Dentistry Uncensored with Howard Farran
Dentistry Uncensored with Howard Farran
How to perform dentistry faster, easier, higher in quality and lower in cost.
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1148 Cindy Kleiman CDA, RDH, BS, Oral Care Consultant with medically compromised patients : Dentistry Uncensored with Howard Farran

1148 Cindy Kleiman CDA, RDH, BS, Oral Care Consultant with medically compromised patients : Dentistry Uncensored with Howard Farran

3/1/2019 6:01:33 PM   |   Comments: 0   |   Views: 133

Cindy has spent her entire career working with the medically compromised patient. She was faculty at Phoenix College for 20 years. 

VIDEO - DUwHF #1148 - Cindy Kleiman

AUDIO - DUwHF #1148 - Cindy Kleiman

Cindy is a national speaker on medical emergencies as well as care of the disabled patient. She also lectures internationally on oral care for critical care patients. Cindy has published in both dental hygiene and nursing journals. She has been profiled in six national journals and has received five awards for providing unique care.

Howard: Well it is just a huge honor for me today to be podcast interviewing Cindy Kleiman. Did I say it right?

Cindy: Absolutely

Howard: Cindy Klieman you've lectured at townie meeting before and we're gonna have you back this year I'm so excited about that. Cindy has spent her entire career working with the medically compromised patient, she was faculty at Phoenix College for 20 years, she's a national speaker on medical emergencies as well as care of the disabled patient. She also lectures internationally on oral care for critical care patients. Cindy has published in both dental hygiene and nursing journals she's been profiled in six national journals and has received five awards for providing unique care and what I'm so excited about she's lectured in Japan over 20 times but this is our first podcast.

Cindy: Your right, you're my first.

Howard: So I want to start on that and I can't believe you were born in Phoenix.

Cindy: I was born in Phoenix, absolutely.

Howard: because I started practicing in Phoenix and in 87 in Ahwatukee and I don't think I ever had a patient that was born in Phoenix for decades. I mean usually everybody was a migrant so how did you get here how were you born in Phoenix where your mom and are you second, third, fourth generation?

Cindy: No actually it's interesting my father lived in Pittsburgh and his father was very ill this is like around 1950 and those days physicians told you if you're ill with lung to go to Arizona.

Howard: Was it TB?

Cindy: No wasn't but so my father got ready to move his parents to Arizona and the day the moving van came to Pittsburgh his father died so at that point he was already all moved everything was sold and they were moving to Arizona. So they just came so they were moving for my grandfather he died the day the moving van, so my father just moved out here and yes it was a very different place in the 1950s.

Howard: Now you live in Scottsdale she lives in the rich section I live in the poor yeah did you bring a gun to come visit me today?

Cindy: Not at all. No guns I have no guns

Howard: It's funny that I'm sure if you're listening to you're a young millennial dentist but lung functions serious because there's a lot of retirees in Arizona and I just was talking to a patient just real recently who lived in Phoenix but that's a mile I mean it lived in Colorado at a mile high right and he retired here and everybody thinks he retired here for the weather but he's just says he breaths a lot better

Cindy: Interesting

Howard: At sea level than a mile high and Richard Nixon his brother lived in Arizona man but when TB was a big thing. So if you have if you have lung function problems yeah living a sea level with no humidity is a better breath. So I want to start off with let's go historical because a lot of a lot of them younger kids how was hygiene change from when you started and became a hygienist and taught for two decades at Phoenix College how was it changed from then to now?

Cindy: Great question I think in my career which has been outside of the box my entire career because my very first job was in a rehabilitation hospital and if you're thinking years ago dental hygienists were not working in rehabilitation hospitals. Today the I think the opportunity for hygienist is just wide open that I hopefully I'm not that unique to work in ICU I'm not that unique to work in nursing home or rehab but forty years ago it was very very unique, it was very unique but the opportunities today I wish I won't be around the next forty years but the next forty years will bring huge changes to the field of dental hygiene and opened up our model is me going to be much more like a nurse practitioners model.

Howard: and what nurse practitioner model

Cindy: They're basically much more independent they they're much more independent practitioners and I think that is the way that dental hygiene for those who want to there will be a huge group who will never want to be outside the box it's much harder to have a career outside the box. So I think a huge we need those hygienists in private practice however for those people who do want to be a little bit more outside of the box the opportunities are going to really be there where for me it was a lot of banging on doors, it was a much more pushing and I think you still have to push you still have to really work hard to open the door but not as much.

Howard: So the independent practitioner is any individual permitted by law and the organization to provide care and services without direct supervision. I think it's humans they always want to believe that what's best and true in their own economic self-interest they they never they never get to say it seems like dentists have been trying to control hygienist my entire career and then when they when they asked for independent practitioners the dentist's is just like outrageous like shouldn't the patient be first and not the dentist economic business model because where I saw independent practitioner takes off first was in Colorado. I met many of the independent practitioners the they usually were in a town of a thousand that didn't even have a dental office right yes the dental societies are fighting independent practitioners. It's like it's kind of like specialist they don't want to teach you how to do orthodontics in school but half of American lives in 147 metros like the Phoenix Valley the other half live in 19,000 small towns. Where I've read that as many as 5,000 of those nights towns don't have one specialty recommended by the ADA and you go to a dental school and you say well these kids you learn Invisalign they say you know if you want to learn orthodontics you should go to ortho school it's like dude well this guy is going to a town of 1200 and they don't have any specialist and they should just... So talk about independent practitioners.

