Dentistry Uncensored with Howard Farran

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Howard: It's just a huge honor to start the new year 2019 my first podcast here with Dr. Dan Grob. Thank you so much yeah he is a legend in Arizona. Dr. Dan Grob owned Scottsdale Orthodontic Care in Scottsdale, Arizona, after selling his successful practice of over 25 years to two orthodontists in Tucson, Arizona. He decided to move with his wife Nancy enjoying his ASU educated children in Scottsdale Arizona. Prior to his move to Arizona he and his wife of 30 years were residents of Milwaukee, Wisconsin where they grew up within one mile of each other. Marquette University is where he received all of his dental orthodontic and prosthodontic education and he was honored with numerous awards upon graduation. This included the OKU Honorary Dental Fraternity as well as the ASN Honorary Jesuit Fraternity, He received the American Society of Dentistry for children and Senior Student Dental Award for his exemplary work with young patients. During the past five years he has been fortunate to accomplish practically everything a successful professional would desire including president of the Southern Arizona Dental Society directing the cleft lip and palate clinic at Tucson Medical Center. Instructor of histology and Embryology of Pima Community College, assistant professor of prosthodontics at the Marquette University School of Dentistry, Clinical Instructor of orthodontics at the Marquette University School of Dentistry, member of the Invisalign speaker Bureau. Being asked to publish in the prestigious American journal Orthodontics and dental facial orthopedics was an honor following his presentation of treated patients to the american-born orthodontics where he was certified as a diplomat. Dr. Grob also has published in the Dental Clinics North America as well as Orthotown magazine, You've been the director of what's now magazine for years it was 4 years as of today well thank you so much.

Daniel: Thank you and that's what kind of started my career up here in the Phoenix area that's great.

Howard: Really that's a certain yet so in addition Dr. Grob has been named the top doctor in Tucson for the past several years including 2014 we moved to Scottsdale and that same issue I was voted bottom doctor we have the top and the bottom and one time but I wanted to start the year with you because we both been doing this for three decades my office is 31 years old and I look back when I got out of school there hasn't been really radical changes than most of the night versus I mean the only controversy in pediatric dentistry is silver diamine fluoride you either love it or hate it. Endodontists I don't really if I had dinner with five endodontists they're not really there's really no big issues that are shaking but thirty years ago periodontal was the most turned upside down because of implants, from quadrant pareo surgeries and then you have the early doctors saying treated with extractions and implants and now you're seeing a shift back as you start seeing that after five years 40 percent of these implants that very implant tightness and all these very nice saying gosh I wish I would have kept the molar, but you know so you should be but your profession orthodontics just completely has the most change Invisalign, Smiles Direct Club. Even yesterday throw insult into injury I know you probably saw this but the German government posted a did you see that about that out they find no need, let me you see right here.

Daniel: I'll be real honest I didn't hear what the German government said yesterday.

Howard: Okay of course they're the ones paying for the work, they published an article as an "No proof dental braces work" German government report finds the study reached a damning conclusion that their was no evidence of black claims that braces provide long term dental benefits. I mean I'm sure you could say the same thing about it I mean you know so many things happen but so anyway so thanks for starting off the new year because I wanted to get to the most controversial topics Invisalign, Smiles Direct Club and the German government. Now you know the German government saying that because they're paying a billion dollars a month in ortho loans.

 Daniel: Right

Howard: So they're sitting back saying well we don't see that Suzy lives longer or last long, you know we don't see their's a health benefit so now Germany what's the pain so what what controversies

Daniel: Well I think we can learn I think we can address that topic by reflecting on the previous discussion we had about the Polish government pulling out of dental care in Poland and you offering a sum of money to a number of the Polish dentists to have a front tooth removed and none of them take the money. The beauty about orthodontics is that the government can tell us all day long that straight teeth isn't going to provide a health benefit and yet they'll still be beating a path to the door to have their teeth straightened as evidenced by Smile Direct Club and Invisalign and yes those are disruptors in the way we provide services. I don't really think it's disrupted the profession of orthodontics in the sense of we still do orthodontics to straighten your teeth. We still try to do the best job we can, we solve issues of growth and we don't solve issues of growth and development but we're we work with growth and development to provide a healthy individual as they go from youth to adulthood. So the controversial topics that you bring up are more delivery of care rather than the specialty of orthodontics. Orthodontics is still growth development cooperation, the pendulum has swung from non extraction, extraction probably a couple times in my career. You know you and I each have three decades of you know 30, 35 years of practice and I can still remember my program director, you know talking about the need to remove teeth and we went through the need to not remove teeth and now we're doing a lot more early treatment. People were beating down the doors to get in orthodontic practices and orthodontists found it was easier to just do one phase treatment and we really didn't know the benefits of early phase treatment. We said well you can just wait until all your teeth come in crooked we'll put braces on I can finish you in 14 months. Well I live in Scottsdale and practice in Scottsdale and I can tell all of my seven eight nine year old patients whose mothers bring their kid in with the first crooked tooth and say oh just come back when they're all nasty crooked and they look like a jack-o'-lantern and we'll straighten in twelve months because I've got the best brace that will take care of that. So people demand care and I think orthodontists have been reacting to that and yes Invisalign and and Smile Direct Club have really turned the business side of orthodontics upside down and it's basically a different way to do the same thing. When I gave a lecture at Marquette we had our fifty five year anniversary of the program and I was asked to give kind of a reflective lecture on my experience with Invisalign and I showed patient number one and I showed my most recent patient and what I tried to leave the audience with is, we use cosmetic appliances whether they be clear braces or we use cosmetic appliances whether and it might be plastic but we're still doing the same thing. So we bend the plastic to move the teeth or we banded the arch wire to move the teeth and the arch wire anchors to the teeth with clear braces, so we're still doing the same thing and it's upset everyone we had to learn a whole new technique and I can tell you after 15 or 20 years of doing Invisalign I feel finally that I'm getting comfortable at tackling virtually any project with clear aligner therapy.

