Dentistry Uncensored with Howard Farran
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1471 Dr. Robert Mier & Dr. Stan Farrell on the Specialty of Orofacial Pain : Dentistry Uncensored with Howard Farran

1471 Dr. Robert Mier & Dr. Stan Farrell on the Specialty of Orofacial Pain : Dentistry Uncensored with Howard Farran

9/30/2020 3:00:00 AM   |   Comments: 0   |   Views: 532
Dr. Mier completed undergraduate studies at Albion College, then received his dental degree from University of Detroit in 1984. His journey to orofacial pain primarily began as a patient looking for answers, and eventually led to the craniofacial pain center at Tufts University. He completed a one-year fellowship, and then completed a Masters program in 2011. Subsequently he joined the faculty and was eventually the director of postgraduate education in orofacial pain. He returned to full-time private practice in 2015 to the present. He has been active in the American Academy of Orofacial Pain (AAOP) leadership and is currently the president-elect of the organization. Dr. Farrell was born in Toronto, Canada. He completed undergraduate studies at Arizona State University and attended Columbia University School of Dental Surgery. He later attended UCLA’s Orofacial Pain program and successfully received his Board Certification in Orofacial Pain. Since then has practiced Orofacial Pain in Scottsdale, Arizona. His practice evolved into the Head Pain Institute, a center for clinical excellence founded on evidence-based practices, research and development, and a center for learning to help keep general dentists and specialists on the cutting edge.

VIDEO - DUwHF #1471 - Robert Mier & Stan Farrell

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It is just a  huge honor for me today to be podcast interviewing two of my neighbors who are just about oh I don't know 10 miles up the street I’m down here in the very poor section of phoenix they're up there where all the money is in Scottsdale you can tell by their attire I can't even afford a jacket down here in phoenix uh on the right is Dr Robert w Mirror DDS MS you know him from Dentaltown he has 4 000 posts on Dentaltown he completed his undergraduate studies at Albion college and received his dental degree from university of Detroit in 84. he then completed a general practice residency with a focus on oral surgery at Rhode island hospital he then owned a private practice in Rhode island from 85 to 2014 his journey to oral facial pain primarily began as a patient looking for answers and eventually led to a craniofacial pain center at tufts university he completed a one-year fellowship and then completed a master's program in 2011. subsequently he joined the faculty was eventually the director of postgraduate education and oral facial pain he returned to full-time practice in 2015 to the present he has been an active uh member in the American academy of oral facial pain the aaop leadership and is currently the president-elect of the organization congratulations on that bob that's amazing and then to the left Stanley e Farrell DDS he was born in Toronto Canada completed high school in Scottsdale Arizona completed undergraduate studies at asu Arizona state university attended Columbia university school of dental surgery followed by a gpr at montefore medical center an oral surgery fellowship at the university of Chicago he then practiced dentistry with a concentration in oral surgery implants full mouth reconstruction and tmd in Arizona for 12 years he then attended ucla's orofacial pain program and successfully received his board certification in oral facial pain since then he's practiced oral facial pain in Scottsdale Arizona his practice evolved into the head pain institute a center for clinical excellence founded on evidence-based practices research and development and a center for learning to help keep general dentists and specialists on the cutting edge um I um gosh stan and bob I know this is a dumb question but um I got a quarter of our listeners are still in dental kindergarten school they're at a t still midwestern I knew I want to start with just the basic what is oral facial pain because I mean they already know um you know there's 12 specialties now and it's a new one so exactly what is oral facial pain and why is it a specialty well I think we can you know kind of distill it down to the simplest situation it's kind of the diagnosis management of treatment uh pain conditions in the jaw mouth face and associated structures think of it that way so I look at patients from the shoulders up any pain condition up there we kind of you know falls into our wheelhouse that we can treat problem is that specialty came about for a couple reasons one a huge issue with access to care there's not enough people trained in oral facial pain so there's a tremendous shortage if you look at maybe what uh endodontists or oral surgeons figure around ten thousand in the country there's 250 of us that are board certified so secondly it's kind of out of the public view nobody really knows what it is so I think you know we need to publicize that understanding so people know who and what to refer to us and then far as creating a an improvement in you know the um educational component as far as the pathophysiology of understanding these conditions and increasing the evidence base to allow us to more effectively treat patients so it's in between medicine and dentistry and it's not taught in undergrad medicine or dental school so a lot of people fall through the cracks with a lot of conditions that go years without treatment that we I think we can help now well speaking of cracks you know when you look at the floor of the pole you  can't ever find the mb2 but you can definitely see that crack on the floor um out of all the specialties you could have been how what was going on in your life in your journey where you ended up in a place where only 250 other