Cindy: Well I am not, I think there are many independent practitioners who were doing private care that's kind of not been my hat I have been independent but within a team sometimes the team like when I did homebound care for eight years with portable dental equipment prior to anyone having it as a business it was a public health grant. I did work with a dentist but she and I were not in the same patients home at the same time these were the years she had to wear a beeper in case I needed her.

Howard: Motorola beeper

Cindy: Yes yeah so we did do that or in nursing home care there is which I've done 18 years in Arizona there was a dentist but we were never there in the same day when I do hospital care I am supervised but I'm supervised by a nurse practitioner not a dentist because I'm not doing anything different than a nurse would do I'm not picking up a curette I'm not doing clinical care I'm doing bedside oral hygiene just like a nurse or nurse's aide would do so my supervisor is a nurse practitioner. So sometimes when you think about independent care it's not like I'm out there doing anything in the world I want but my supervisors are not necessarily a dentist because I'm not a private practitioner.

Howard: So the four four and a half percent of Americans will finish their lives in a nursing home I'm lucky I'm a man and there's almost no men in a nursing home.

Cindy: because they're all dead

Howard: Yeah they're all dead you girls live 5 years longer than us boys and which is just not fair and but when you go into I am I have spent several days where I went to an Arizona nursing home and I they're all there's a lot of things you say about them, they're all understaffed mostly cda, their's licensed practitioner nurses or certified dental or

Cindy: Certified nursing assistants

 Howard: The CNAs

 Cindy: Right CNAs

Howard: Which one year training and then LPN which is two

Cindy: Right

Howard: So an RN which is four years there's almost none of the four actor

Cindy: Correct

Howard: They're all so I hope this one's come off as racial or sexist wherever but they seem to be very small or women.

Cindy: I never noticed that

Howard: Well whether it's a lot of Latino and Filipino okay I mean in Arizona it's mostly Latino and Filipino so you know and so when you have some six foot 250 pound persons fall down they have to call an ambulance.

Cindy: It's hard, that's right, to pick them up.

Howard: and my first thinking of the nursing home is that there should be a state law that says there's got to be a man in here that's weighs 200 pounds that because a dead weight in the shower 

Cindy: To pick up somebody right

Howard: To get him to his feet and back in bed I mean that you you're not gonna do it with two little girls and but the oral hygiene is what I was interested in.

Cindy: Right

Howard: and this poor girl's gotta you know she works a wing she's gotta feed them all and give him meds. So the brushing came down to a little toothbrush a little pea swish swish swish swish swish spit in a cup and then the...

CIndy: but it's changing

Howard: Is it changing, what are you seeing now?

Cindy: It is changing, the number one reason why people die in a nursing home is due to pneumonia.

Howard: That's the number one, wow

Cindy: number one reason they die and the number one reason the number one connection is oral health or poor oral hygiene because if they culture vikas pneumonia they culture the sputum of the mucous 76% of the time it came from the mouth 76% of the time. So what in a nursing home what is a business and if a patient has to be transferred from the nursing home to the hospital that nursing home cannot get paid and they are losing two to three hundred dollars per day when their patient gets transferred to the hospital therefore oral hygiene is in their financial best interest to keep the patient healthy you keep the patient healthy you are paid for that care and you the number one reason is for them not to get pneumonia the number one connection the most evidence-based research oral systemic is on the oral health connection to pneumonia so that is like...

Howard: Isn't their vaccines for pneumonia

Cindy: That is only, yes that's one kind of pneumonia when the majority of people who die on a ventilator due to complications it's pneumonia, nursing home it's pneumonia, number one reason people get pneumonia Alzheimer's that's aspiration pneumonia. So it is pneumonia is really changing the game in nursing homes, assisted living, hospital care. It's huge and the nursing profession knows about it they are being pushed the most interesting thing is if you go to because I'm a hybrid I work with nurses as much as I worked with dental the nursing profession in critical care has had more push for oral care than any other kind of care because in ICU the number one reason why patients will die on a ventilator is because of pneumonia and it's from the mouth.

Howard: Wow

Cindy: So it's a huge push the dental profession is not as educated right now in what's going on in the nursing profession they are very tuned in to oral care because their patients die. So if you could imagine coming to to have a huge surgery and you pick the best surgeon you could find and they tell you're gonna be on a ventilator for a little bit and the surgeon just an amazing job yet you get pneumonia because the nurse does not do good oral care that patient dies that surgeons surgery is a failure from post-op so it's a huge issue and the hospital's know about it because they will not get reimbursed if a patient gets pneumonia. The hospital say look it's a preventable infection oh well so we're not gonna pay for it and it cost $50,000 per case if they live and 50% will die. So I would say the nursing profession that's why half of my lectures are to the nursing field is they're very much pushed for good oral care we're not sure what that means good oral care but that's what being there strongly being pushed to do it.

Howard: Wow so I always thought I I've had this one dental fantasy of my whole life I don't know like a an automatic car washer where you just stick in their mouth they bite into and it scrubs all their teeth. When I'm in nursing homes a lot of people have dementia Alzheimer's a lot of them have rheumatism arthritis how and then that that CDA is so stretched, how do you and then the other thing that I keep reading about is a geriatric dentist saying I've seen a couple studies where the average American gets one root surface cavity per month that they're in an extended living home. so grandma's been in the nursing home for a year she's got 12 root source cavities so what type of them how can you do oral hygiene when you're a CDA the patients got dementia what do you recommend?

