we've made it real. I would say, Howard, our biggest flaw is that we came out of the gate, made it really complicated to start with and it really started in academia and with research and any time you put something in the hands of the academics and the researchers and the engineers it's going to be way more complicated than it needs to be and it's more complicated than people could integrate into their practice. I go back and look at some of the early recommendations that we did and it's no wonder people struggle with it and then just gave up on the entire concept because it was too complicated. So, I spent the last fifteen years trying to simplify it, not to the point that it waters it down to the point it doesn't have value, but to simplify it so that you and I could go into our practice every day and do this and have it be effective and make it simple to do.

Howard:  So where you at with CAMBRA now? Which is Caries Management By Risk Assessment.

Kim:  Where I'm at with it now, Howard, is I try to teach. The thing I've been doing the last three or four years is trying to teach dentists the John Kois kind of principle, diagnose them at hello. If you look at the patient and just have a conversation with them in that chair we know the major risk factors are for dental caries. You know the number one is saliva. And for most patients now that's medication related. We've got 70% of our of our entire population in the U.S. take one prescription medication per day and that's across all age demographics. 50% take two or more and 20% five or more and you see these people every day in your dental practice [00:06:37] and you sound [0.7] and they start talking in their mouth is dry. There was a study done in the JADA that was published a few years ago and it was a survey of patient self-reporting dry mouth and it was somewhere around 7%. We did the same study based on our caries risk assessment forms and they came in at 63% of my patients self-identified that they feel like they have a dry mouth at some time of the day or night. Some of this is related to other general systemic issues or auto immune stuff, but primarily it's medications. Howard, even our kids... We've got like seventeen million children in the United States taking anti... Psychiatric drugs, anti-anxiety drugs, antidepressants, ADHD drugs. That's the crazy part of this. We've got kids that are coming in with dry mouth when they sit down typically... You and I struggled with trying to get isolation in the mouth so you could do any dentistry, because there's so much saliva and now we've got kids that have dry mouth. So that's the number one risk factor for dental caries. So look at them and ask if they have a dry mouth.

The second in our caries risk assessment for by survey, and this is now over thirteen thousand patients at six different dental practices, 55% of them self-identified that they have a dietary issue. They're either eating too much sugar or they're eating too frequently. They're snacking throughout the day and I think that's part of our lifestyle as well, but Howard, the American diet... We eat twenty three teaspoons of sugar a day. I'd recommend everybody listening to this podcast is go home tonight, pull out a Ziploc bag and put twenty three teaspoons of sugar in there and see what that looks like. World Health Organization recommends that we should be eating somewhere around two thirds of one teaspoon per day. And on top of that we consume the most high fructose corn syrup of any country on the planet at fifty one pounds per person per year. So we've got a huge dietary risk and it's based primarily on the amount of sugar or the frequency we're eating.

You start asking people. We have the risk assessment form that identifies that as well. The third major risk factor is bacteria and typically you see these people, they come in, they got it all over their teeth. It's primarily a home situation or they've got the wrong bacteria growing on their teeth and then the fourth risk factor really in my mind is genetics and that's kind of a wild card. I can't diagnose  what your risk genetically is for dental caries. There are a few patterns we've identified and there will be a time someday that we'll be able to properly diagnose that, but in the meantime... So those are the four usual suspects typically that I see in my practice and if I can simplify it to, "your major problem here is not enough saliva and I know how to help you resolve that or mitigate that". If it's a dietary issue I know I need to focus on that. If it's a bacterial issue we know how to help you with that as well. And if it's genetic I can't do anything, but just talk to you about wellness and making sure that you have a healthy diet and you're trying [00:09:50] to be effective [0.5] If we just started thinking about the usual suspects and the major patterns I see for this disease then it suddenly comes a lot simpler than looking at these huge flowcharts and all of these stratifications, because it's literally: "here's what's causing the disease, let's just break it down and simplify it and help you figure out how to solve it..."

Howard: Man! You said so many things I don't even know where to jump back in...

Kim: I think, Howard, for where I'm at in my practice and with that and a lot of that comes from... I've been doing this for seventeen years, so a lot of that is just experience. Sit down and look at a patient, but you pick that up, but you need a caries risk assessment form if you're going to do this in your practice. That's ground zero, but you need a simple caries risk assessment form that you can have a patient fill out and self-identify their risk factors and there are really important reasons for that. Number one is... When I first started doing this I was having the hygienist interview the patient. Hygienists don't have time to do that. We've already logged so many things on their shoulders that we require them to do in a one hour appointment it's insane. So, what I did was, you take that problem out of the hygiene operatory by having the patient self-identify and fill out the form themselves. The other thing that psychologically happens, when that patient fills out a form and says, "Yes, I identify this problem that I have", rather than you going in and sitting down talking to a patient telling them they have a problem they don't perceive they have, and they get really defensive and push back, they come into that operatory, and I've identified this, and now I'm expecting that you're going to talk about this to me. So, you need that risk assessment form, but it needs to be simple and we use it on every patient at least once a year in my practice on every new patient and that gives us the starting point.

The other thing I would say that you really need to do is you need to have your hygienist on board. Like in my practice, they do most of the education with the patients. I mean they've been doing this for a long time now as well, but typically I'll come in to see a new patient or even an existing patient that's now having some issues and the hygienists have already talked and they've helped identify what their risks are. They've asked them specific questions targeted to that and then they've made recommendations on how they can help mitigate that. So, for me it's just a matter of coming in and kind of confirming that or spending a little more with time, with my experience, with other patients to kind of help that patient figure it out and you need maybe the thirty second elevator conversation like you ask, "Where am I at with this?" Well, it's really just a matter of being able to sit down and tell a patient in thirty seconds why we're doing this differently. We can sit here and drill until you run out of teeth or die, but it would make a lot more sense to figure out what's causing that problem and fix that instead.

I've not had a patient yet that didn't opt to have that done, so that's a real simple process. So that's kind of where I'm at with it today.

Howard: Talking about how this applies. I'm old school. Are there still just three types of cavities, root surface, pit and fissure and inner proximal?