dentists are instead of where the other 200 000 dinosaur did you get lost yeah how'd you do it stan I mean I think our stories are a little similar but yeah pretty  similar so you know we uh you know as Dennis you end up finding things that you like in your practice right you like to treat so like you know for me and I think for well you know bob as well is like we had an interest in tmd and full mouth and doing all these things and we both went to panky and kind of did that whole thing and you find out like yeah you know a lot of this stuff works but there's something missing there's something missing because you know you can only get a percentage of the patients better and  what you find out is it's not all occlusion it's not all teeth it's there's someone else involved in treating the actual head the entire head and neck of a person right as well as the jaws and uh you know when you get into looking into or facial pain or medicine you find out yeah there's a lot of things you know the joint is a joint uh independent of occlusion and independent of these things as well as the uh the nervous system the musculoskeletal system all those things and then once you the further you get into you realize wow this is more of a medical condition and less of a dental condition but the thing is as a dentist you're not exposed to that and that's the thing a lot of a lot of the dental schools and a lot of the programs they either aren't going into that territory you know for whatever reason um but whatever reason it is that they're not going into the medical side of things I think a lot is missed and what we've found is that by going into that into the field of you know or facial pain which is more medical than dental we're able to treat patients more comprehensively and we get really good results so our success rates are in the 90s for getting patients better with tmd and it's funny because you know for the longest time dentists would be like these are crazy patients you can't get them better you know what I mean and what we're finding is a lot of these people are actually crazy or nuts because they're not getting better and they've seen three or four different people and they get frustrated and their behavior becomes you know erratic and weird so they get labeled as crazy so there's very few actual crazy people uh it's mostly just they're frustrated with not getting better and um so it just became a specialty this year I mean um bob you posted this on Dentaltown I think it was uh um just April 3rd this year today the ads announced oral facial pain and you had a link you had a link that um um basically um below is a link to a recent national academies report that recommended this due to the fragmented nature of the field and the poor access to care with patients and I’ve always been saying all along that um specialties you know the ada always is you know a bunch of dentists get in a room decide if it's going to be a specialist and I think that dentistry doesn't even begin until a patient goes to a dentist and gives them a coin and says can you fix my tooth so we should be patient focused not dentist focused and that was the case in Texas where that guy was saying he was an implantologist and then you know the board was saying well that's not one of the specialties the judge said according to who and they said the ada and they go well the ada is a membership program it's not a government agency but I always thought my god if I had an implant and um you know and one guy had to place it and one to restore it and someone else you know it'd be nice just to go to well here's a guy that just does implants uh so I think the specialty should come from the patient's want not what the dentist demand but um is especially working out I mean how's it going well sure I mean it was 40 years struggle you know to get us here it started 40 years ago so I think it's so early on that we're still trying to let the dust settle from the decision certainly you know this fields can be fragmented at times and so I think our goal is to make people understand we're not trying to usurp anybody's ability to treat patients any more than any other specialty does we're just looking to evolve it and give patients access to care where they haven't had it before with somebody whose primary focus is on just those issues all day long and our practices stan alluded to is you know more of a medical model than a dental model but out of necessity so we bill medical insurance not dental insurance which is another big leap for a lot of dentists although I know that's become a little more of an issue with sleep coming into dentistry with people understanding that um you know my journey same as stands although different in one aspect was I was a patient and had a lot of issues that had no resolution that I could find even though I went many places trying to find help when I finally did I kind of decided it was something I should dedicate myself to helping people avoid the travails that I had to go through to get some answers now will hipaa allow you to share your story or is that or is that or is it personal would you prefer not to I mean no I if you know me you know that there's not a lot personal to me right so uh well it started when I was young so I had you know jaw clicking and some pain and you know as a as a adolescent and young adult male I didn't really care because you know you power through and you get through life it wasn't that big of a deal and then it started to get more and more severe and as I got my 40s I started breaking teeth and having lots of damage because of loss of support in my jaw joints and then the pain got worse and I had headaches maybe 25 days a month so when I finally went through some dental treatment for that the dentistry I had done was you know uh as about as good as you could get by some of the best dentists in the country but it didn't resolve my pain so my teeth were improved