Howard: What were some of your aces can you do within this one

Daniel: I gotta say 3/4 80% probably, I mean we've got in the in the lecture that I delivered I had class 1 division 1 class 2 division 2 class 3. Their are some of the Invisalign studs out there that are doing surgical cases with Invisalign. So I don't think their are many cases that can't be handled with Invisalign and the technology the techniques are there sometimes I'll start off a case with a fixed appliance maybe on the pallet or in the buccal segments like a carrier appliance or something like that to get some of the mass movement done but the vast majority of patients can be treated with Invisalign.

Howard: So this is Dentistry Uncensored, I don't want to talk about anything anybody else is talking about, so Invisalign has now opened up their first store.

Daniel: Yes

Howard: In Scottsdale Fashion Center

Daniel: Yes

Howard: Is that done in Scottsdale

Daniel: Yes

Howard: For those who don't know, he lives in the very rich part of town and I live in the poverty Phoenix area, but it's the only store in Arizona it's

Daniel: It's the only Invisalign branded town where I believe there is a like a scanning store in the Chandler mall

Howard: That's owned by Invisalign?

Daniel: No that's owned by someone else.

Howard: Smiles Direct Club?

Daniel: No I don't even know if it's owned by them

Howard: but the question is do orthodontists, what is your relationship with Invisalign? Is that love is it hate is it just competition? If your in Scottsdale and they have a store in Scottsdale do you feel like now the company you're using is competing against you? How does that relationship work?

Daniel: Well the way those stores work is that, they've branded themselves and I think quite honestly they're in the middle of redefining themself and then they're offered a couple of different options, do you want your teeth a little bit straight average straight or dolak straight I disagree totally with that concept and I'll explain why in a second but basically it's a referral service. The the guns from Invisalign had visited my office and basically said this is the the business model that we're providing and we see ourselves as we go forward as becoming a like a referral source for orthodontist we have had a couple of patients call from that store both of them have an account they haven’t scheduled, they've cancelled or rescheduled. So I don't know what the 6x will be. The thing that I find really interesting is for the first 10 to 15 years of Invisaligns existence they spent tons and tons of time and money educating doctors and proving to themselves as well as people like myself that Invisalign can do the most complex cases to fix brachytherapy standards and now they've turned themselves around and said ok patient you come in and you tell us what you want done and we'll treat to your standard. So I quite honestly I think they're kind of made a mistake, I think a lot of us that have educated ourselves to work with clear aligners have figured out how to do it you know really productive and effective manner and can deliver just the finest care and now because of Smile Direct Club they feel they have to react to the mass market.

Howard: Does Invisalign still own 19%?

Daniel: I understand that they've divested themselves at that and that some other manufacturers is doing the manufacturing for Small Direct Club because of the conflicts Smile Direct Club is becoming pretty successful with their you know let the patient decide I mean and we can go on here and you know their's postings on Facebook and my daughter has stories of her hairdresser that's going back and forth and there's all kinds of you know tragic stories of Smile Direct Club. The fact of the matter is as you know in dentistry their's patients that are disappointed after they visit an orthodontist also so in the world of dentistry Howard, I'm sure you've seen it when a big trend takes takes hold it takes would you say five to ten years for the population to kind of sift through what they've been told and then get back to reality and then once again dentistry is on a path to prosperity and and the way it used to be done there's their's always changes their's new technology there's new material but for the most part of fixing teeth and in orthodontics for the most part were making them look nice. I think the biggest thing in our profession right now is at least for me as an old guy is what cone beam technology has done as far as allowing us to look at patients in terms of volumes rather than panner X's and steps and photos.

Howard: I like that word you used "volumes"

Daniel: I didn't coin it I mean that's Shawn Carlson out of San Francisco is pretty much leading the trend in that and says...

Howard: We podcast interviewed him, I podcast interviewed him as a warm-up for you.

Daniel: Well Sean and his practice and Sean is an educator and a researcher and as you know he's he's starting on the ortho science which basically is working to document digitally everything that every orthodontist is doing in the world, so that we can all you know gain knowledge from that but looking at patients in terms of volumes and air spaces and airway is a whole different way of approaching orthodontics and I think over the next 10 to 15 years you're going to see that to take hold.

Howard: One of the things I can get my hands around is a concept about the legal about what do they call that, the standard of care. It seems like it's different for all 50 states it seems odd but is a CB/CT approaching the standard of care for an orthodontic work up or is that a far stretch?

Daniel: I think that's probably still a stretch at this point. I just think that you can solve other issues with CB/CT and I can still practice without a CB/CT. I mean I can find some pathology with a CB/CT for me it helps me do my job better and an approach growth and development better but you can still practice good orthodontics with a pan set and photos following the AAO guidelines which is kind of a kind of a nebulous contractor and or nebulous paper that talks about how you should have x-rays and photographs and these things. It depends upon what the orthodontist is trying to achieve and what and what he's presenting the patient's like I said orthodontics is a largely an elective business I love it when when parents come in or typically the father brings the child and you know he's looking to pick a fight because he wants me to say that his daughter needs braces and I as soon as the father is sitting in the chair I say well as we all know orthodontics is a highly elective business and if you're happy with the way your daughter appears right now we you know we can end the discussion if you'd like to go on we can talk some more and typically he'll fall back in the chair and let us take over and we'll have spacers in the patient by the end of the appointment. So it's the beauty of the profession Russ Kittleson my mentor in Marquette basically said you know as long as people can smile and see themselves in the mirror and they see the gap in the in the tooth or they see protrusion, they'll still want orthodontic care and I don't ever have to spend a lot of time on you know their bite this or their bite that or your bite is off or your bite is on the fact of the matter is everybody bites you know and and you can go to a third world country and everybody's doing fine in the streets with crooked teeth and so I just go out I can make this a lot better you know.

Howard: Dan I grew up in Kansas and both my grandparents are from Parsons, Kansas, but I had uncles that had zero teeth and would sit there and eat it all.

Daniel: That's right

Howard: and when I was in dental school I was there one time with one of my uncles and I said do you care if I hold up your lip and see you eat an almond, they're ridges are completely calloused and they would crunch almonds like they were getting hit by hammers. So I think there's plenty of evidence that edentulous and they were obese. So they're edentulous and they can eat so well they're you know I called it fat "feature meals already taken" and they were all carrying 50 meals of pre chewed stored food.  Is their very good alternatives to Invisalign any clear aligners?