Cindy: I accept it's not easy, I think many in our field kind of kind of go well how come the nurses are not doing a better job it is not easy but if oral hygiene is important we have to put better tools in the hands of that CNA. We have to give them better tools to use, if something is important at times like in hospital why do you get a toothbrush it costs two cents you know you're to not telling that nurse this is important so we have to give them better tools to use. We have to give them the time to do it and these are huge issues sometimes their would be more with varnish nurse they could do that it could be fluoride it could be chewing different products there's a lot of different products out there.

Howard: They'll want you to name them

CIndy: They'll want me to name them

Howard: They will, it's one of the bigger complaints we got there's no advertising on these no one pays money okay this isn't an ad but they always say like I'm like when you see a varnish time that a fluoride varnish what what brand?

Cindy: I don't know

Howard: You don't know but you like the fluoride varnish

CIndy: Yeah

Howard: Would you recommend that CDA uses manual or electric?

Cindy: A toothbrush if you can spend the money or if the family can bring in a power toothbrush absolutely that's gonna be the best bet to use. Number one it's easier for the nurse or the CNA if it's easier for them more likely they're going to use it right anything easier and they could do their job faster easier and better they're more likely to use it I've had patients if the facility does not have I talked to the families and bring it in it's very easy special you know is if the family knows the connection the oral health connection to disease, to pneumonia, to decay you know I always say they bring in Kleenex they bring in hand lotion they'll bring in the products as well so I don't find that an issue if I'm working in ICU and a family member comes and they go what is the hygienist doing in the ICU this is kind of strange and I explained what is the dirtiest part of the body ever they all go the mouth and I said where's the ventilator a breathing tube where's it going through to get to the lungs it's going directly through the mouth and then they go oh come on in hurry hurry you know and do the care. So families are very easy if you just explain it to them they will do it. They will help me if I don't have the right products they will go get it.

Howard: You know I have to shout out to my mom I think my mom is the only person is listen to all my podcasts I don't think I'm pretty sure there's no one else but mom was so neat so many people when you talk to nurse home people they tell you a lot of the kids are scared and my mom was a big believer and visiting the sick and the dying and she took me and my five sisters to a nursing home I mean all the time and we'd even back then you could even take your dog in you know yeah and our dog's name was lunatic and we would go visiting my mom says and I remember you know I had two older sisters and three younger and younger ones would be scared but I'm telling you yeah and you know you're supposed to visit the sick and you're supposed to visit the dying.

Cindy: Good for her.

Howard: and it's also about hustle like you know you have an hour lunch break and you're and you're one mile from a nursing home and you've never set foot in there and maybe after work you know it's about hustling I know a lot of dentists now or going in there and applying silver diamine fluoride to root surface cavities right and there's even a Medicaid bill like a lot of dentists their upper wealthy areas they take Delta but they don't take any Medicaid or Medicare but you're supposed to visit the sick the poor the dying and I know dentists now that are starting to participate in Medicare or Medicaid I mean Medicaid not Medicare just to try to put some dent in this route service decay problem dude what what are your thoughts on silver diamine fluoride?

Cindy: Oh well I've been lectured quite a bit by Judy Benton who I know you have had here and I know the results are supposedly very good. So anything we could do prevention hygienist is a prevention guru, so anything we can do prevent is much better than to treat. So I think that is great and your point about people being uncomfortable when I worked with students for 20 years going into either nursing homes or Hospital I brought hygienists, hygiene students into an ICU talk about being scared or being nervous I had some who love the experience and I had some who will never do it again and that's okay because I always say you know we're all not meant to do the same thing, we don't all have the same career. I cannot be in a pareo practice work as a private clinician and a periodontal practice I would be fired in a day that's not where I do well put me in ICU with the sickest the most sad horrible sad case and I see you and I'm right in there and I could do that but other things I can't do. So I think we're all different you have to kind of find your spot.

Howard: I remember in dental school the first day of oral surgery my bestest bestest friend when he saw the extraction passed out landed face first on the floor and broke his front two teeth yeah and he eventually got over and all that stuff but

Cindy: Did he become an oral surgeon?

Howard: No no he's in Santa Fe New Mexico and Chris Speier and there was a but then when we did another rotation we had to go to Kansas City Children's Hospital and it was four stories and the first floor was all the oncology and we had to do a week rotation in there and I just cried, I mean I thought those poor girls had the worst job in the world but some people they...

Cindy: That is where they're meant to be, that is where their meant to be it doesn't mean because you cry doesn't mean you don't have heart it doesn't mean if you could do this work, you know you still get care and some days are so hard and so sad but you pick yourself up and you go back the next day.

Howard: I remember that for one of the first faces I asked him I said how are you doing and it was this little bitty boy, bald, chemo and he says I just want to go to sleep and never wake up and I had to take a knee, you know what do you.

Cindy: Broke your heart

Howard: Oh it's like I wanted out of that place so fast. You worked at Phoenix College for 20 years I want to tell you, you're a big fan of access to care, going in nursing homes, stuff like that. The problem we have in dental schools which I think A.T. Still has addressed but most dental schools haven't is that I'll give you the story first and you know these dentists will be in small towns by two-hour drive from a big city and they tell me 20, 30 years ago you know I can't get any hygienist to drive from Wichita Kansas two hours down highway 54 to come practice and in my town I said well this is what you do you have your local high school do an essay contest so why want to be a hygienist and then whoever wins it you're gonna pay the scholarship Wow to go to the hygiene school and because the only the only kid who's gonna live in a town of 2,000 is a kid born there, nobody's gonna be Scottsdale and move to Safford Arizona. I mean you're going the wrong way you're swimming upstream the only people that truly live and Jack Dillenberg when he became the dean of A.T. Still, he said why are there no Navajo Indian dentist on the tribe, he said anybody that applied from any of these Indian reservations he was gonna accept and guess where every one of them went when they graduated do you think they wanted to go live in Scottsdale?