and my bite felt fine but my pain levels and my degenerative joint disease didn't get any better so then I finally got into more of an of a medical issue with oral facial pain and I finally got some help and now maybe I get one or two headaches a month instead of 25 or 26 so it's been life-changing to me and I hope no one ever has to go through what I went through and maybe had they paid attention to me when I was young and caught me early I would never have gone down that road in the first place and a lot of people that are in pain um you know when I get out of school in 87 you know I got to remind people um when I got out of school in 87 no one ever mentioned that an opium had a problem I never heard of that it could be an addiction I mean and I but I also never heard of sleep they never discussed sleep or anything like that um but a lot of people who end up um having a lot of pain you know like back pain or whatever um got addicted to opioids and that turned out to be a nightmare for their life and your specialty is called um you know oral facial pain so is narcotics a big problem in um in your patients because they've been in a pain for a long time that now they're dealing with addiction and pain I think you'd agree with me that we see it some um you know we almost never use narcotics virtually ever sometimes in acute instances of trauma and such but we rarely use it they've also kind of shown through research that the trigeminal nerve system gets sensitized from the first dose of opioids so you try your best to avoid doing that in people if you can help and then that changes their ability to manage pain in the head and neck region for the rest of their lives so it is a big deal um but the patients we get that have gone down that road oftentimes you know we're not going to send them through you know rehab and detox but we'll work with people who do and many times when you get them off of the narcotic a lot of their overall pain is better because they've been sensitized to more pain simply because they've been on opioids for a while yeah so I’ve seen the same thing and really what it comes down to is I’ve seen that patients that are on opioids uh or medications of that nature typically get worse over time even though they appear to feel better and obviously you know they build up tolerance and they require more and then they get the addiction issue um and they don't clinically get better they actually clinically get worse because of the sensitization of the nervous system and like bob was saying when we get a patient like that I tell them that from the get-go and i'm like are you okay getting off the narcotics and if they say no I don't treat them because i'm not going to get them better if they say yes then we get them onto different medications that are more curative from a neurological standpoint get them off the narcotics and they get better you know and that's and that's success for these people right so um I don't want to get weird or negative or that but there was opposition to it in fact when you announced it um another townie um Ira Shapira um posted a big um basically a big rant that he didn't like it why was there why was the tmj tmd why was there pushback was it just competition was it where where's the jest of their heart and soul coming from on you know I think that's probably a whole other podcast Howard to go through but short shortened down of dirty in my perspective is simply that there's a lot of history between a lot of fragmented groups that fall under that umbrella that treated those entities and some of that kept is still continuing I think to spill over to some degree but I think the main gist of it is that people were afraid that you know the goal here was to try to stop them from being able to practice which was not the goal in any way shape or form at any point in any of the conversations that I was party to while we evolved through this so our goal was never in any way like the American academy of you know indo or oral surgery or perio is not trying to tell general dentists they can't perform you know those treatments but you do it to a certain standard under a certain guise of evidence base that's been evolved and that body of knowledge grows as time goes by part of the problem with this field is the research has been very uh you know difficult to interpret because it's not homogeneous in how they treat patients how they classify diagnostic categories so all of that has led to a lot of just random research that people choose to interpret in such a way to promote their way of practice so nobody has a way of practice that's against the law or improper or inappropriate as long as our goal is always to help patients get better that's really what I care about if a caring compassionate doctor is able to render care and improve a patient how is that ever a bad thing right so I think the goal here is to make all of these people who disagree finally find a way to get along and focus on the main thing which is to get patients better that's what I would like to see as a president-elect I would love to see us move in that direction so we can work with all these different groups and just help patients that's my that's what I care about the most you know I’ve always I’ve always agreed with you 100 you know it's a fine line between a um numerator and a denominator right and uh you know and people the dentists just want to see it their way and they don't want the insurance company to you know they but it's dentistry it's specialists it's insurance companies it's government it's employers all divided by the patient so you know when people have these insurance debates it's like uh I always tell a dentist well if it's so easy to go sell insurance and why don't you go start an insurance company I mean I remember the ada started an insurance company direct reimbursement I still haven't got one dollar of direct reimbursement so and you know