Daniel: Their are new you know I know Henry Schein 3m, so great legs there's probably a half a dozen other companies that are now manufacturing aligners, plus big practices are buying their own their own software you can actually get software online for free that will do basic alignment they by a 3d printer and they suck down splints and they're making their own so some of the larger practices and some other boutique practices they're just making their own in-house aligners and it can be done.

 Howard: because the Invisalign(inaudible 18:27)

Daniel: It's a big cost yeah and that's a tough one, I mean I you know when I look at my practice and I you know and I look at the the percentages spent on labs and things it's definitely a business consideration and I've written about it in Orthotown where the modern orthodontic practice is not you know 10 chairs lined up and well there aren't you practices like that I take that back but I guess what I'm saying is that the modern orthodontic practice can function with fewer staff people in different positions in other words you certainly need a digital assistant. The skill set for the modern orthodontic assistant is very different I mean they have...

Howard: Did you even have a computer in dental school?

Daniel: No I didn't and I did my master's thesis using those IBM punch cards they were run through a like a card reader.

 I tell my I told my four boys there on New Year's Eve you know I said trust me you know you're 21, 23, 25, 28. I said you know when you're a grandpa 1/3 of the economy will be with stuff that's not even invented yet. I mean even you never saw any of this coming.

Daniel: My day yesterday, I mean I worked Saturday morning on patients, which we do once a month but I went back to the office you know Sunday and I had to do 8 Glen checks on Invisalign. I mean basically you bring up the that patient folder you double-check the work that the technicians have done in Costa Rica and you change things and you make it the way you want and this is what I've learned to do and now I'm starting to enjoy it at first it was Invisalign is kind of funny because when it came out they had technicians and you would write a note and say dear technician please do this and we come back was done very well at one point I had my own technician now they've gone to two teams of technicians. So in the beginning when clinched X software came out I thought wouldn't it be nice if we could do that ourselves and then of course we got spoiled because they were doing it for us and then they got big and their technicians weren't as well skilled and they said well you've got to do it yourself and I was spoiled I said I don't want to do it myself anymore but that was my first idea. I thought gee I should be able to do that well now we're back to the I'm pretty sure that the listeners will agree that if you want to deliver high-level clear aligner therapy you have to get in there and bend the wire yourself or have your technician do it to your standards you have to have preferences organized in your software for uploading saying okay I have a class 2 Division 1 patient, I want you to do this first and basically have detailed instructions and then we copy and paste those various instructions. So we have we have instructions for class one class two for anterior cross-bite and my digital assistant copies and pastes the word document into my prescription clinical prescription and then we upload it to Invisalign and it just saves time.

Howard: What macroeconomic numbers are you here like what percent of the 325 million Americans you think have had ortho?

Daniel: oh gosh have had ortho...

Howard: I'm hearing the five% and I really got religion on the power of orthodontics why was there no lecture I took three months for boys it was South Africa, Cambodia, Malaysia and I think Hong Kong, Japan but when I was in Cambodia and Malaysia I mean we were having dinner one night and the waitress was talking to us boys and she figured out I was a dentist. Immediately goes to Invisalign and so when we first start asking people about straightening their teeth and the brand name of Invisalign was gold in these developing countries like Cambodia where they're very poor and this lady, this girl very young beautiful she's probably low 20s and was spending twelve hundred and fifty US when she has a annual income of about five thousand dollars and there was asked her why she was Invisalign and when I have served you in the math and then I cross referenced other things like they're very many communities in Asia where women will spend forty percent of their income on health and beauty makeup this that and this girl who, nope no boy in Cambodia say she wasn't beautiful and she's spending 1,000 of her five thousand dollar annual income because this one's a little crowded and this one, and then we see that I believe when I'm Joe Hogan the CEO of the line technology was on him oh the CNBC who's that bald guy?

Daniel: Oh yeah Kramer

Howard: Kramer and what a handsome man and he was saying that only 5% of Americans have ever had ortho. So the upside for ortho for in my opinion the upside for ortho for the next century it's gonna be manic. I could easily see countries as they get richer and richer richer go from five percent of population having ortho to maybe a quarter.

Daniel: Well I think straight teeth and a nice you know the power smile like you said we going back to your discussion your polish experience. I think having straight teeth is one of the first things developing countries can do to kind of westernize  their appearance. I mean it might have been blue jeans and years past or whatever but now they can show that they're actually taking care of their body with a nice smile, that's a tremendous benefit.

Howard: What would his reference on that polish experiences on it was back in the 89, I think it was December maybe nine the Berlin Wall fell and my buddies in Poland were all upset because the government used to pay for all dental. They went to the dental government they did it and they said no you don't understand communism. Out here in American these people been taken care of cradle to grave and they're all they're never gonna spend their own money on their teeth and I said well that's based on the assumption that Polish people aren't the same types of humans as America's melting pot. I said that's crazy, I don't believe it for a second, so I went down there lecture and every time a Polish dentists would tell me that then back in 89, 90 that the Polish never spent money other teeth. I'd say okay well I'll give you $1,000 and I pull out 10 $100 bills if I can extract your front tooth and these women polish dentists their's like no way. They remind me of the you know what we learned at MBA school the health care is a little blue pill and the little blue pill you know humans they sing one thing they do another. The government people always said we spent too much money on health care, well that's not what I hear from the people because the people, if I go to a person and they tell me their five-year-old child is going to die of a disease and I say well I have a little blue pill if I give you this little blue pill then your child takes it, it won't die but it's gonna cost you, you have to give me your house your car, your phone, your computer, your teeth. You have to give me everything and what percent of the moms say take it all.

 Daniel: They all say it sure

Howard: They all say it, well that's funny because the government never says we spent too much money on housing and cars and phones and computers but I've never met a mother or a father that wouldn't go completely to live under a bridge in a box to save their child from dying from a disease when they could buy a little blue pill. So I said you know the Polish women want whiter brighter or straighter teeth as much as the women in Cambodia or New York. This beauty is huge and they just want to be beautiful.