Kim: You know...

Howard: That's...

Kim:  I'd say maybe a little more complex than that, but yeah.

Howard: Go through that, because, Kim, I'm out here in Phoenix and it's a big retirement community.

Howard:I've been doing dentistry for thirty years and when I go into the nursing home, see my patients, they get one root surface cavity per month... And I've never... Root surface decay spreads like a dam break. It's crazy. I've never seen pit and fissure decay or inner proximal decay spread like root surface decay and then these dentist... Talk about the three different types of decay and let's start with the four hundred pound gorilla in the room that 4,5% of us are going to end up dying in a nursing home and we're going to get a root surface cavity every month.  Kim, I've gone into a dozen nursing homes in Phoenix and I wanted to see what was going on. They got a CBA who makes $11-$18 an hour. She's got a whole wing and she's got to go to each one give them their meds, brush their teeth. She takes a toothbrush, puts a little pea on there, she goes back and forth the front teeth like six times, has her spit in a Dixie cup and she's done. It reminds me of my yearly physical exam. My physician forever has me open my mouth, puts a Popsicle stick my mouth and says, "Say Ah". I say "Ah" and then he throws a stick when I'm thinking, "Okay, I've been a dentist for three decades. What the hell did you just do?"

Howard: So, talk about root surface decay. It's a plague in America. Do you agree or disagree

Kim:  Oh, I totally agree, Howard, and if you go back to the pit and fissure lesions those are primarily, if we look at the bacteria in each of those different sites. The one thing that we know now, we've mapped out geographically in the mouth where the different bacteria actually inhabit, the little microcosms that they actually live in. New kinds of streptococcus only lives primarily an in the pits and fissures and so that's probably a bacteria that plays a major role there, but when you get to the interproximals you're going to see a lot more of the periodontal bacteria and anaerobic bacteria that enter the proximal zone because that's what the environment looks like. So, you're going to see more lactobacillus and things there, but then you get down onto the root surface and you've got that kind of [00:15:26] Vice's Israeli [1.2] you've got a whole different host of bacteria that are living there in that environment to begin with. So, the old model that this was a disease a new kind of streptococci and lactobacillus, you can throw that out the window. The challenge we've got is that it's not any specific bacteria anymore. What we know now is that there's a lot of these bacteria. As soon as the mouth becomes acidic they adapt. They switch it on like fifty five different genes.

They share genetic information with each other within that biofilm and they switch on and they all adapt to become a living and they actually produce acid and become aciduric like strep-mutants or lactobacillus does. Indeed it plays a huge role in dental caries and so you're probably seeing in the nursing home a lot of candida stuff going on as well. We've just really identified that the last two or three years, but here's the challenge, you've got all those patients, she brushes their teeth six strokes and then hands them their meds and has to swallow that and there's probably ten or twelve, fifteen, pills in the one cup and then they swirl with the water in the other. So, these people don't have any saliva. So we as prevention did a great job over the last forty years of our careers, Howard, being able to save all of these teeth. They've got some recession, but now we've got all these exposed root surfaces, these people didn't have serious dental caries, but now they're on these medications, they don't have any saliva and now they're in a situation where they're not getting adequate home care as well. Their diet there probably might be better, but you've got the perfect storm. So, you've got these exposed root surfaces.

The critical pH of enamel is 5.5 of fluorapatite. Once it's been exposed to fluoride on enamel the critical pH is about 4.5. The critical pH of dentin on those root surfaces is 6.7 and resting saliva in a healthy person has a pH of 6.75. So, you're talking about... We've got no room for error and then you have those exposed root surfaces, you've got the lack of... You pull the saliva out of the equation. Saliva is supersaturated with hydroxyapatite nanoparticles and fluorapatite nanoparticles and the body maintains the teeth by having them constantly bathed in a basic supersaturated solution of the mineral that they're made out of and without that we wouldn't have teeth and without that... That's why these patients in a nursing home are breaking down so rapidly, but it's a whole different group of bacteria that are causing that. That are at the pit and fissure series.

So, you've got not only three different types of cavities. You've actually got three different, probably ecological biofilms that are responsible for that and then some of the most current research we've got going on is indicating that not only do we know that these bacteria within the biofilm communicate with each other, they communicate with our host cells. This biofilm is so integral as part of our body that our host cells are communicating with the biofilm as well. So, there's a lot going on there and I don't have an answer for you, Howard. The one thing I'm using a lot in this situations is silver diamine fluoride. It's hope and pray. You know, put a little silver diamine fluoride on it and hope that you can harden those lesions up, because it's like, I don't know what we're going to do for all these people.

Howard: And so ... I mean when you look at the only publicly traded corporate dental offices around the world, they don't even allow general sedation for anyone over under thirteen or over sixty five, because those are the high danger zones.

Kim: Oh, yeah.

Howard: And then they're dragging all these two year olds to an operating room and it seems like once a quarter that turns out really bad and it's splashed all over social media.

Kim: Well, that just happened, I think, in May and here's the challenge, Howard. If you're in that restorative model, I mean this is the statistic that I think bothers me. You take that child that's high dental caries risk, they've got... It used to be called early childhood caries. Now it's called severe early childhood caries, because they have so many lesions and some of it is educational driven, some of it is socioeconomic driven, but you take that child to the OR, you put them out. You do that, restore all their teeth. That cost on average about, costs the system about $12,000 to do that. Do you know what the average retreatment time on that same kid is going back to that OR?

Howard: What's that?

Kim: Twenty months.

Howard: That's insane.

Kim: Howard, this is what I challenge our pediatric side of our profession with, how many times you have to take the same child back to the same OR every twenty months to do the same thing before you stop and say this doesn't work. You know, what we're doing here isn't working for this kid. This doesn't make sense and you're putting him at risk. We lost a child in California just... That little girl, three year old, in May or early June and it's like... I can't imagine the horror of being a pediatric dentist that day that that happened to... Or the anesthetist or anesthesiologist. I cannot imagine, Howard, because by and large that's a preventable disease and so you lost that three year old, and this happens all the time. You're absolutely right. Listen this happens every year, we're losing children in the United States. The complications morbidity mortality from the anesthesia from a disease that could have been prevented and that's what drives me nuts.