Cindy: They went back home didn't they?

Howard: They went back home the reservation

Cindy: Yeah that's great

Howard: and these hygiene schools and dental schools it's the same thing you're a Phoenix College for 20 years, when I go to Kingman Arizona here's another class Kingman Arizona and then a mile inward towards Flagstaff, there's a the mining town and we were there my boy was looking at the mine and I asked the mining guy said what what is the biggest problem is your thinking he was gonna say some international competition or whatever and guess what he said it was he is we need mechanical engineers but every time we kid from this small town applies to ASU yeah he doesn't have the high enough grades to get in. So then all the kids that graduate with 4.0 they all want to be engineers in Phoenix in LA and all these big cities so when it comes to access to care until the hygiene schools and dental schools that they should be top priority you're applying from a town that doesn't have a hygienist shouldn't that beat the kid with a 4.0 in calculus and geometry and trig. I mean there's just they're just and Jack Dillenberg was I think the first one that started saying okay this guy's got better grades than you but you're gonna go live in Tuba City Arizona and practice on the reservation.

Cindy: and the other one isn't

Howard: and the other one isnt.

Cindy: and Jack Dylan Dillenberg was the one who started the homebound program that I did for eight years. Access to care in private homes he was

Howard: and guess where he is where he is now so you know you're retired right?

Cindy: Yeah isn't he in Jerome? He's in Jerome

Howard: Yeah so guess what guess what he's doing in Jerome...

CIndy: I think it's just hanging out

Howard: No Jack Dillenberg the dean of the dental school yeah the most ambitious hyper guy you've ever met in your life I said well you're never gonna retire he says no I actually my wife said I got to retire I gotta go back to Jerome, three months later they were have an election for the mayor of Jerome so now

Cindy: He's the mayor of Jerome?!

Howard: Oh only Jack Dillenberg, he is so hilarious. He called me up yeah I'm talking to everyone going to the restaurants, I'm meeting everybody.

Cindy: He's the mayor of Jerome... sun of a gun I had no idea.

Howard: He's the mayor of Jerome, he owns a house there for a week and now he the mayor.

Cindy: He owned a house a week. Well he started...

Howard: I guess he lived in that house way, I guess his wife had the house

Cindy: I had no clue but he did

Howard: Maybe that'll be your retirement?

Cindy: No I don't think so but he started the homebound program but he believed in that access to care many years ago.

Howard: and when you're when you guys are talking about there's too many dentists their's too many hygienists and the crowded markets everything yet we have a distribution problem you know McDonald's doesn't say we have thirty thousand McDonald's because that doesn't mean anything to them that they have a McDonald's for every fifteen thousand people no it's 25,000 people. That doesn't mean anything they have a dentist they have a McDonald's for every 25 thousand people they it doesn't mean anything when they say we have thirty thousand McDonald's because they don't have them all in one corner and that's the problem with dentists and hygienists is they're not spread out demographically even and it all begins at the entrance and these like if you googled dental schools in California all the dental schools come up on Google search showing what their average GPA was of their freshman class well that's because they're trying to be oh we're the best dental school we're on US News and World Report right all these crap that has nothing to do about being a good healthcare provider which is going where you need and doing bread-and-butter dentistry where you're needed and I just wish they would just they get better on their distribution. So as hygiene school how does that changed in the last 20 years from you were you were there 20 years.

Cindy: I was there 20 years teaching

Howard: Thank you for that.

Cindy: It was my pleasure was totally my pleasure. You know I'm not in the I'm not there anymore so I'm not exactly sure how they're doing how things are going now but it was fun it was fun while it lasted so 20 years was really a lot a lot of fun I enjoyed it. I enjoy teaching whether it's this students whether it's in a course lecture whether it's in Japan to nurses or family members that's just what I the only thing I really know how to do is teach.

Howard: So you lectured 22 times in Japan?

Cindy: Uh-huh

Howard: My god I and I only done taped three podcasts I think from life from Japan.

Cindy: All over the country I've been I've been in probably every city in Japan

Howard: I always have said it's the most advanced civilization on earth. I mean every the trains everything works it works everything.

Cindy: The trains are if you are not there within you know I've told people going to Japan if they say a train leaves at 10:10 that does not mean 10:10 in five seconds that train will leave at tent town so you're on time.

Howard: and no one speaks on the train

Cindy: Oh yeah not like us, not here

Howard: America are redneck hillbillies but the thing I love about Japan is the culture bubbles up to make the longest-lasting cars on the road Toyota and

Cindy: I drive one absolutely

Howard: I Drive the Lexus you know my

Cindy: I have a Toyota

Howard: Mine is 2004 and it still hasn't even stumbled or blinked or whatever every time I'm going to the get the oil change they're like you want to upgrade to a new one it's like...

Cindy: Why, I have a Camry Hybrid I have a hundred seventy thousand miles on it are you have you beat me?

Howard: I've have a hundred and I think I'm at 160,000

Cindy: Okay right there nothing goes wrong.