Daniel: I talked about the fact that orthodontics is highly elective and back to CB/CT in and the importance of volume imaging and things like that. We are seriously learning a lot more about airway and breathing and removing teeth versus not removing teeth this discussion comes up in the message boards and Orthotown all the time you know where cases are posted which teach should I take out and I'll respond sometimes say what wait a minute why don't we jump to which teeth are we taking on, why don't we look beyond that and say me perhaps there's some muscle habits my functional issues and airway issues and things and their's a difference in the way that topic is being approached in various programs across the country. So their are you know we are kind of in a crossroads now between those that are latching on to that concept and those that are still stuck in the you know measure tooth size discrepancy and overbite and overjet and curve and you know you're diagnosing at 12 or 14 year old and deciding what that twelve or fourteen year old is supposed to look like, not realizing that the smile on the face ages into age 45 and the lips hang and they don't show as much incisor and they might be breathing differently or they had them off habit. So I'm a big mouth habit kind of guy you know I mean I believe that we as orthodontists are in because of mouth habits clenching, grinding, thumb sucking, nail biting ,oral facial issues, breathing habits, all that kind of stuff.

Howard: Their was a big controversy on the message boards. It was a very famous rapper Bhad Bhabie, she spent $40,000 on veneers and she's 15 and the dentist on Dentaltown had it out for because they thought 15 you're not old enough to have the teeth filed down for veneers, she should have braces and bleaching. Now when you and I were little and got out of school they were always filing down crooked teeth because many dentists, the biggest names in cosmetic dentistry lectured all the conventions were and it made me cringe. I mean I was a baby and they were sticking all the teeth and pencil sharpeners and couldn't PFMs and he thought what is that gonna look like in ten years they all said oh my crowns never failed, yeah i don't believe that. So the transitions come from sticking every anterior tooth into a pencil sharpener to do it work though bleaching bunnies. So I'm going to ask you specifically about this case 15 even 15 year olds and make a decision to file all their teeth down for veneers or bleaching? Well that's that's a price of being a rapper.

Daniel: 'm sure that that decision was made in conjunction with a business coach and parents and all kinds of things and they probably said well if we take the time out of your life for a year or a year and a half to put you through orthodontics it's gonna cut into your income or your tour or whatever so i don't know that that's actually the answer, better here's a good thing that I hear a lot is I have an awful lot of parents bring their child in with missing lateral incisors and a lot of

Howard: genetic

Daniel:  genetic missing lateral incisors and of course sometimes the dentists and what we just want closed all the spaces as if that has no long-term consequence and the parents asked what should we do and I said well tell you but what's usually done parents come in with her their kid and they say I want you to close the spaces because they're just thinking it's gonna cost $5,000 a tooth for implants and I said and sometimes we can do that I said but I've had any number of patients come back at age 25, 35 and 45 say can you open up those spaces again. So you know the best industry I don't know if this is the proper form to say this but probably that the best dentistry all things being equal would be none.

Howard: Absolutely

Daniel: You know but and I was that was taught to me by my prosthodontics mentors you know the best dentistry is none, unfortunately because of mouths habits and things orthodontics becomes like a necessity and in the developed world and their's any number of patients that I'm seeing for the second or third time on orthodontics and sometimes it's the orthodontist says well I can do it better than the last guy, he does the same damn thing and nothing really changes but you have to kind of take a step back and say okay so why did the I mean I try to give the first guy the benefit the doubt saying, I'm sure he or she did the best job he or she could do and now now we're left with this why did it end up like this? You know is it aging, is it habit, is it degeneration the temporomandibular joint. I got started with Orthotown with my my legendary article I'm going to call it that just because I get to "Treatment by 12's" which said you know in orthodontics you're dealing with the first 12 teeth that come in which is more upper and lower incisors and the formal four molars and then you deal with the side teeth which is the cuspids and versus second bias that's the next 12 then you deal with the 12 year molars. So I agree orthodontics into you know three different time periods age 6 to 9 10 to 14 and 14 and above and and during those periods of time you have to always look at the same thing which which teeth are in the mouth how are the jaws forming how's the joint working and our other habits, breathing habits are or muscular habits or things like that and I swear every time in those three periods you're always going to be reacting to those four influences on the dentition and if you look at relapse or if you look at stable cases it's because stable cases are because those factors are under control and relapses are because one of those factors overpowered the other. Degeneration of the joint oral facial muscular issues job problems that weren't address or teeth that didn't erupt or keep that drift because of missing teeth. I can't tell you how many parents or how many of adults come in with missing posterior teeth with flared upper teeth and spaces and they want they want that fix. I said well we got to kind of build up the back so that it's stable, well I don't, ya my dentist keeps telling me that I need that to the implanted or whatever but I just wanted my front teeth straight I said well you got a unstable situation, teeth are drifting shifting and all that guy stuff you'll be back again in five years. So it's education I mean you've seen it.

Howard: So the missing tooth genetic that lateral? Does that run in families?

Daniel: Oh yes totally totally

Howard: I mean we talked about the Invisalign store

Daniel: Yes

Howard: and now Smiles Direct if I go to my phone that's why I mean there's five centersm so let's talk about them for though what were they ...

Daniel: Well here's a good story because Saturday my first exam was a 35 year old guy who came in with an anterior cross-bite and spacing and we did it an Invisalign workup for him, he took a proposal away and my assistant came up to me afterwards and said just so you know he married so-and-so who came in for a Invisalign consult six months ago or even longer ago and she ended up doing Smile Direct Club, so I'm sure he's going to do the same thing. So it's impacting us I can't get I can't fall on my sword over it. I mean it's out there, when I look back at it I go okay so you know there's an adult with he had orthodontics in the past he had some orthodontic relapse, spacing and Smile Direct Club will probably solve his immediate need and life goes on. I guess my attitude is I think it's almost up to dentistry to decide does the Dental Board have regulatory authority over orthodontics. I for years said that orthodontics should be its own specialty and that we should have an obligation to refer our orthodontic patients to dentists and dentists should have their responsibility to refer to orthodontist and if you think about it we both be busier but instead we've gotten into this turf war over the years. If orthodontics would have started off as its own regulatory board years ago rather than you know sucking up to the ADA or whatever and you know we have to be nice to them where they will be nice to us but my good referring dentist won't send me anybody well if we were our own thing we would be our own thing.