Howard: So, what would you do if you're a dentist listening to this and your mom is eighty eight years old and she's in a nursing home? She has rheumatoid arthritis and she knows she's going to get the thirty second toothbrush every night. What would your solution be for the nursing home?

Kim: You know and I see these patients too, Howard, right, and so, I'm just trying to help these people exit this life with as little pain and need for more surgical restorative procedures as possible. Right. Just trying to ease them to the grave. That's what I want for my own mom. That's what I want for me, hopefully,  God forbid we end up there, but I hope I get more than six swipes with a toothbrush when I'm there, but that's the reality right. So, for that patient try and... you certainly want to use. You know I developed a whole line of products that act like saliva and that are alkaline and...

Howard: You're talking about your website

Kim: Yeah, at we have products there that we know really help and really work for patients like that. So you know there's [00:22:24] sacer [0.5] xylitol. So we're throwing, you know every strategy that we can. They're only getting six strokes with the brush, but at least I'm using a product I know [00:22:33] that's five thousand part in Florida [1.8] . I'm doing everything I can from a product site, you know. On the other side of that then, it's really a matter of let's try and get some silver diamine fluoride in these lesions and try and arrest that for the patient in the mouth...

Howard: Talk about a...

Kim: No, last thing...

Howard: Where do you get the silver diamine fluoride

Kim: Advantage Arrest and that's in..

Howard: Okay.

Kim: So they... Go look that up and there is a code for that. We even have a code now. Not every insurance and a lot of those people don't have insurance in the first place, but that's a d1354 code. So we're starting slowly, Howard, to get some codes. We've got caries risk assessment codes that I helped write. The d0601, 602, 603 codes. We're starting slowly to see reimbursement for different procedures like that, that are minimally invasive related and Delta is actually has a couple of beta test sites right now...

Howard: Is that...

Kim: We...

Howard: Hang on a second, when you said Advantage Arrest is that

Kim: Exactly, that's elevate oral care. Yeah, exactly.

Howard: Come on I'm getting old and senile. You can't play tricks on me like that.

Kim: Sorry...

Howard: But...

Kim: That's the product name. Elevate Oral Care I think is the company that...

Howard: So talk about When did that come along in your journey and what's..? How's that going..? And talk about that a little bit.

Kim: It's going really well. It's interesting, Howard. I came home. I'd done a bunch of lectures in Australia. I was there for about five weeks, this was back in 2001, and when I came home from that I spent a lot of time with Ian [00:24:17] no [0.4] down there. He was at University of Adelaide at the time and I came home from there with a different mindset. I've been involved in lasers and abrasion and minimally invasive dentistry for thirty years now, but I really came home for the first time from that trip and looked at dental caries like a disease and not like a series of holes in teeth, and so I got home and I contacted Doug Young at [00:24:42] (?) [0.1] and John Featherstone, who probably has lead this whole CAMBRA movement. He's Dean, currently at UCSF. He's retiring at the end of the year, but those two men really helped shape my mind around how we do this and so I started [00:24:55] about a term [0.8] when I was going to figure out how to do this in private practice. So I started in my own practice at that point in time and I was using quinoxaline and then I switched, as an antimicrobial rinse, and then I switched to povidone iodine for crying out loud. 10% povidone iodine, which everybody should at least swish with one time just know what that experience is like, but I tried this for a couple of years and I really wasn't getting the results that I wanted, and so Doug and I got together. We spent a weekend and I said, "You know... We... There's got to be something better. I mean these things work, but they don't work as well. They're not doing what I want. I want a knockout punch here." And so we started digging through all the scientific literature. We found this paper by Phillip Marsh back in the late 1980's, 1988, 1989. Philip Morris and David Bradshaw demonstrated that it's not the sugar availability that's actually causing the selection for these aciduric bacteria it's actually the acid itself. So, I told Doug if he's right, then we should get the highest pH product we could find, start using it on patients and see if that changes the biofilm and if it changes their incidence of dental caries, changes the clinical outcome. So I went to Wal-Mart. We literally bought everything on the shelf and I went home to test them. I had a... From my first company I still had a scientific lab. I had a highly sensitive scientific pH reader, so we tested all these products and I was horrified when I just... I had no idea. When I discovered the pH of these products it's like, well one of them which still holds a record of 3.13. So you're trying to get rid of aciduric bacteria with a product that has a pH of 3 and most of them are between 4 and 5 and even below 5.5, and you look at that and go, "Well here I'm trying to get rid of these things and I'm bathing them in the acid I'm trying to get rid of."

And we know that the body does this with... Your stimulated saliva has a pH of 8.0. So, I told Doug if he's right we need to raise the pH on a product and try that and see what happens. So we did. I switched to sodium hypochlorite as an antimicrobial treatment and then we started making products just had a real high pH and it's like... Three or four days I saw a change in my own mouth in terms of the biofilm when I woke up in the morning. So, that's how the... All we did was copy nature and then try to improve on it, but that's... So, I told Doug it's like I really didn't want to start another dental company, but, at this point in my life, but I know how to do that. I know how to interact with the FDA. I know how to file patents. I know how to build companies. So, you know what, nobody else was going to do this, so let's start and then it took us about four years to figure out how to stabilize an alkaline product for shelf life stability, for like at least a couple of years. So that's not an easy task in itself and one of the reasons so many things are acidic on all of our products and food is because... It's easy. Once you acidify it it's pretty shelf stable. So once you take it into the alkaline range a lot of things want to grow in it. So it took us a few years solve that, but once we got that solved we started launching the products and it's grown internationally. We're, right now, expanding into Japan, helping teach preventive dentistry and caries management in that in that society. We've done really well in the U.S. and Canada, Mexico, New Zealand Australia, a couple of countries in Europe and now Japan. So the company is doing very well, it's growing. We've trained probably six thousand dentists in the U.S. alone on how to do caries management and a couple of thousand of them I know do it on a regular basis in their practice, but when you look at the whole landscape of dentists in the United States, Howard, that's you know we're talking about 96% are... This isn't on their radar.