Howard: Nothing goes wrong but the thing I like the most about lecturing around the world is you all have the same patience the same disease but you get to see how variables work like I was so stunned when I learned that the decay rate of Tokyo and Singapore because these are right across the water there one has water fluoridation the other one didn't but there DMFT disease missing and fill teeth trended down. So when I was at University of Tokyo and in Singapore their dental schools like so water fluoridation doesn't you know so what's the deal it's a non you know one has it one doesn't but there DMFT rates right down the side and they said that the their research shows that it was the increase educated behavior of taking care of your teeth was a far greater factor than water obviously than water foundation and so that's what I liked about going around these different countries. You know we put water fluoridation whoa just fluoride in the water a lot of European countries do it with their salt like we do with iodine salt for goiter. It's just easier to put fluoridize salt just like we do iodized salt so our country treats goiter with iodized salt other countries treated with but it seems like the bottom line is how your mom and dad and your hygienists and your dentist teach you to take care of your teeth is a greater variable than water fluoridation

Cindy: I didn't know that I don't know that but one thing I love about Japan is if you're talking about working access to care of disabled or medically complex patients nurses and dental professions are all together in the same room you when I go to London you lecture in the same room you go to Tel Aviv the professions are all together and I don't know why we're not doing that in the United States. Why do I have to go outside if you're gonna talk oral systemic it's so much better if you have something you could talk to about it.

Howard: It needs to be changed, so it all goes back to University of Baltimore it all comes back to the deal where the physicians needed to lay down bed and the dentists needed sit up chair and that chair to bed is why we separated in the West they didn't in the Soviet Union. S you went same for years undergrads and then then you decided that you decide that you're gonna go be a dermatologist Buster wants to be an ear nose and throat and I go into odontology so we're all the same what I liked about that is dentistry is all surgery.You know a lot of physicians don't do any surgery right just like most the far majority of lawyers never do trial work right and so we've you lose an eye or you get the disability and you're a communist dentist, you can just say well you know what I'm gonna go do another rotation and be an ophthalmologist, dermatologist so...

Cindy: I didn't know that, how interesting.

 Howard: It's easy to move around I like that part of it so much.

Cindy: I do to another country so that's much nicer to have different professions in London, speech and language therapists do oral care in hospitals not dental people not nurses speech a language therapists. So it's so nice to have a whole group of professions so you could sit down and talk together but in the U.S. I'm not going to be just speech a language conference with dental people together and it's you know a lot of people think we do it right here in the US but in some ways we don't at all.

Howard: and I think use the food chain and were beneath the MD's because in my 21 years in Ahwatukee anytime I invited a physician over to my house for dinner out for dinner or whatever it's like you count in 31 years maybe three or four but a hundred percent of the chiropractors and all which they've been to my house damn near all the pharmacists naturopaths it's kind of like the MDS they they don't want to come and they say what do you want to have us sleep apnea TMJ you know just any anything yeah so they're there it's a they're really separate. So you're speaking at Townie meeting which is what date...

Cindy: I'm Friday afternoon

Howard: Friday afternoon how many so that's about 35 day about a month away okay is it a month away

Cindy: I'll be there

Howard: So what date is um so you're

Cindy: I'm Friday afternoon

 Howard: On Friday afternoon so is that the what date is that's the March 20 so your March 22nd

Cindy: Okay I'll be there

Howard: Okay that's one two three four five weeks. What are you gonna be talking about March 22nd and will your course have beer? It's Friday!

Cindy: I don't drink beer it's probably drink beer

Howard: What do you drink? Some water?

Cindy: A little Sauvignon blanc, I could do a little Sauvignon blanc but I don't drink beer

Howard: I'm so Kansas I can't even say that word sauvignon blanc sounds French

Cindy: Yes actually generally new from New Zealand Sauvignon Blanc yes a little sweet little grapefruity, little sweet.

Howard: You know what I was most surprised when I lectured in New Zealand is how every restaurant you went to like America they all have steak right he's there they all offer sheep in the wines were pumpkin wine.

Cindy: I love pumpkin

Howard: You love pumpkin wine?

Cindy: I've never had it in my whole life.

Howard: I've always told my boys I said you know what forget college forget everything a lot of companies sell almost all their product on one day year like Valentine's Day roses and 2/3 of all the avocados in America are sold on Super Bowl Sunday I said if you just got the Halloween wine for Halloween yeah you have a hundred million dollar company because

Cindy: You got a good idea.

Howard: If 10% of Americans bought it just during Halloween you're the wealthy person on earth.

Cindy: Have you tasted it before?

Howard: Oh yeah it's amazing

Cindy: I love pumpkin

Howard: because people work with what they have local to when they eat so if

Cindy: New Zealand has a lot of pumpkins

Howard: Yeah New Zealand, Australia, New Zealand and Australia yeah the sheep and the goat and the but anyway eating sheep and drinking pumpkin wine.

Cindy Interesting, okay so we're we're going back what is my course gonna be? My course it's gonna be we're gonna start with ICU and the canal

Howard: What is ICU, there might be someone who doesn't know what ICU.

Cindy: Oh intensive care, critical care patients in critical care and we're going to touch about patients in critical care on ventilators because they're at highest risk from getting pneumonia and seventy six percent of the time it came from the mouth and I'll also show an assessment, nurses generally did oral care in a hospital blindly meaning they don't know how to look in a mouth everyone got you know it's one-stop shopping. Everyone have the same oral care whether you had horrible oral health or you had great oral health because they didn't know how to look in the mouth. So we'll talk about now worldwide how nurses are required to look in the mouth and how do you teach a nurse to look in the mouth, do you give them a probe do you give them a mouth mirror what do you do. So I have will I'll share a guide for nurses and we'll start with that. What is the oral health connection to pneumonia, why is this important and then we'll take that patient hopefully survives ICU, went into acute care maybe rehab and all the way into long-term care and what can we do as health dental health professionals for this patient from ICU all the way to long term care and hopefully to home.