as long as when you're when dentists and the ada and delta and all these stakeholders sitting there it's all divided by the patient and that's why I say you know think globally act locally and panic internally if you um you know it doesn't matter if the ada says especially or not it's um it's your autonomy to decide i'm gonna try to retreat this failed molar endo and that's when the panic sets in and you start wondering if you're gonna be able to get all the old gutta perch out and be able to uh you panic internally so yeah just put the patient first it's like it's like google I mean their mantra they started as first do no evil uh which I thought was a I mean just it's just pretty clear I mean because all technology I mean look at the new look at Einstein’s work you could use it to blow up a city or you could use it to make nuclear energy and uh I don't think we're gonna get off coal and gas and petrol without a nuclear component but uh so anyway um you got a lot of kids um right here in your backyard you got a.t still and you got midwestern and a lot of the kids are coming out in the middle of a pandemic and so after they can't find a job and you know I mean I mean I’ve talked to so many dentists they can't even get a return phone call and i'm talking about in our city right here um there's nothing there and so a lot of them are thinking well hell maybe this is a good time to specialize what would you say to some young kid at eighty still who said well I think i'm gonna go specialize in this new oral facial pain that just became a specialty in the year 2020 maybe it was an omen um what would you tell them what would you say stan so yeah so I would say um I would say it's excellent I mean like uh bob was saying underserved you know 250 out of potentially 10 000 right uh and now the fact that we've you know developed we've got we've got the residency programs right and fellowships and uh we've developed uh protocols to getting patients better right and getting reimbursed by medical insurance so really what it comes down to it's a good uh growing specialty that at this point can be relatively profitable as well for somebody so they can look at it as a career and say hey i'm going to go into specialty I’ll be able to earn as much as say any of the other specialties like oral surgery or orthodontics or whatever and if I have an interest in the science because really that's the main thing is it's a lot more cerebral I think than other specialties because you got to keep up with the research and every patient is different you have to analyze them from a medical standpoint which is different from dip from dentists because it's less technical and uh more diagnostic and uh requires a little more cerebral you know input so to speak so I mean if that's the type of person that you know that there is looking for something to do then I would say or facial pain is good if it's more of a hands-on technical person maybe you know oral surgery or endo or things like that might be a better path to go but I think always you know specializing if you've got the drive to do it and the desire to do it I think it's a good idea so um help me um help explain to my homies um yeah what you're what is the oral facial pain patient and how is it different from say you're an older guy just pretend say this dennis is like 58 years old short fat and bald and practiced 33 years and no one comes to mind uh but there's got to be one dentist like that uh right here in phoenix and all with tooky um what is the oral facial pain patient and how was it unique than what you might have thought of was you know you know a tmd tmj grinder clencher migraine headaches um you know the traditional well okay so you may see the same thing in dental practices as we do sure but it's somebody who comes in they got job pain popping clicking headaches you know pain behind the eye right maybe a little nausea things like that right and then you know typically from a dental standpoint you're like oh let me look at the occlusion let me do this exam that exam and whatnot and then see if I you know if I get their occlusion better maybe it'll get better right make them an appliance do some equilibration things of that nature and sometimes people get better with that and sometimes they don't uh but what we do is we're going to do a neurological exam we're going to do a musculoskeletal exam of the head and neck uh and then we're going to do a dental exam as well you know we're gonna look at the occlusion as well um and then we take it you know all of it we take their past medical history right people with diagnosis of fibromyalgia or ms or things like that um thyroid disorders all these other things they play into it and if you don't take those things as well as the medications they're taking you take all these things into a play you're not going to get an accurate view of the whole person both medically and dentally but more medically you know um and then especially from a musculoskeletal standpoint you want to make sure you do the right imaging and really know how to read the imaging and know if they have you know significant osteoarthritis or disc displacement different types of djd and their history on that as well too and like really get a you know a whole picture and then you diagnose them and then you go ahead and you put together what you think is the best treatment plan for that person and again all your treatment plans are going to be different right some get appliances some don't get appliances the type of appliances that they get you know will be different based on their problem um and then you know it comes into like we do different types of injections based again on what's going on and medications as well you know some medications that we do usually prescribe are not of a narcotic or an addictive nature most of the medications that we do prescribe are specifically for the problem that we see that that patient