Howard: I mean you're never supposed to talking about religion, politics, sex or violence and I tried very hard to all those but some things you have to. It seems like it might 56 years but the best way to understand this grass of America and other countries in the healthcare system if go back to the 1984 book the the rise and fall of the health care by Polestar, did you ever read that?

Daniel: I did

Howard: What is the best  book of the year called again (Inaudible 36:38)in fact I went back and read it again in like 2000, it's such a documentary but basically the were all because right now you where America if you study it it's last few years you can really advise to Health Care's and other developing countries where should I go to but it started out in 1900 where there was no regulation and everybody was just riding around curing everything with lotions and potions

 Daniel: That's right

Howard: So usually all have the same thing, alcohol, cocaine, heroin, you know they were all they would ride into town and no matter what disease you had you need to the same potion and it was about 1900 where the government finds this is crazy. So they rolled out the deal of the state borders and they made them the judge, the jury and the executioner. They said the boards will license the school of the med schools and med schools and when you come out of that and they will get your license in the state and so they were going to judge her and you can't sue the board if you go to the board and you don't like them you can't get an attorney and appeal it, you know you can't appeal it to anyone. So there the judge during the execution so that so in that one like five year period like 90% of all the med schools and doctors were unlicensed they said you're not so then he started that and that and at that time health care was 1% of the GDP and a century after that decision it was 14%. It was the largest rise of any economic sector. If you think Henry Ford's car was a big deal you haven't studied healthcare it was the biggest deal but now listening to the comments for instance members was in Tennessee where Smiles Direct Club is from, where their was a lawsuit with the said that was a mall can't bleach teeth and the local board sued them said sit down which of the court and the court said well you're a cartel you're just protecting your members this is competition and then I listened to all the young the  we have very few senators are with I think theirs 5, their's never been a president that's been a dentist or a senator that's a dentist or spring court dentist but their's fighting in Congress but you listen to the other congressmen and and they're using the term that these regulations are cartels to protect their customers and then the Smiles Direct Club you know when it started coming out on a lot of dentists are saying well these illegally and and but I haven't seen any legal challenge stop them and then there was the big Texas thing last year which was an earthquake where a guy was an implantologist saying he specializes in implantology then the local boards all said theirs only nine specialties recognized by the ADA and it was the court the court says ease a membership organization you're not a regulatory agency.  They asked this guy do you only do implants; he says yeah. Well he's not lying and you guys are a club so it looks like to me the last century of going from zero regulation to the strict boards is now gonna swing to deregulation over the next this is several generations.

Daniel: This is a timely topic because the column the first column that I'm introducing in the January, February issue of Orthotown talks about how we have to look at the institutions that have guided us all these years. My daughter is a classic example she's a millennial has worked for uber corporate she's worked for GoDaddy and now she works for homelight.com. All three of those are internet-based.

Howard: Uber. GoDaddy, and homelight.com. Home light what's that?

Daniel: It's like uber for real estate agents in other words you type in your requirements to homelight.com they find you a broker who is whose commission is cut by 25% and they use their artificial intelligence to find you the best broker to find out in your neighborhood with your requirements. So I kind of document her work history and I say boy this is the millennial generation is used to disruptive technology so to tell a millennial generation that old-time technology like dentistry and the boards and everything is the way it's got to be isn't gonna fly. So I think what we're gonna have to see or what we will see is that the old institutions like for four year dental education or maybe we'll go back to preceptorship or whatever our apprenticeships in orthodontics. You know Edward angle I think started its own school or tweet or something I can kind of mixed up but I mean there was...

Howard: He was the father of orthodontics

Daniel: Right I mean angle was but I mean their was a time where he wanted to be an orthodontist you latched on to a seasoned orthodontist followed him around in the office for a while you came out you're an orthodontist. So now we convinced generations that they have to borrow hundreds of thousands of dollars to get a quote-unquote degree in orthodontics meanwhile patients are you know taking iphone photos of their teeth and probably be scanning them with their iPhone soon and getting their teeth straight. So my point in the column is going to be that I think we're gonna have to look at the institutions of Education regulation a little differently because it's going to be changing.

Howard: So you and I live in the Phoenix Valley which has two dental schools, AT Still's in Mesa and Midwestern Glendale what do you think of their orthodontic education I mean they're dropping a hundred grand in there so they paid four hundred thousand dollars and most of them are coming out about how much state loans what letter grade would you give them on their orthodontic education when they graduate.

Daniel: Well the orthodontic specialty program at AT Still that's almost second to none of this doctor Dr. Park has been elevated to the board of orthodontics, that is a high level orthodontic program out in Mesa. They don't have an orthodontic program in Midwestern but they teach the basics of orthodontics. I employ a general dentist in my orthodontic practice to do some of the work that I don't have to do because she can do and she was taught very well at Midwestern on occlusion and aesthetics and follows directions and years ago we employed a hygienist in our genomic practice in Tucson who did our D bands and scanning for Invisalign and things that were legal and when I decided to venture into my second practice in Peoria is now I'm partnered up with a kid's dentist in Peoria. I didn't want to let the Scottsdale practice slow down, so I employ a general dentist and she bands you know but the first job of an orthodontist when a orthodontist is employed by another orthodontist ,okay you're gonna be banding second molars and you're going to be taking off braces and getting the adhesive off so that's the kind of stuff Dr. Van Dijk does in my practice and she's very happy. She enjoys her day and she's learning about aesthetics and that came and go farther. I mean we've done so far as to say okay when we have an hour booked for our patient have their braces off, offer to do a cosmetic workup on the mom you know we do you know photos and x-rays and things and we can talk to the mom about making their smile better. I've always been a big believer that everything and I'm sure you are too every general dentist should have photos of every patient just because when you bring them back to the recall appointment and they get this look at their teeth they instantly see things that you just couldn't convey to them you know in a verbal exam.