Howard: So you build us a course on CAMBRA made simple.

Kim: Yeah.

Howard: Does that explain all your products and all that?

Kim: Yeah, pretty much. If not, the website, we've just got a brand new website we launched, which has a lot of video on it. It has a lot of explanation, and then if there's anybody that's interested in this or learning more about it, we do free training. So I mean we do webinar based trainings to the office and train the staff at the same time. We train a lot of offices, like every month. Like I say, my trainer's there... And that's free a service. We train... I know personally we've trained over six thousand practices in the US. So they are.

Howard: Holy moly!

Kim: Yes.

Howard: What are All my homies' favorite products? What are you selling the most of? What do they like the most?

Kim: The number one product is CTx-4 gel and that's a five thousand part per million fluoride gel.

Kim: C-T-X?

Kim: CTx, caries treatment that's an acronym for caries treatment. The five thousand part gel. So it's five thousand parts sodium fluoride. It is saturated in xylitol, which is close to 30% xylitol in the product. It has a pH of  9.0 and then it also has an optimum amount of nanoparticles of hydroxyapatite. So, it's got four strategies there trying to help create an environmental healthy balance in the mouth. Probably our second most popular product is the CTx4 rinse and that's a 0.05% fluoride rinse, also has xylitol in it and it also has sodium hypochlorite in it. It has a pH of 10.5.

Howard: What's the four stand for on the CTx4

Kim: Ok, so the four stands for... There's four different strategies there. So we have some CTx2 products that would have just a high pH and xylitol. A CTx3 product might have... Like we have a CTx3 gel and a CTx3 rinse that would have a high pH, it would have xylitol and have nanoparticles of H.A., but it doesn't have fluoride. So when you get to the CTx4 product line they've got high pH, fluoride, xylitol and then also nano H.A.. So we just wanted to kind of differentiate nano.

Howard: Nano H.A. for hydroxyapatite

Kim: Yeah, and it's twenty nanometers average particle size which is exactly biomimetic for what is in your saliva.

Howard: Now can you only buy it on Or does...

Kim: You could buy it on Amazon. So it's available on Amazon. It's available on You can buy directly from the company. So we have offices that stock and supply it. I get that in my own practice. Then we've got practices that don't want to handle any products, you don't see any of that, and you can just send the patient either to our website or to Amazon.

Howard: And how's it going?

Kim: Amazon, they can't buy the five thousand part per million gel. And they can't buy the sodium hypochlorite rinse.

Howard: From dealing with Amazon do you think they're going to give these distributors like Schein and Patterson and Benco and Burghardt (32:07) or some challenge?

Kim: I think they're already giving them a challenge. I mean in my mind they're the Wal-Mart, I've have been saying this for a couple of years. Over 50% of all Internet sales for everything that's sold on the Internet, over 50% are from Amazon. They have 50% Internet market share for sales. I mean they're bigger than Wal-Mart in terms of... I don't know what Wal-Mart’s market share is in terms of retail, maybe you know, but I'm sure they're not 51%.

Howard: I like that one stop shopping. I hate going to websites and getting... You've got your credit card and address on the scrap and... You go to Amazon and that's the item you want... In fact, what's funny for me, I'm an old dog. I used to send a text or an e-mail to my assistant to tell them I needed something, but...

Kim: Right.

Howard: It's actually now, for me, faster and easier to pull out my iPhone, find it and then hit the button click and...  [00:33:08] (inaudible mumbling). [0.1]

Kim: It's there within two days, right.

Howard: Yeah.

Kim: And so I mean we all do that. I mean I check Amazon Prime before I leave the house, right? So, I think you're going to see more and more growth of that in the future. There's a lot of different dental materials and supplies in there. I think that it's going to give them...

Howard: I want you to talk some more of your ingredients. I think they understand the NHA, the Nano HA, and the high pH, but xylitol, I mean, it's confusing, because so many of your patients come in they say, "Oh yeah I only chew gum with xylitol", but is there a dose that you think that's therapeutic versus a dose that's a marketing and advertising...

Kim: Yeah.

Howard: And all these products at Walgreens.

Kim: Based on research, Howard, you really need to have seven tenths to one gram per stick of gum and you need to chew at least five of those a day. So, literally, if you're going to have xylitol you need somewhere around five to seven grams of xylitol per day. That's kind of like an optimal dose. You get a lot higher, you get past about ten or eleven and you start to get some gastro sometimes if you swallow it, maybe some diarrhea up in the twenty range, but, so that five and seven seems to be optimal in terms of treating dental caries. Xylitol, I did a whole webinar last year on xylitol, it's pretty interesting. The whole process. Is it a genetically modified corn? Is it tree bark? I mean you get into a lot of... And I understand people thinking, should be concerned about all those questions, but they use heavy nickel in the process of it, although at the end it's just sugar. It's a sugar alcohol five carbon sugar alcohol and there isn't any heavy nickel in it. There isn't any of that and so we have really good research on it.

You have the xylitol, the study that came out of, the exact study that was xylitol adult dental caries study that came out. They had, I think, [00:35:09] six hundred and seven odd adults [2.6] in that study. They gave them five xylitol mints a day, Howard, for three years and at the end that was the entire treatment. These were high caries risk patients, they were adults and at the end of the treatment there was no outcome and so that got published in The New York Times and then all the anti xylitol people came out of the woodwork. I got more e-mail responses to that than anything I've done my life and everybody said, "see it doesn't work". It was on [00:35:39] all the way through, [0.7] it was on CNN. "Xylitol doesn't work it doesn't help treat dental caries." So, that was published in JADA like in January of 2013. In June of 2013 they did secondary analysis of that data and this is where it gets interesting. Those patients that you and I were talking about, that have those lesions on the root surfaces in the nursing home. Right. People that had primarily class five root surface lesions, Those five xylitol mints a day reduced their caries incidence by 40%. Which I can't even name anything else that's ever been studied that reduced anybody's caries rate by an average of 40%. I mean most of the fluoride [00:36:22] Straits [0.3] come in around 28% to 32% at best. The CAMBRAs study that Featherstone did, he met at 27%. I mean, 40% from five xylitol a day. So, when you talk about what would you do for your mom in that nursing home, make sure she has cases of xylitol lozenges. You know... Next... You know, she can eat five. Limit her to five, right. Have five xylitol mints a day. That alone reduced the caries rate by 40%. So, there's a lot of research on xylitol. Xylitol gum transferring bacteria from mother to child. There's enough scientific information and conference data to go talk about that all day long, but xylitol is a fairly still somewhat controversial subject, which surprises me.