has and we know that at some point we can get them off the medications once they're feeling better so that I know I said a lot you know real quick but that kind of you know should present that that what you know as dentists uh what we do and what we're trained is significantly different and that's that kind of you know I would think kind of sums up the difference between or facial pain you know uh experience for a patient versus the dental experience well I think of it Howard you know like what do you do when it's not the teeth right so we see a bunch of patients that have already been through those failed attempts um the goal for me would be to love to see general dentists be educated to the point where they can understand how to discriminate between those types of patients that could be easily treated straightforwardly by simple conservative treatment in a dental practice or something that's not quite exactly what it seems because the problem is stemming from something else that's kind of where oral facial pain comes in is helping to learn to discriminate between something that's not quite as straightforward as it appears so those patients don't go through multiple failed attempts and delays of sometimes years in trying to get resolution or even just a diagnosis and we treat a lot of neuralgia and neuropathies and those can be difficult and I mean every class I’ve ever taught I mean we've all got x-rays uh showing patients with 30 root canals where they chase the pain around the face and no matter what they do it keeps coming back and then they keep doing another root canal so rather than treating a patient like an annuity you know you make a diagnosis and treat them appropriately and then they can have pain relief or you refer them to a surgical approach that might resolve the issue as well but that's all part of the diagnostic thing so I think we spend most of our day kind of playing dr house and you know so it's a it's a it's a cerebral stance said uh profession but it's not physical but most of what we do is from history you know consultation exam and then we render the right treatment after we get an appropriate diagnosis so the diagnosis is really the goal of what we're after so you're basically you said that oral facial pain is the bed bath and beyond the teeth sure that's a good way to look at it I’ll go with that for me i'm going to attribute that to you Howard yeah but i'm going to say we don't have a 20 cue ball yeah well um you know one thing I always notice that um you know um I love that you know it's beyond the teeth because I always wonder you know whenever you know you get dragged into bed bath and beyond you always want to know what the hell's the beyond part but when um when you stand when you were talking um I just rolled out a whole bunch of clusters of autoimmune disease you said fibromyalgia thyroid ms arthritis uh rheumatoid arthritis the only thing you didn't say was celiac spirit and diabetes because I i'm really fascinated a paper I was reading that once they started doing 23 and me and getting big family trees they started finding out that if someone in your family has ms and diabetes and thyroid issues you know if you expand the tree big enough you'll find them all and so families uh so with health histories when you see someone in your office with say insulin dependent diabetes and his mom has arthritis um i'm kind of looking at this person thinking god if I had the dna of all your whole family tree I should be able to find the whole cluster so my question is um is a big part of oral facial pain on autoimmune disease um no it can be you know due to trauma right so you can have post-traumatic type things uh you know whether it's neuropathies or you know musculoskeletal uh and those are probably easier to treat than inflammatory diseases or autoimmune and those become trickier you know to get under control but we can get them under control so like for example with a fibromyalgia patient I usually have a disclaimer I kind of give them in the you know or pneumatic rheumatoid arthritis patients I say look I can get your pain better but i'm not going to get rid of it you're always going to have some level of discomfort right so but if we can get it so that you can function and you're feeling better and your pain levels are at least you know 50 percent better you know I mentioned that to them they get all excited they go 50 I’ll take that in a minute you know they get excited so yeah so you know it's a matter of knowing you know who these people are and what they have the other thing you mentioned you know cluster so we have something called comorbidities and there is there is a lot of comorbidities with some tmd patients uh such as migraine depression um what else well so I you know well you alluded to it earlier but one of the other things we get a lot of training in in our programs is sleep so all of those sleep needs yeah sleep disorders sleep medicine so we have to be well versed in that because you know when you look at research one bad night of sleep predicts two weeks of increased pain levels for any pain producing entity so if we don't pay attention to that then many of our patients are going to be resistant to improvement that includes fibromyalgia patients rheumatoid arthritis patients because a lot of research has been done on those two groups if you get a fibromyalgia patient being able to sleep more effectively with less arousal more restorative sleep they're immediately going to feel improvement in their overall condition because fibro has a big issue with just pain processing and then genetics so a lot of tmj oral facial pain has a genetic kind of umbrella over it so we're starting to identify you know phenotypes in the genetic code that predict onset through some big studies being done in east coast uh they're fabulous still ongoing and they're still you know uncovering data and mining it for answers but we're