Howard: Well you know when dentist asks me if they think they should get 140,000 cad/cam or higher for CB/CT or $125,000 laser, I always tell them that the number one return on investment of any piece of elam technology is always the camera.

Daniel: Is a camera

Howard: and what they went and I see I've got a scene as many or more dental websites than any dentists in America because every time a dentist sends an email these kind of website link in there I look at it and the people that I podcast interview marketing agree with me that 50 percent of dental websites get an F and then the next forty percent you get like a D or C and then you see that one guy who's usually gives it to the assistant but they have digital photography their website shows all their own work what they don't realize that the internet so you say someone wants to get veneers or bleaching your bonding or implants or whatever and they go to your website and it's like just a mugshot of the dentist that says he was born in this town and then that's it and then they go to another website and there's like 20 before and after cases of an implant and overdenture for cosmetics or veneer and you're seeing when I was little only the rich people can fly in airplanes or they work for the government or the fortune 500 and what Southwest Airlines these people are getting on airplanes in Wichita and flying too Oklahoma City or Kansas City or whatever and I'm thinking okay you just left Wichita to go to Kansas City to have this guy do your implants and crowns or veneers or bleaching and their's like ten studs that I know of in wichita, you go to their website and their's no evidence of any of it. I mean to nail photography digital photography what he's just said it's treatment plan presentation, it's marketing on your website. This is different I like to go to some very uncensored things because I'm I think extremism is a big part of the human condition, I mean I see with my family my two older sisters went straight into the numbers yes that's taking a Catholic school to extremism.

Paul: Right

Howard: and you and whereas the other sisters were moderates, you know but I see these dentists making these extreme things like their orthodontist recommend extraction so they won't refer to memory and I not extraction the extremists. I understand that thirty years ago their was too much extraction but to say that there is no indication for I can the message boards I'm on Dentaltown all day every day. Their's a ton of dentists that think that their's no reason to extract. Well what would you tell that extremist who thinks that there's no reason to extract four bicuspids ever period, is he right or is he wrong?

Daniel: He's getting closer to where I am, if I look back and I don't want to come across as a non extraction orthodontics but if you become aware of the four factors that I talked about tooth eruption, skeletal, airway and the joint and you blend into it proper breathing, absence of habits and develop into the jaws you'll find that you can treat an awful lot more patients without removing teeth than you could in the past.

Howard: I want a percent for the United States

Daniel:  Jim McNamara who is older than I am, who I started my career with back in the 80s says that he probably removes for bi's in less than 10%of his patients.

Howard: Okay 

Daniel: and that's on a slide that he presents in his lectures on management early treatment I'll have to(inaudible 48:20)

Howard: Is that 10% of people who were properly managed from six seven years old all the way up or is that ten percent of his people just show up at your door for the first time?

Daniel: Well Jim McNamara is a professor emeritus in Michigan and he has the luxury of being able to see all kinds of young children at the proper time the ADA says you're supposed to see your kids dentists at age two they're supposed to your orthodontist age seven. So let's just let's let's talk in a perfect world and say if I get to see a kid at age seven and do everything I'm taught to do and wish to do and the parents can do to that kid, probably 10% or less where you need to take those bicuspids out.

 Howard: I got him to stand in the fire pit dude when you say never extractions ever it's a minimum of 10% now I'm granted when I was growing up there were dentists that their were thunders you did it on everyone well and don't be an extremist. It's the same thing with amalgam, when you tell me that you're metal free first like this immediately I think you're a freak. I mean do you fly in metal free airplanes, is your car metal? What is metal the devil. I mean what does that even be metal free and when you have the fastest growing population is women over a hundred, second is one women ninety two hundred third is women eighty to ninety and when they're going in there with full-blown dementia and when they go into nursing homes which is about four and a half percent of Americans end up in nursing home and they're getting a root surface cavity one month one per month is our average and they've taken into a dentists and they don't miss this lady doesn't even know the name of her children, doesn't know where she's at does own who she is and you fixed five root service cavities with an inert plastic composite when every geriatric dentists I talked she says that won't even last six months and you put amalgam in there or at least a glass onimir, and amalgam could last year's and you say well you don't you know you don't have a mouth yeah you're telling me that you got 2,000 patients he never saw one instant for an amount of when it's a little Johnny he doesn't brush it as and flaws he's worn the same UofA shirt three days in a row and you know he's got a little occlusal ted you put a little occlusal amalgam in there it'll probably last a 38 years and you put a occlusal composite there and a lot of six years and you say and your answer as a doctor dental surgeries that your metal-free you're not metal free you're a freak. That's what you are you're an extremist freak. So the extraction you know if you don't have an amalgam in your office this is probably the last episode of my show you'll ever watch because I just called you freak but the bottom line is their's a lot of extremism. I would like to talk about one other extremist issue, their are many many dentists who have told me in the last thirty years out there in the field lecturing that they're in a small town and say redneck Texas say they're in Edna, Texas or Beeville, Texas and he said if I did Invisalign I mean I'm in a small town going like ten of us managed everyone or enough if I do Invisalign case that orthodontist he'd never even talk to me again and we go hog hunting and we go red fishing and their's just a lot of dentists who feel but I never see that with the endodontist. I have never met an oral surgeon that said well you pull a tooth I'm not your friend or if you do a root canal you know don't call me.

Daniel: So here so you're saying that the orthodontist will never refer a patient to the general dentist too because it doesn't

Howard: He won't be his friend anymore, he won't be his friend. I know one guy just recently I was Texas well they, I don't want to get too many clues away or the other guy and he was doing an Invisalign case and so she went to the orthodontist because she was having trouble with one and he said to her you know if you want to learn ortho go to ortho school and turned around and walk away, wouldn't even talk to her about this case but she says and we agree if she had that problem with the root canal and went to an endodontist that other specialists would have said you're a sovereign colleague let's talk and she got basically the door shut in her face.