Howard: Well let's TED X the controversy on xylitol and move to fluoride.

Kim: Okay.

Howard: I mean there's even dentists on Facebook and Dental Town that don't believe in water fluoridation. There's a lot of patients who say they want... They ask for a natural toothpaste and natural is such a red flag for me. I always say, "You mean natural like HPV or natural like HIV, which had a natural?" You talk about natural, you know, a supernova exploding star which makes all the ingredients for an amalgam that, you know, an amalgam is completely natural made in a supernova exploding star of mercury, silver, zinc, copper. Whereas these tooth colored fillings are made by these men in lab coats and with beakers and chemicals and then they're so stupid they always go, "Oh I want the colored one". Dude I thought you just said natural. And now we're.

Kim: Right.

Howard: Now we're like, "Screw natural. We went tooth color." So, how do you deal..? And you're in, no offense I know you, but you're in Oregon and that's some of the biggest nature lovers, crystal conventions... I mean at...

Kim: I..

Howard:Compare Oregon...

Kim: I...

Howard: To Oklahoma.

Kim: I practice in the People's, what we lovingly refer to as, the People's Republic of Oregon. You know and it's true. I mean I have patients that come in and I've got a new product. Actually I'll be launching the first quarter of next year that will be virtually. I think you're going to freak out when you see it because it is going to be all natural, right down to bamboo particles for the abrasive. I mean they will eat the stuff. There will be no preservatives and I'm pretty excited about that, because that's a growing segment of the market right, and I have patients that come in and they say, "No, I don't want any fluoride." What am I going to do for that? That's my major treatment weapon, right. So if I've got something that has... I know it's got an elevated pH and I know that I've given them xylitol and I know that I've given them some nano-HA. The minute that they have a dry mouth having that nano-HA kind of goes away, because suddenly it's not in the saliva because they don't have enough saliva. So I want to add that back to the equation and they tie my hands my not being able to add any fluoride to the situation. The Fluoride is a controversial subject and I kind of understand. I mean I have some of my own misgivings about it, Howard. If you go back to 1945 in Michigan, that was ground zero for first water fluoridation and it worked tremendously at one part per million right out of the gate. It worked through your children. My children are probably... I don't know about your kids, but my kids are all decay free, right. My grandchildren are starting to get cavities. So it's like it worked for an entire generation and it's almost like the biofilm, the bacteria, have learned how to adapt and survive and change. That's what bacteria do. Right. I mean they know how to do that and the best way to give them a chance to do that is to put them and give them a very small dose over a long period of time. So, we might have been better off, in the early days, rather than fluoridating the water at one part per million, using the fifty thousand part per million varnish just on the people that needed it. You know, use the big gun and come in with a heavy dose on those selected and targeted individuals. I don't know. I mean I can't prove that, but I can understand that from an ecological or biofilm standpoint that could possibly happen. One of the things that happened in our children in the last twenty years is that the decay rate went up double digits for about four reporting years with the Health Organization here in the U.S. but in the last, and this study just came out, in the last ten years it's flat-lined. It's not getting worse but is not improving. Although, from the CDC we do get data that we do believe fluoride reduces the decay rate, about 27% of the country annually. So with the rampant decay that we're seeing today... I mean, Howard, you're seeing stuff you didn't see when you graduated dental school. I mean I know you are in your practice, because I am too, right.

Howard: Right.

Kim: We've got a decay epidemic and lesions and things that I've never seen in my life. I'm seeing more of these NCCLs than I've ever. I spent... I can't tell you how many of those I treat every day and it's like we have all these theories on what's causing that, but you know just getting back to the fluoride.  So, on the flip side of that we have all this research that indicates that Fluoride helps reduce the decay rate and I'm still using it and I still believe in it, but I've got patients that won't accept it so I've got to try and come up with the best alternatives for them to help get their mouth a healthy balance. So that's what we're working on.

Howard:  I do agree that when a patient comes in and they don't agree you're still their dentist. I mean when they show up and they say... You know, I'm still a dentist, but one thing I've always thought about fluoride is on the periodic table it's second from the right. It's in group seventeen, but it's the halogen elements as in that includes fluorine, then you drop down it's chlorine, then bromine, then iodine and then acetone, but you see it in swimming pools today. I think it's so funny how they're so... Well it's not funny, just they're so concerned about the fluorine in the water...

Kim: Right.

Howard: But right beneath that is chlorine and there's... And if you think fluoride in the water is toxic. You've got almost nothing to stand on, but when you look at the levels of chlorine use you got a lot of stuff to stand on, but they don't talk about chlorine and then the swimming pool companies I'm in Arizona where if you don't have a swimming pool, you know, you'd better be a lizard, and so they're advertising chlorine free pools, but what do they do? They just drop down to column seventeen and drop right down to bromine and I always wondered, if you don't like fluoride maybe a chlorine mouth rinse.

Howard: Remember when Omar Reid came out with the chlorine?

Kim: Oh, yeah.

Howard: Radcliffe you know...

Kim: Yeah.

Howard: Like, "Well you don't like fluorine why don't you just go get a glass of swimming pool water every morning out of your Jacuzzi and swish with chlorine?" You know.