starting to get some predictors to who would be susceptible to the onset and it's like anything else that's genetic if you get the right set of switches flipped in your life you know environment then you're going to start express symptoms so some of that plays into a lot of these entities as well when you guys throw around the word arthritis is that always rheumatoid arthritis or do you break up arthritis into different deals and does that come into play diagnostically you know someone has rheumatism versus just old age arthritis that's usually our osteoarthritis is the most common type of arthritis yeah so there's there is different types of arthritis right some are more common than others right and rheumatoid is not hugely you know common but you know we'll see it occasionally right and it presents differently and usually they have problems elsewhere in their body and that's kind of the clue that that's what's going on as opposed to osteoarthritis where you may see in just one joint right and it can be really bad and you know and they may have one or two other places in their body but it's not uh it's not a systemic thing sure and you look for it in children you know rheumatoid arthritis can hit kids and then there's another entity that you know we find a lot more now because of the advent of cbct and I know you had dr tamimi on who's fantastic um so it used to be called uh cheerleaders disease then it was idiopathic condylar resorption and so basically it's a rapidly evolving loss of volume in the bone and the condyle of the jaw joint in adolescence primarily females it can be up to five to one credit election over males and then if you appropriately treat them conservatively that process will burn itself out and then they'll stabilize and they can live a long life without a surgical intervention uh un uh untreated a lot of these kids end up needing you know total joint replacement so I think that's a travesty to let kids see bob to a point where they need a joint replaced before they're 20. you know that's horrible so all of those fall under that issue sort of as a side branch off the arthritis issue but those are things we're vigilant for so if a if a young lady presents with you know clicking and joint pain or intermittent locking and or a sudden bite change that's the first thing we go to look for oftentimes orthodontists will see those kids because they present with a malocclusion when in reality it's not it's a joint based issue that had nothing to do with the teeth so um we always like to work together with our orthodontic colleagues to identify those kids and treat them efficiently and effectively and let them have a normal life so um that's so part of the diagnostic issue when we start wow I cannot I missed the cheerleaders syndrome I never picked that one up in dental school uh I uh now i'm worried that there might be a water boy syndrome um could I be more susceptible to water boarding syndrome all right I didn't make the team but I was the water boy is there a is there a water boy syndrome that I need to start looking over that was a you may be case zero Howard we'll start with you maybe um my gosh um is any of this um and your diagnosis you talked about the different exams you did but as far as imaging um what is your routine imaging and does much of your diagnosis show up on like a cbct or um talk imaging in your oral facial pain great yeah okay so uh yeah I mean preliminary uh you know imaging is a cbct uh you know panorax really doesn't show enough we need to we need some thickness and some decent slices so we can see what's going on through you know through the whole head and neck really right and uh and then from that point then we decide do you need an mri right uh but the cbct is pretty good you can see the airway obviously and you know we uh we get cross-sectional uh analysis of the airway so being that we look at the sleep condition as well that's important as far as the joints go it shows us joint positioning the condition of the condyle and the fossa um you know some of the other details involved in what's going on with the with the tmj you can also see other things you know in the face sinuses that's important um as well as the you know the jaws you know uh you know what's going on in there is there anything else going on in the mandible or maxilla that nobody else is caught it could be causing this discomfort and it may not be tmj or tmd right it could be something else you know right um so I think I think the cbct is an excellent screening um source of imaging and then I think you can decide from that point if you need to order uh further imaging and usually it's an mri um you know in in most cases if we need to so just for the kids uh you know uh cbct is more for heart tissue bones and stuff or an mri is more for soft tissue yeah soft tissue so like say for example disc displacement right we know that if somebody's got popping and clicking they have some degree of disc displacement right and if we do a cbct and we can say you know what the bones look okay everything looks pretty okay right maybe a little bit of osteoarthritis but we could see that the condyle has posteriorly positioned and we they got some popping clicking and we know that it's displaced the question is do we need to see the disc is that going to help us most of the time we don't need to see the disc we can start treatment with them you know and then we have to decide when would we need to see the disc right and it's usually if we're not successful in recapturing the discs which we can almost consistently uh through treatment uh if we're having difficulty with that we're like okay let's see where the disc is why are we not able to recapture it or if we're looking at them and we're like yeah I think you might be a surgical case uh let's go ahead and get an mri and see if in fact you are a surgical case and we'll get you to the surgeon you know so that that