Howard: As I get older I'm more curious myself, why is someone usually in ICU?

Cindy: Oh okay so example I am at Barrow Neurological Institute which is obviously we

Howard: The number one neurological institute in America.

Cindy: It is the largest neuro ICU in the world we have a hundred and twenty-four beds just  for 64 of them are ICU.

Howard: How many beds?

Cindy: 124 beds 64 of them are ICU and those are patients who either have a brain injury and had neurosurgery, had trauma to their brain, massive stroke. So these patients are often on life support they're on life support and that's kind of where for years I've done research on the oral health connection to pneumonia and it's been probably the highlight of my career to work with the nurse practitioner in the ICU because that research is life-saving and I could say probably with a toothbrush, with a toothbrush I have saved a patient's life not with a probe not with a curette with a toothbrush I believe I save lives. So that has really been the highlight I say the end and the highlight of my career is doing research in that area. So we're gonna start with that and we're gonna go all the way through.

Howard: and it's not just a local yeah I know everybody thinks their local team is the best on the stuff but I'm even on Google Barrow Neurological Institute is the world's largest neurological disease treatment and research institution and is ranked as the best neurosurgical training center in the United States founded in 1961 damn that's old I was born in 62 I didn't know I am barrows about is starting to get mentally ill and decrepit?

Cindy: No they're building more beds

Howard: but I cannot tell you how many stories I've heard in 31 years miracle stories from barrows neurological institute where someone else. I got to tell you that craziest story was with the dentist, nobody could find but I wasn't barrows it was actually mayo's his local town he was just getting sick dying sick dying the wife thought okay we're in a small town we're gonna go to the biggest city went there and after a day they said you know we don't know what's wrong with your husband but he's his organs are shutting down and he's gonna die and you need to accept that the wife was just like you know what I'm gonna bring about the Mayo Clinic. So she brought him to Mayo Clinic al was dead before he got there guess what they never checked a male dentist for? A yeast infection and they put him on nystatin and he was cured in a day because when because just the just the human condition I mean if I was really sick probably the last two things you'd think yeast infection.

Cindy: Yes I would agree.

Howard: but Mayo Clinic it's all they in fact she told me I had dinner with them both and she told me they said now which two hospitals did you go too and they said they said st. Joe and Kansas City okay those are good hospitals either one. So we're just gonna test you for everything that you wouldn't test.

Cindy: Sun of a gun

Howard: Yeah so you men out there remember that but anyway yeah barrows you must have a lot of fun out there?

Cindy: I have a lot of fun, interesting word fun, do I have fun and ICU. I don't know if I would use the word fun in ICU I have a lot of commitment I have a lot of passion I have a lot of purpose to doing it and it is wonderful it's wonderful to be able to help nurses do better care to do research be involved with a research team in doing better care but it's not easy to be in an ICU it's not easy to go into those rooms it's not easy to deal with these patients who could barely open or at all it's not easy to be with family who is who their loved one could be dead in a few hours hopefully get better but many sometimes they don't. So it is hard work it's emotionally could be very emotionally hard at times.

Howard: So if you listen to what she just said you're the biggest problem with all the big Internet companies FANG stocks Facebook, Apple, Amazon, Netflix, Google, is employee turnover. Do you know the average the average employ to Apple dating stay here a year and Facebook's only two years and it was Frederick Nietzsche who said in that lady Tanner's 1844 1900 he who has a why to live can bear almost any how and when I asked her it's nice working barrows all she talked about was commitment purpose and so I still think looking back at when I served my dental office the first thing we did is we my group got together Jack Dillenberg started the Arizona citizens for general health because I was so young dumb I thought we'd fluoridate Phoenix and in like two weeks. I knew as soon as I talked to the eighth city councilor they'd all vote for it.

Cindy: How did that work?

Howard: It was every Friday for two years but what I noticed is that it's like another friend of mine practices four days a week in his office but he teaches one day a week at A.T. Still. Well the one day a week is his purpose.

Cindy: Exactly

Howard: and that gets him through just drilling, filling, billing.

Cindy: I get it

Howard: and my team everybody who worked on that water fluoridation deal they had so much profound purpose and you and humans need hope they need purpose and

Cindy: I agree and a passion.

Howard: Yeah

Cindy: You got be passionate about it

Howard: Okay so how many hygienists and dentists have told us their burned out and fried?

Cindy: I bet a lot

Howard: Yeah cuz that's because the Frederick Nietzsche would say because he has a why to live can bear almost anyhow so if you're not if you can't bear it anymore and you're burned out and you're drinking beer for breakfast. What advice would you give them to get a better why a better purpose a better passion

Cindy: You know what you have to find it and sometimes I think it's a lot of luck sometimes you meet someone who finds see something in you that you didn't know you had and that was my luck that I was the director of my program somehow knew A this girl was not very good at scaling so she really is not going to be a great private practitioner some outs true absolutely true.

Howard: Really

Cindy: and somehow thought I would do good in a rehabilitation hospital working with traumatic brain injuries stroke and spinal cord and I said I don't think so and she goes just go go go take look interview see about the job and I got the job and this is many many years ago and somehow what she saw on me I'd lucked out that I didn't know I had is what it was inside of me and this person brought it out and I had two wonderful dentist who were my mentors who instilled in me that passion and I think people get burned out you somehow maybe you meet someone who gives you an idea on how to do something different or find a different challenge and then all of a sudden you get that excitement back and we all we still need this no matter how old we are we still need to have some excitement or desire and passion for what you're doing that hasn't ended yet.