Kim: Well it's interesting. I mean most of our water supplies are chlorinated that's how we reduce the bacteria levels there. Right. We chlorinate water. Even our drinking water. So, it's a challenge. Again like you say they're still my patient, I'm still their dentist. You know they said, "OK, I'm not going to accept this" then I want to be able to say, "OK, so I've got these other strategies that I can help you with."

Howard: Hey where did he... Where is he and Noah now? Last I heard he was a dean of some dental school in the Middle East.

Kim: Yeah, and I think he's still there. I mean he went from Adelaide up to Singapore back to Brisbane and then I think he's in Dubai or someplace last I heard. I haven't talked to him for a couple of years now.

Howard: Yeah. On your recommendation I flew him down to Phoenix myself from Adelaide, Australia, to lecture at a study club, but you mentioned he was in Adelaide then he went to Singapore. Now he's in Dubai, but when I was lecturing in Singapore and Tokyo it was very interesting how Dennis would show me how the disease [00:44:09] they see in [0.5] filled teeth was going down equally in both of those great civilizations, but one had water fluoridation in Singapore and one in Tokyo didn't and in Japan and Singapore they were convinced that that the key was getting parents to teach home care to their children. I mean you're getting, like you say a more holistic approach, talking about diet and home care. That was what was important, not some magic splash of one part per million fluoride in the water.

Kim: Well, I think, Howard, honestly if you have an effective diet. So, you're not eating sugar. You're not drinking the six big gulps of Mountain Dew every day and if you have really good health care, you can have a healthy mouth without any fluoride at all. Right. I mean I would expect that, but yes. So we're using fluoride to kind of overcome some of those challenges and in part it has, but I mean you look at it... I don't know, Howard. My own experience was, when I first got out of dental school we had [00:45:09] the foam  [0.7] you know first came out the fluoride [00:45:11] foam, [0.4] right, and I'd get a little kid that'd come in and had, you know, three or four lesions and I'd give him a fluoride treatment in the office and boy everything came to a dead halt. Now it's like these kids are coming in and I'm paying fifty thousand [00:45:25] part [0.2] money in fluorine four times a year and it's not even slowing it down. So it's like something has changed in my mind and you know. Some of that is diet. Our diet has changed in the U.S. with all the sugar. There's a lot of those different major risk factors that go into that. Interesting in Japan, and I'm spending quite a bit of time there in the last year, but the interesting part about Japan is the government hasn't paid for preventive dentistry. So consequently there really hasn't been any. You could go get your teeth cleaned if you call up and ask for a cleaning, but they didn't pay for that and suddenly they're starting to pay for that and so there's this huge interest in the dentists that, we want to know how to set up a re-care system. We want to know how to create these programs and systems for in our practice and at the same time get more involved in preventive dentistry as well. So, like CAMBRA and looking at caries management. So there's a major push in Japan right now going on, because they've got, as the Western diet I think is probably spread around the planet.

Howard: Oh my God.

Kim: You know.

Howard: You know these people.

Kim:  Right.

Howard: You know who's worst? [6.2]

Kim: Oh yeah.

Howard: The middle East is the worst.

Kim:  You look at it from going to Australia for the last forty years and teaching down there. I used to go down there and these people were lean and fit and I'd always come home and go, "Wow, something's wrong with the Americans". When you're gone for long and you come home and you're look and you go "shhh", you know, we're not healthy here and now Australians look like a... You know forty years later you go walk down the street and there's a burger... And not to pick on a particular thing, but there's all of these food chains from a Western diet and now Australians look like Americans right and I'm like...

Howard:  Kim, when you go to Dubai and Kuwait there is a fast food restaurant every hundred yards. I mean it is amazing.

Kim: You know, and so that diet is... It's created some health issues for us, I think, systemic health issues for us in the U.S., but it certainly contributed. Our diet's contributed to our overall health and well-being as well.

Howard: Kim, you've been a mentor of mine since 1987. For thirty years you've been a mentor. Who turned me on to intra oral cameras? you. Who turned me on to minimally invasive dentistry? You. Who turned me on to air abrasion? You. Who turned me on to glass ionomer? You. You've been a big influence in my life, so I want to go through those four. I'm a big believer in digital X-rays, because your consumer patient can't read the film and I like you to talk with your hands with an intra oral camera in there. What intraoral camera do you like?

Kim:  I think we've got the Digital Doc, but at the moment...

Howard: Digit Doc or Digital Doc?

Kim: I think you..

Howard: Digit Doc...

Kim: Yeah, you know, I couldn't really even tell you, so yeah, but I tell you what, I... There's a lot of really good intraoral cameras on the market right now and any camera...

Howard: When we started the first one was $38,000...

Kim: Oh my gosh.

Howard:  And half the size of a refrigerator.

Kim: I still have mine which I'll reveal the cost. It cost so much, Howard, I just couldn't bear to throw him away. I still have..

Howard:  And what was funny is the early leading edge adopters like you and... Turn everybody onto this thing. I bought my $38,000 Fuji cam from Patterson. and even though they were only $10,000 the next year I still made up for it. It's still... You show people with their internal camera. Oh my god. Can you do that today and I don't know anyone who paid 38 grand for that thing that regretted it.

Kim: Oh no, I have nobody selling them back that I'm aware of. I mean, I have no regrets...

Howard: And I love air abrasion. My assistant, Jan, she is so mad whenever I use air abrasion, because it makes a mess. Gosh darn, I love that thing. What's the status of air abrasion these days

Kim: I mean I think it's probably the kind of plateaued. People don't use it as much as they were probably in the 1990's where we were actively involved in manufacturing those kinds of products, but I still use it every day. I mean I think...

Howard:  What do you use it? What was it called? The Mach 4 or the...

Kim: Yeah, I had actually the Mach 4 and then the Mach 5 and the Mach 6. The Mach 6 was like our best device. You know, I still have a couple of those in my practice, but again there's three or four different devices on the market. The one... Oh gosh I'm trying hard to think here. The Prep Start, you know, there's a great little device for the money and they work well. So I use it to clean props. I use it for, you know...