Daniel: My absolute best I don't have in Scottsdale and everybody's a super dentist okay you know they all do implants, kids in play you know Invisalign braces everything. So but my absolute best referring dentist in in Scottsdale those probably more Invisalign than any of my other referring dentists do and I know it, he knows it. He refers, the ones that he refers to me are the ones we talked about earlier on in the podcast can you do anything with Invisalign we can do it pretty much everything with Invisalign but he's an all-star cosmetic dentist who does he believes in myofunctional therapy, he understands the concept of growth development, he's a non extractionist. He does phenomenal job, he did my teeth. I mean he does a phenomenal work and he's a highly educated dentist and if you in  orthodontist has the luxury of being able to work with highly educated dentists both prosper well you know.

Howard: You just walked into the most controversial myofunctional therapy I mean whenever anybody says they believe in myofunctional on Dentaltown, I asked, I probably done twenty five of the greatest orthodontists ever on the podcast and every single one of them said what what percent are orthodontists believe in myofunctional therapy, they'll just blatantly say "none of them it's quackers" what I mean this ones are saying these are some of the most famous orthodontists in the  world total quackery but also to walk into that one my lips will very first have you confirmed the controversy of it?

Daniel:  I confirmed the controversy, I confirm the fact that it's very difficult to put your finger on the exact specialty itself, it really doesn't have an official licensing board but most of the myofunctional therapists that I've met are I'll say this jokingly and lovingly but it's kind of frustrated dental hygienist and looking for something else to do when they decided that they're gonna branch it into that group. They're very professional.

Howard: First explain what is

Daniel: Myofunctional therapy is muscle function therapy when I alluded to James McNamara starting my profession back in the 80s he was treating people with functional orthodontic appliances which is basically myofunctional  therapy for orthodontists. I don't believe that myofunctional therapy can solve every problem but I think everybody has to be aware of it and I think if you like I said if you follow my for tenants eruption of the teeth jaw balance joint function the last one is airway and muscle function and airway and muscle function has to be normal. I think a lot of myofunctional therapy needs are because of bad airway a lot of bad airways is being solved now with expansion phase one treatment, which of course is controversial also if you followed the orthodontist board or read the column that I write I'll talk about how early the orthodontic care is becoming more of a norm and I'm accused of being in it for the money and you know darn well you can straighten people's teeth if you in 14 months if you wait till they all come in crooked. I'll say I agree but you haven't done the patient of service. If I look back at my 30 years of finished cases and they're like 20,000 or so. 

Howard: 20,000 Wow

Daniel: Yeah that's pretty good right. If I look back at my finished cases they look nice and I got my boards and I put my plaster on the table which is what you're supposed to do. I don't think I have enough expect lateral expansion in my cases and I think you need a lateral expansion to solve a lot of problems better.

 Howard: How many orthodontists do you think are the United States?

 Daniel: 15,000 or less

Howard: How many do we mail Orthotown too?

Daniel: Something like that

Howard: Okay 15,000

Daniel: Yeah

Howard: Okay so let's say 15,000 orthodontists each did 20,000 cases like you, which you've been doing it for three decades they haven't. So you have another meeting and I only get you for a couple more minutes

Daniel: I'll come back

Howard: I'm going to go into the other... You know I tried to be a journalist. I've had a monthly column since 1894 I mean I'm a dentist but I tried to be a journalist and I think journalist look for clues and the clue is usually pop up and the controversies, that's why I call this dentistry and censored I don't want to talk about anything everyone agrees on but the most controversial thing on Dentaltown, we started it on the st. Patrick's Day we got the idea in 98 when we got it up and running on March 17th 1999. So we're coming up on our 20 year anniversary and is occlusion I mean my god they don't have these big boars on I mean occlusion and the only way thing I can summarize it is world religion like my sisters do you think I could done the online dental course and change my oldest sister Catholic nun to a Hindu or Buddhism or Judaism. I mean I couldn't even convert her to a Lutheran and I'm not really sure I mean the difference between the Lutheran and the Catholic you almost have to be an attorney.

 Daniel: Right it's Mother Mary and(inaudible 58:27)

Howard: I don't know if im even smart enough to describe the universe in numbers but I know I could not convert it to a Lutheran and to me the occlusal hands are the same. First of all do you confirm that.

Daniel: I will confirm that I started my career in dentistry during the occlusal Wars

Howard: Yeah the Wars they were fighting they were there were ricing words

Daniel: Their was you know pinky man and we had Ron Roth orthodontics and then there was the argument articulators worthwhile or not worthwhile. I lectured down at AT Still and I bring my articulate and they look at me like I'm crazy I think I think occlusion is is is important I think that it's it's influenced by myofunctional issues. I think that people that have horrendous bites get by because they meet muscular compromises or what yeah I guess if the muscular compromises so a patient with an open bite sticks their tongue between their teeth or maybe sticking their time between their teeth cause the open bite I don't know but that patient will do fine when they bite down we'll see we're on the back teeth and the dentist gets up worked up and says oh my god you're wearing down your teeth. Well perhaps the jaw joint is dissolving causing the back teeth to hit harder so now they're wearing down their teeth because of the jaw joint dissolving. I mean you know it's just multifactorial and and I you know whatever when a young dentist comes out within the first five years they see one of each of these little problems and they you know they go crazy because they, oh we can't have this well take a look and you'll see that this patient is perhaps lived with this for a long time or they made compensatory function arrangements for it and it's kind of like my father you know goes to the dentist stage you know 75 and he's totally is six cavities that have to be done instantly when he hasn't had anything done for 25 years and and you kind of wanted well you know his immune response is pretty good or it's working or whatever but I mean, I do believe in you know in a stable position from which to diagnose. I mean my first life was a prosthodontist so I mean I went through Stuart articulate errs and dinars in hand house and all this kind of stuff and did full mouth reconstruction but oh god there arch tracings  you know all the lingo and I remember it but I don't know how to do it anymore. I don't think,

Howard: Why did you not stay as a prosthodontist, why did you journey to ortho?