Howard: I'm so old you know who my first dentist mentor was it was GV black that's how old I am. So you also have spoken many a time over the years on medical emergencies and the problem with the medical emergencies you know if you're not very good at dentures if you make one denture a year you're really gonna fillings if you do five a day, a lot of these guys don't have a medical emergency for ten years and then when it happens it's like a deer staring at a headlight.

Cindy: Okay got that one covered for you that's my other because I taught that for a decade that's my other really strong passion as medical emergencies and how I you are absolutely right, how are you going to do a good job if you haven't done it in many years and this is the answer this is the answer, when I teach classes they have to bring into the course like I'm in Atlanta next week 180 people I ask them to bring in their AED to bring in their medical emergency kit and we go through it we go through it. The dental profession is doing an excellent job of buying AEDs medical emergency kits they put them on the shelf and that's and they have no clue what's in it so...

Howard: They don't know what AED is.

Cindy: Oh a defibrillator for cardiac arrest and what I have them do because you are absolutely right, how are they going to be sharp if you don't do it all the time is once a month then I ask at someone else that's one person in the office and they get assigned once a month someone goes and they check that AED to be sure the batteries are okay the pads are okay once a month someone checks the medical emergency kit and that means from the receptionist to the doctor. So everyone knows plus I have cheat sheets I have label makers that how you use a certain product the in directions is not on the piece of paper that came with it's on the actual drug every single thing what to use because exactly you were right people can't remember and so that's how we do it they go through it and I would say the record so far was in Minnesota where someone brought in an AED and the pads that you would put on expired 13 years ago. So that's why the course is very hands-on they bring it in because they know they bought an AED they have no clue if they have batteries in it they have no clue if the pads have expired and or where's it kept. So it so has to be in a complete team approach where every single person in that office knows where that AED is because as a health kit as a staff member as a staff this is what happens someone goes into cardiac arrest if the dentist who has not had cardiac arrest patient their whole life owns in a AED but doesn't remember to get the AED because they're in a panic you should have every other employee who knows where it is and that's not always the case and the employees the staff follow the lead of the doctor and as I tell them dentists are human beings panic it doesn't matter how many degrees behind your name. So if the dentist panics or I panic and I taught CPR also for many years if I panic help me I don't care if it's a front office I don't care if it's a bookkeeper it has to be a team and everyone needs to be on the same page and that's fun to do too.

Howard: You say dentist are human beings yes but then explain why dentist can't swim because we jump in the pool we just walk on the water yeah we can't we can't kept beneath the water. You know I am the one thing I've instilled in my staff over the years at all the medical emergency is that you don't need a chain of command you don't need my permission to call 911 I mean we're all taxpayers.

Cindy: No but they will follow your lead right however 50% of the time when there's cardiac arrest in a dentist office.

Howard: It's the dentist

Cindy: The dentist is having you yes 50% of the time when the AED has been used in the general office it's not the patient it's on the dentist's.

Howard: Holy moly.

Cindy: You better make sure your staff knows what to do.

Howard: Wow I wondered why my staff threw away are AED.

Cindy: That's right

Howard: but you know but the last time we call the 9-1-1. I tell my staff, I said if you're a receptionist your front desk you're a dry hand and someone passes out in the waiting room well the time it take to come back and get me you could have already called 9-1-1 and the last time and I'm only I'm so lucky because I'm only exactly 1.0 miles from I'm at 48th and Elliot and 48th and Warner is a fire station so they're just

Cindy: Excuse me sometimes they're not waiting for you they're at another call and if you call 911 they may have to come ten minutes away because they were out on another call yeah that sometimes happens.

Howard: but some woman passed out and everyone up front said it felt like a bowling ball hit the floor but my office manager immediately called 911 and by the time I got to the front she was already hanging up on the phone and when you look at some of these deaths in Arizona where the staff is running down the hall trying to find other doctors in the deal and no one had call 911 and then later they in the lawsuit they say this kid asphyxiated they set the chair up so the child lost its airway and then the staff left the dental office looking for other doctors in the building.

CIndy: Yeah you can't leave the patient.

Howard: No one call 911

Cindy: and you don't need to ask a patient call 9-1-1 you do not need them for consent.

Howard: and the other thing I look at is like you pay a lot of you know a lot of Americans you say what's the most expensive thing you did with all your money in all your life they're always gonna say their house and it's always taxes. So the most money you'll ever spend your entire life is taxes, houses number two cars number three so that's one of the services you get for you get 911 and I've also I've called I think I've about every ten years we call 911 which they send out a fireman and it's usually fainting you know it's been all because and the and then I've called 911 twice on a patient that's gone up over the top on my staff you know out there's a front desk dropping f-bombs and being and I just tell them I said you know leave right now I'm gonna call 911 and then they answer with profanity so it's like okay I call nine one one then when the cops got there they said well he's gone now so are we good no no I have his chart here's this frickin chart here's his address he embarrassed everybody in here she's shaking her you know she's shaking but anyway. I got to tell you my funny story the first time I did I thought I was so young and dumb I thought well he's gonna go before a judge and I'm gonna go down there here they told me I went down there I thought she might want to hear my story yeah did he didn't get to me you know what she said no some judge some some woman says what did I tell you the last time you're in front of me what did I tell you so he'd been there before she sent him to jail she don't she's that I told you I never want to see you again and now what am I looking at yeah so yeah 911 when patients are dropping f-bombs and being completely inappropriate there's they're called police officers and when someone has a medical emergency dial 911 and then get your automated external defibrillator and all that which now they have at airports and there's a lot of public places where you see these.