would have been a tmd case you know what we're looking for but you know in other cases um you know if you're looking you know you would look at your cbct and you see some weird things like weird calcifications little joint mice things like that and you're like yeah I think we need more detail on what's going on here but the key but would you say you know when you hear the popping and clicking it's got to be a pain I mean um I don't know if any of you grew up catholic but uh when I go to church on to this day with my mom and my sister I mean you know catholics they stand sit neal stan sit no they just can't sit there for an hour and every time they stand said no you hear all these knees popping and clicking and popping and clicking and it sounds like the fourth of july um but would but you're saying there needs to be pain along with those noises just noises by themselves in the jaw does that concern you much if there's no pain associated with it yeah I mean so typically a lot of people have you know noisy joints right but if they don't have any like other pathology or discomfort or it doesn't interfere with eating and it doesn't lock you know the point where they can open and close um we just keep an eye on it we don't really treat it you know we would agree that could be up to a third of the population has jaw joints and make some noise so in and of itself it's not really a huge problem like we used to believe it was you know somebody that's locked and can't open from the obstruction that's a whole different ball game you would least want to get them moving back and forth if you can't do it and get cartilage reduction so at least there's some movement then inevitably over time it's treatment physical therapy sometimes injections and you're getting basically the retro-distal tissue to stretch out and try to get a little denser and resistant and they can still function fine I mean if you look at 100 people like that at the end of the year you know close to 90 percent of them are probably functioning pretty close to a normal level again given some conservative medical intervention so yeah I don't care so much if it's a non-painful click but I always want to tell them just to be vigilant for something advancing or progressive and I hate to be uh so pedantic asking such basic questions but it's so new and it's so confusing um the new specialties so um your oral facial pain there's also oral medicine right an oral pathology so if you were in uh dental kindergarten school and you're like what's the difference in oral medicine and oral pain um so what is the difference between oral facial pain and oral medicine an oral path and oral radiology maybe start with oral facial pain oral med well I think the difference between the discriminate between those two is oral medicines typically focused on treating medically complicated patients right and so they look at uh soft tissue conditions and systemic illnesses and you know pathology will look at tissue disorders right so our bone disorders are a pathologic entity that's present that you can find in the body or that you're concerned about so they discriminate into I think oral pathology focuses more appropriately on diagnosis of resistant or things that don't improve on their own we all know things in the mouth typically heal fairly completely and fairly predictably and when they don't then you want to investigate that I mean when I was young in the practice because i'm I think i'm older than you I think Howard I think we would always refer those patients just to the oral surgeon because we just assumed everything was a biopsy and sent it to get you know examined by uh medical pathologists and we'll get an answer now we have oral pathologists to do that for us because they're just as well trained as our medical colleagues I think oral medicine the focus has been on in in academics treating medically complicated patients in the dental school so I think that evolved from that trunk of a tree and now they've branched out to trying to get in private practice now there's a dual program at usc that does oral medicine slash oral facial pain so they can graduate with a dual degree in that which you know is fantastic because we do end up treating as oral facial pain specialists a lot of medically complicated patients as well so yeah of course there's some spillover um I think that will get refined as time goes by because some of these specialties are so new but we look at our problem is oral medicine doesn't necessarily focus just on painful conditions they can treat more chronic you know soft tissue conditions and things like that that might be end up being diagnosed by our oral pathology colleagues as well um when you when you talk about surgery I mean um gosh we've been out a long time I mean I don't know how old you are bob but I found out monday night um that uh on monday night football I sat down to enjoy monday night football man to start with it's the 50-year anniversary and I thought damn i'm eight years older than monday night football that's not how you want to start monday night football but it was really great they were showing the uh clips from uh um the originals but when you said earlier you know sometimes you look at this you send them to the surgeon I mean we're old enough to remember when um and um dr kent back in louisiana state university they were doing uh disc replacement surgeries and things like that and um that was that was pioneering work three decades ago is that a thing now are there a lot of more joint surgeries disk replacement condyle stuff or is that still got a long way to go can we respond to that first yeah well so there's a couple problems with that right so we've learned over the years what worked and what didn't so now I would say maybe one percent of our patients end up having to face a surgical potential it's gotten much better as far as it used to be you know eighty percent of them went to