Daniel: I think you can probably tell them a little more animated and a kid at heart and I just kind of I think the prosthodontics practice back then there wasn't a lot of delegation. So it was 100% hands-on in other words I would have patience for you know four or five six hours you can bring a lunch you know and and that's just my attention span is too short. So I met another dual trained you know chuck bull was another dual trained prosthodontist / orthodontist in Milwaukee, Wisconsin he encouraged me to go back to ortho school. I was teaching at the time and I got free tuition.

Howard: and your teacher at Marquette 

Daniel: Yeah

Howard:That was back when it was a Jesuit school

Daniel: It's still a Jesuit school

Howard: but do you remember the story was Rudy Shelters at Lord jano studio .

Daniel: No

Howard: So you know it was a Jesuit school but they decided to budgetary those everything close it down yeah and the biggest lab in Wisconsin it's Lord jano studio at the time the CEO is Rudy Shelters, he's like what do you mean you can't close this school down. They go no its losing money for too many years we're closing down. So he aragned it, so he got the state and the Jesuits sit down so it's the only half Jesuit half government.

Daniel: Subsidized

Howard: Yeah right and Rudy Shelters saved an entire school and so for all you right wingers you think everything should be free enterprise there's a classic example with that school, you know I think the most functional government, when the government and the private sector work together well.

Daniel: I have nothing but great things to say about Marquette, I mean they launched my career as a prosthodontist. I got tuition went back to school and yeah rick kirschner was my lab partner

Howard: of Comfort Dental and he million dollars

Daniel:Comfort Dental,  a million dollars., and after graduation I told Rick I said well you can go to Colorado you'll never make any money in that blue sky state and he still digs me on that one.

Howard: He was your lab partner

Daniel: Yeah

Howard: Tell Rick to come on the show. He's got the most expensive home in Cave Creek right 

Daniel: Desert Mountain or something

Howard: Desert Mountain or something it was in the newspapers, I think two or three years ago when he bought it, it was and he gave a million dollars in Marquette.

Daniel: and I told me he'd never make a living

Howard: We've been best friends forever and he won't come on the show

Daniel: Rick and I sat right next to each other in dental school.

Howard: Yeah what a hell of a man, I think he and Aspen are controversial because they focused on the poor the Medicaid the Medicare.

Daniel: Well I think what Rick also brings to light is that the time to do something disruptive is when you don't have to. You know back in the days when Rick decided to drop fees and treat the people under served, he didn't have to do that because you could go out in the 80s and 90s and make a damn good living without doing that but he said you know we can really change the world by doing this. Just like Uber, just like Smile Direct Club, I mean so disruptive technology always comes from outside the industry you know and I think Rick really disrupted the industry.

Howard: and that's why dentistry a long history of elitism and that's what Rick and I really agree on the most that's our blood connection yeah that's way both. When you grew up in Kansas I mean it's hard to be an elitist  I mean Peter Rose when I was little both of my grandmother's still in Parsons, Kansas had an outhouse.

Daniel: Well I star on a map on the south side of Milwaukee and with pretty much I mean pretty much and when I meet people in this neck of the woods or in Phoenix I mean and I meet someone from Milwaukee it's never from my book it's always from the upper you know North Side or whatever says oh really you know, so yeah I mean I have roots.

Howard: Last question because you got to run, one of the bizarre things that I keep reading about it is coming from the anthropologist not the orthodontist but you keep seeing articles and I keep posting them on Dentaltown under the orthodontist section, where anthropologists are saying we don't see all these metal occlusions going back the last month they just popped up out of nowhere and their widespread and I mean look into that thing and you know feeds ASU has Lucy the oldest hunted fossil ever found a 1.6 million years old I think she's 40 inches long 17 years old still didn't have her third molars in and when you start talking to an anthropologist now they're starting to ask orthodontist do you realize that and then you go back just a few hundred years of it just pretty much disappears. So that makes you realize it had changing the diet, habits, breathing....

Daniel: Habits and breathing, sure

Howard: So do you see the words orthodontic community light like they use I've got Parker's up here takes you self do you think the orthodontic community is gonna try to do a deep dive into finding out why do all the Neanderthals and cro-magnons and Nelson's not have it and we all do?

Daniel: Well it seems like the advances in the research in orthodontics is always just like it is in medicine I'm treating the problem rather than looking for the source. Shawn Carlson's ortho science project is looking back at treatment I don't know that we're really going back to look at the cause. I think it supports my interest in myofunctional therapy understanding that proper breathing airway ,width of the maxilla all these kind of things are very important. So I think not that I'm not that I'm a leader in the field but at least I have latched on to that part of treatment I write about it in Orthotown and I think that we start we have to start looking at it.

Howard: Well do that because to me it's massive or asking but imagine the last 2 million years that's about how alert species is 2 million years the little kid would have been chewing on meat on a bone and meat and now nearly breastfed for years and now the minute the child has just a little problem breastfeeding you switch them to a bottle which is nothing on that so they're not developing the muscles they're not chewing on plants.

Daniel: You also be amazed at how many young kids that come in and we're real big I'm referring for lingual frenum removal and I can't tell you how many kids come in with narrow maxilla and protrusion are tongue-tied and we're having our piedadontist friends and and other lactation specialists cut the lingual frenum to help you get the tongue to the roof of the mouth develop the maxilla things like that.

Howard: and dan mentioned  allergies couple times, that's another thing they're finding out that see the asthma and allergy problems are massively more in the 20 richest countries than in the 50 poorest countries because the immune system needs to be developed you need to be crawling around in the dirt getting grating our boiling bottles and hand wipes and this kid never gets exposed to an allergen and then you want to know why he has all these allergies and all these problems and I say many of these in my mom and it's so funny I say teaser so much I say thanks for not being a good cleaner because none of your kids have these allergies, we grew up in Kansas, you would do just play on the back door, we all had a garden no one you didn't have to take your shoes off when you come inside and and by having a that type of lifestyle your immune system is developed in and there was just another article on it this Sunday again saying kids need to be exposed to a lot more allergens at a real early age and that does it coinciding with hand wipes and cleaning everything.

Daniel: Yeah I agree with that.

Howard: Gosh thank you so much for coming on the show, Happy four year anniversary to Dan Grob

Daniel: Thank you