Cindy: Absolutely there's no reason if you think about 50% of the time it happens to us not our patients you want to protect yourself yeah I have one in my home.

Howard: Really

Cindy: Absolutely

Howard: So that means if you have a heart attack you want to be brought back to life

Cindy: Today, I'm not that old yet, their will be a point but if you come to my home for dinner I got baby aspirin case you have our attack, I have an AED and one time a neighbor did call one time.

Howard: Now does barrows have a, do they have a dentist's on staff there?

Cindy: They do not have there's not a dental program they're not dentist to go up to the bedside that's a hygienist.

Howard: Last topic because I can't believe we already went over an hour but the one thing that really concerns me you know we talked about the dental schools and hygiene schools accepting on GPA and not distribution that's got to be fixed I think Jack Dillenberg is the pioneer of fixing that and he learned that from I think it was, who's that were that honest they named UofP after university of Pacific dental school the yeah oh my gosh I can't believe it's not disrespectful it's just old age, Dugoni the new Dugoni school of dentistry Art Dugoni and I got that before looking up he came to me the other the other issue that really bothers me where I think dentistry and hygiene dropped the ball is that in Arizona eight percent of medical emergency room visits or odontogenic in oralgenic.

Cindy: Oh yeah

Howard: I asked you a barrows had a dentist on staff and how come when I go to a hospital they could remove a tumor from my brain they could re plumb my heart they and they could amputate my leg but they can't do any odontogenic. Every one of those patients comes out with pen VK 500 million 28 times 16 to 20 vicodin I even had one patient I swear to God I still want a posting he brought in a two foot by three foot side picture I'm looking at a skeleton view for his toothache and it's like if 8% of all medical room emergencies not just in Arizona but for the United States America why isn't there a dang operatory and a dentist and a hygienist in every emergency room in America.

Cindy: Let's change that absolutely why is the I know a PA and she does abscesses you know why do you have a PA who's working on patients abscess.

Howard: Tell them what a PA is.

Cindy: Oh Physicians assistant right she could do an abscess i she does them every day why isn't it dental I don't know, you could do this

Howard: and I bet you also if you changes $400,000 of student loans and you're looking at gonna buy land and building or build something out you know you just got to be an entrepreneur I bet if you walked in half the hospitals of America and say hey will you give me free rent on five hundred square foot you know facility and I'm gonna put in a dental chair and cuz in triage when you go to a waiting room full of people right and you can get rid of basically one in ten by saying who's here because of a toothache and Cindy raised her hand well now you're not backing up triage I'm gonna say well you need to go down the hall and turn the left and we have the dental triage here but I think it's absolutely insane that in Arizona and another thing for demographics you know there's a lot of pre manufactured mobile homes I mean Ben Co I think it's the leader in that I mean there's they have they're working with the company that pre manufactures a dental office so you could be in some small town America where it's hard to get electricians and cement and all that stuff and bring in a whole dental office that's another thing you go to the hospital and say can I drop my prefab dental manufacturing deal in your parking lot and I because I know I've had breakfast lunch and dinner and I'm doing it again when is that Cass breakfast are you going to that one I forgot when it was it's one of these Tuesday's coming yeah it's next Tuesday 7:30 to 9:00 Chris volchek at brighter way Institute, which there's that's the place that does demonstrate for vets and it's a homeless shelter with the dental deal because when you're in a homeless shelter they might not be able to treat you for colon cancer or something like that but if when you got a toothache an abscess its primary care and I've met with so many of the movers and shakers in health care and those hospitals said that it's just it's a plague when eight out of a hundred people have a dental problem and there's no one in the hospital that can extract a tooth, do a root canal, do a filling and back to where...

Cindy: We need access to care.

Howard: Yeah it's like we're not part of the human body

Cindy: I know and it has to be we have to be attached. I like your you're saying about we split when one being in a chair and one needed to be in a bed I'd never heard that, that was great.

Howard: Yeah but it's so bizarre that I'm the mouth

Cindy: Is considered not connected.

Howard: So Ill end on my favorite trivia my dental trivia muster and you'll have to come a nice name the only animal with their jaw their mandible and maxilla is longer than the rest of their body you have to get that because you live in Arizona you're born are left in Arizona.

Cindy: Okay Arizona this is a related

Howard: You have one in your yard

Cindy: I do. I have a rabbit in my yard I've coyotes we have Bobcats what else do we have in Arizona

Howard: Hummingbirds

Cindy: I wouldn't have never gotten that

Howard: The only one whose jaw whose maxilla and mandible is longer than their entire body.

Cindy: Gosh never did I know that I would learn that today.

Howard: and that information is so important

Cindy: It's so important

Howard: You'll need that answer so many times.

Cindy: Well thank you for that

Howard: It's honor that you drove all the way down to the poor part of town today and look look at Buster you could jog you what's the chance Buster's packing Buster you packing a weapon in this part of town?

Buster: I only have a cell phone on me today.

Howard: You only have a cell phone, yeah to call 911 that's what I tell my boys

Cindy: Good that's all you need, we don't need anything else.

Howard: If you see a fight break down don't break it up, your not paid to break up fights you're paid to get out your cell phone and dial 911 but thank you so much for speaking at the Townie meeting and thank you for all you've done for dentistry.

Cindy: My pleasure Thanks 

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