Howard: What's the name of the one you like?

Kim: I think it's Prep Start.

Howard: Prep start?

Kim: Check that one out.

Howard: Okay, right.

Kim: But, you know I use it to clean restorations. I use it to clean preparations. I use it on minimally invasive stuff. You know, it does make a mess, a bit of a mess. That's always been a challenge with it, but there's nothing else like it, you know.

Howard: I love it man, just absolutely love it.  I want you to talk about another thing. You know when you mention [00:50:31] yeah no one [1.4] when we first met it seemed like glass ionomer was only used in Asia. It was only used in Japan, New Zealand, Australia. What's the status of glass ionomer, because a lot of... Basically, in a nutshell, a lot of dentists are starting to think, I see it on Dentaltown all the time, that what we've been doing is making a wooden barn for years and telling them to brush and floss it twice a day and then it gets eaten by termites and, you know, what if you made a filling that had more... You know, some defense. What do you think of these bioactive fillings? What do you think a glass ionomer, as opposed to just an inert resin filling from Ivoclar or 3M. What do you think of their...

Kim: You know, Howard it's hard...

Howard: Versus a...

Kim: The bottom line is that it's probably more technique related than it is material related. Particularly when you get into bonding protocols right. If you don't have good isolation I don't care what product you're using and so I've used glass ionomers on and off over the last thirty years. I did a lot of sandwich restorations in the 1990's. I saw a lot of those fail, because I wasn't treating the rest of the disease and you would actually have mouths that were so acidic that they would dissolve. I saw them dissolve that glass ionomer and the proximal blocks so, you know, it's best... It will... We know for a fact that if you've got fluoridate glass ionomer it's going to recharge and it's going to put a glass ionomer into the dentin. So for terms of preventing secondary decay around lesions you can't beat glass ionomer, but it fails differently. It's going to dissolve slowly. It fails differently than resins do. So, I still use it. Like if you look at glass ionomer...

Howard:  You still use what?

Kim: I use Fuji products for glass ionomer, but then what I've started using... I use resin modified glass ionomer cement, you know. I use [00:52:29] you understand now [0.6] to cover the dentin in those areas and then I go through my entire bonding protocol and use composites on top of that. That seems to work better than the glass ionomer did. I still hear glass out ionomer selectively on the high caries risk patient for, like, a pit and fissure sealant, or I'll use it on a high risk caries patient as a inner restoration. They work extremely well for that, but if you take glass ionomer or resin sealant, they both work but they failed differently. The glass ionomer is going to completely fail by full fracturing and the whole thing will come out. There won't be any decay there, the enamel matured, but you're going to lose the entire ceiling. If you use a resin sealant, your sealants going to stay, but it's going to leak and then you end up with some recurrent decay underneath the lesion. So, if you're going to use sealants, you know, resin sealants, you've got to, basically, .. In the studies, you read the studies, and you know, part of their protocol is, they maintain those sealants, so they reseal like any time you see any leakage. Every six months you're maintaining those sealants and resins will work that way. So they're going to fail by leaking and that, whereas the glass ionomer seal, that's going to fail by my fracture. The same is true for resins and glass ionomers and other restorative areas of the mouth. So, I think it's as... Technique is so critical with both of those materials, so that's what I would... That would be my best recommendation.

Howard: Well, if you and I do a podcast we're going to have a shout out to Stewie. I think we're going to hurt his feelings...

Kim: Ha ha! Stuart retired this year ,although he's still teaching. He's still teaching the laser classes and we've got to do a shout out to Stuart. Stuart has been such a good friend and a great mentor to me as well and you know he's practiced almost fifty years. I cherish... I absolutely admire and respect anybody that puts that many years into treating patients and he did it because he loved it and he retired, but I hear from Stuart every once in a while. He's doing well but he's still teaching laser programs, so he's one of a kind, I tell you.

Howard: And what about the other rat pack? Bill Brown...

Kim: Yeah, Billy Bob is still around. You know, Bill is still at Biolase.  I think Bill's probably getting closer to retirement, but he's certainly... He's been a great friend and mentor to me as well. One of the smartest people I've met.

Howard: So do you order Biolase?

Kim: I do as a matter of fact.

Howard: Well, we'll talk about that. What do you think of Biolase?

Kim: Well, you know, if you're going to buy a laser and buy, you know, hard tissue laser, certainly that's why I've been using them for probably twenty years now. I've got their MD device and I use it... I really like it on minimally invasive restorations, smaller restorations, those class five, those NCCL's, those class five lesions. Class threes, class fours. I use it exclusively for that in my practice, so I drag it out and use it every day and I know that Stuart's teaching some periodontal regeneration with it as well, so I need to learn more about that myself.

Howard: I mean you're the leader in all this about cavities. Does any of this are transfer to perio? I know specifically with implants when I'm reading is that within sixteen months 20% of dental implants placed in America have peri implantitis.

Kim: And I say it again, you're going back to, we haven't diagnosed, maybe, what caused the periodontal disease or whatever the local and local environmental factors were that helped contribute to that. We know there's a huge genetic component. If you look at dental caries as a disease it's a biofilm disease. It has multiple risk factors and it also has genetic components. So does periodontal disease. In fact of the two hundred and ninety diseases that the World Health Organization recognizes and tracks, dental caries is number one in adults. Untreated dental caries is number one and that's in every country of the world, in every age demographic in the world. I mean, woo-hoo, we are number one. Periodontal disease is number two. So we're talking about two complex biofilm diseases that are, if you as a practitioner are struggling with these and feel frustrated from time to time you should. They're the two most prominent diseases, because they're the hardest to treat.

So, I think this whole medical management concept translates to periodontal disease in terms of local factors or environmental factors. The genetic component there is so big I think in periodontal disease that I don't know how you overcome all of that. I mean you know like John Kois says you are for everybody. I mean I'm not sure I can say that for every single person but...

Howard: I want to talk about one other thing that no one's, that a lot of people don't want to accept or talk about or whatever, but you know kissing. I have witnessed for three decades where you have someone, they're all through high school, they don't have any cavities, they don't have any bleeding points. Everything's good. They're moving along and all of sudden he comes in at twenty three and he's got four cavities and he's got gingivitis and I just stand there and I'm like, "Have you started kissing? Did you get a lover? Are you trading saliva with someone?' And he just looks kinda like "Yeah." I mean I've seen so many people but I'll go into dental offices in America and they'll see Grandma every three months for her periodontal cleaning and they haven't seen grandpa one time and after ten years he shows up with a tooth that he's got, bombed out molars 9 millimeter pockets, like do you think. Look at HPV. I mean how does...

Kim: No, Howard, please no.

Howard:  Do you think kissing is causing..?

Kim:  We share bacteria, right, and once a biofilm is established it's really hard to change that biofilm, but so even on a healthy adult. We get most of our bacteria from our mother and there was a study done, it's almost thirty years ago. They did a study on periodontal pathogens and bacteria in the mouth and they took, this is before we were as good at identifying, [00:58:45] Chequerboarding a [0.6] dental bacteria as we are now, but they took twenty couples, blind, and they matched all twenty people based on the bacteria from their oral biofilms.  So, who ever you're kissing, if that's a long period of time, you're in a long relationship with that person, absolutely, your biofilms are mixing mixing. You know, and the bacteria. So, yeah...

Howard: So, you're saying get rid of my...

Kim: ... Healthy doesn't mean you're going to start suddenly getting decay because this is somebody that has that, but I'd be pretty selective about who I started kissing.

Howard: So you think I should give away my three cats

Kim: Well, you know.

Howard: Ha ha! Final question.

Kim: OK.

Howard: And shout out to my mom because you said that we get it from the mom. I've had pretty much a caries free life, a perio free life. She gave me the fluorite drops in the... When I was a little kid and my five sisters and you said Stewie has done it for fifty years.  My next door neighbor Kenny Anderson, who made me a dentist. He just celebrated his fifty years and he's still practicing and he says that he thinks that if he retired he'd be bored. He likes.

Kim: Well I would be.

Howard:  He likes to get out [01:00:03] doing that. [0.4] Final question.

Kim: Yes.

Howard: You have, what is it? Five children, eleven grandchildren, but two of your children became dentists.

Kim: Yeah.

Howard: We just had six thousand kids walk out of school, you know, last May and we just had six thousand new kids just in our dental school and these podcasts are, about a quarter of them are devoured in the schools. What advice would you give to the graduating class, because sometimes they listen to these podcasts and, Kim, I know what they're thinking. I know my own kids are thinking, "Ah, Kim and Howard, they graduated in the glory days and they were lucky and they didn't have student loan debt. They didn't have corporate dentistry." What would you say to those kids coming out of school with all that student loan and debt? They're twenty five years old, they're listening to you right now, on their hour commute to Aspen, what would you say to them?

Kim: I would say get involved in CAMBRA, like as soon as possible. Like once you get your patients decay free, instead of putting yourself out of business, that patient's... You know, Bob Barkley tried to tell us this in the 1970's. Patients don't start buying dentistry until they quit getting cavities. And I didn't understand that as a young dentist, but I'm here to tell you, when you get your patients decay free and healthy magical things happen in your practice. So I would get involved in that out of the gate. If you want to be, have a lot of fulfillment and reward out of your practice, get your patients healthy and that is instead of drilling and filling teeth, be focused on what's causing those problems and solve that instead.

Howard: And you know what's sad is those kids just listening to you, they don't even know who Bob Barkley is and I don't think... I've been trying to find some VCR tape, some thirty five millimeter reel. I want to... Do you have any... You don't.

Kim: You know what I had a VH-tape. I'd have the look, Howard. I may have a tape of one of his lectures yet and I had his textbook. I sent it to a friend and I need to get it back, but I had a copy of his textbook and it's a very, very interesting read. He was, where we are right now, he was in 1970.

Howard: Ryan, we need to take that. What was it when we did the podcast with Brad Gettleman? At the end of that we posted the oldest video of a root canal ever known. Can we cut that out and post that on Dental Town under endodontics and say 'The Oldest Root Canal Ever Recorded'? Maybe under history, you know dental... No, no under endo, 'The Oldest...' But I thought that was so cool. We found, from the founder of Tulsa's dental products, the oldest root canal ever filmed.

Kim: Wow!

Howard: And it was a central, but I'd like to find some more of these legends, like Bob Barkley. If you ever find any of it. Omer Reed says he thinks he might have some tapes in his garage, but he hasn't found them yet. So we had an hour that's our show and that. We went to an hour six. But Kim I just want to say, seriously man, thank you so much for all that you've done for me, my career. Thank you so much for all you've done for dentistry, for posting on Dental Town, for making an online Dental Town. See, I mean, you've just been a mover and a shaker for, since you graduated. What year did you graduate?

Kim: 1979.

Howard: 1979! My god, seriously dude, I'm your biggest fan.

Kim: Howard. Howard, you've always been a hero of mine. I was telling your son, Ryan, before you came on. You've been so good for this profession. I know you don't take compliments well. I loved sharing the podium with you. There's years we spoke together, but you know, Howard, you have a gift of being able to say things that need to be said in this profession and that nobody else wants to say, they don't have the nerve to say and you bring up topics and, I don't know how you do a man, but you do it and you do it well. You know, you build such an incredible network and you have helped so many dentists and I, literally, you've been a hero of mine and a mentor to me and from a business side of this as long as I have known you Howard and I love you man.

Howard:  I love you more. Thanks for the kind words and you and I and Stewart, we've always told what we felt. I think it's a trust tell. I think if I'm going to sit there and put a tie on and lie to you I'm not a good guy and then when I take my tie off and tell you what I really think it offends, you know, a bunch of people, but I'd rather tell you what I thought than lie to you or sugarcoat it and you and I and Stewie, e always shot from the hip and told you what we honestly thought and we're all good for the profession. Thanks so much for coming on the show today.

Kim: Thank you, Howard.

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