the surgeon the other problem is that there are very few surgeons that are well skilled at this because it's not a focus of undergrad training or post-grad training and surgery to my knowledge it wasn't at tufts i'm not aware of any program that does the number of surgeons across the country that are highly valued for their skill at this you can probably count on two hands so that that's an issue so i'm happy to say that I don't have to send many patients to surgery but you know most of these practitioners are fairly advanced in age in practice they're not going to be around forever who's going to pick up the gauntlet and run with that you know the torch and run with that from that point forward you know that's me being midwest practice for a little while east coast practice for a long time and now out in the southwest for a short period of time that's been my perspective from multiple places across the country but out here i'm stan may share his thoughts but I don't think it's a whole lot different than what I said no it's exactly the same you know there's very few people I always you know so there's one particular oral surgeon in Arizona who does most of the surgeries and he does them well um and then there's a handful that kind of do some cases and unfortunately sometimes uh you know if I try to send to one of these oral surgeons they don't always want to do the case because you know the success rate for uh arthroscopy or arthroplastic surgery in the tmj the success rate's not good you know and how many surgeons want to do surgery that they know that their success rate statistically isn't going to be good not many right so that's one of the issues that we run into and that's one of the reasons that it the tendency right now is not to do surgery most of the surgeons kind of they want to extremely they'll do something called arthrocentesis which is really just fleshing out the joint with a large amount of fluid and patients always get relief the question is how long do they get relief you know from it and then the other extreme is total joint and that's kind of you know where it's at uh in oral surgery is like you either just do the one simple arthrocentesis procedure uh or if they're really bad and nothing else works you do total joint and that's kind of the spectrum you know for most oral surgeons right now and there's very few uh oral surgeons that are comfortable doing the total joint uh procedure and that's you know just like what bob said all right so which um who's doing most of them out here is it bob Goyette is it read they who's doing mostly you got that right you got that right but I’ll tell you he's uh he's a very skilled joint replacement surgeon he really is yeah I’ve been in with him on a number of surgeries and I just enjoy watching what he does he does a great job right uh very professional excellent uh technique and results and he gets he gets I think a lot a lot better results than nationally uh what's been shown in the research uh as far as the success rate for total joint or even arthroplasty right well I cut my teeth in in Boston with a guy from Harvard also and bought in mass general uh David Keith who's a phenomenal surgeon I don't know I know you're old enough Howard to remember we went through a period of time where they did a lot of replacements with a with a um a compound called proplast and so that ended up being uh that was kent that was Kent’s though wasn't it right but that those all broke down and right mike do the tissue and it was a nightmare for many patients David keith was one of the guys that did a lot of work repairing those patients and getting them back so I’ve seen uh you know unbelievable cases be resurrected from just you know just a horrible situation to a lifestyle back and um that that impressed me when you need guys to do stuff for you need somebody that's been able to do it enough to do it predictably because those patients are just absolutely at the end of the road as far as options go so yeah that was a it was a neat experiment but it um it had a lot of problems with it I mean he tried he I think he was a pioneer but I think it's safe to say it definitely didn't work out very well that's what's happened with other tmj search you know we've learned over the years what works and what doesn't and what works is probably a lot less surgical intervention than we used to do yeah um but reid reads the man in Arizona though for that the one percent yeah absolutely yeah that's uh that's cool um yeah I know uh I know patients personally that went to read to have uh um orthognathic surgeries and things like that and uh turned out very well um so you also um bob sometimes don't tell you talking about digital scanning 3d printing um do you guys use that technology too well I’ll tell you I you know i'm gonna let stan talk about that because one of the reasons I came here from where I was before was purely the model that stan's developed in this practice of oral facial pain part of which he'll talk about the digital aspect of that the other part is the use of ultrasound for injection which I can tell you in oral facial pain I firmly believe I don't think there's anybody else in the country who does what stan does so I learned that from him even though I did a ton of injections before so he's a technology guru so i'm gonna let him talk to all of those but I want to give him some acknowledgement for creating something that's unique that I think other specialists in my field should share and if you're young and getting into this uh this is the this is the way to go man that's sounds like saying you got to make an online course on dental town I mean we put up 400 courses they've been viewed over a million times and we started that in 2004 I’ve never had an original idea I mean I became a dentist because my next-door neighbor Kenny Anderson was a dentist and I thought it was more exciting to watch him take an x-ray through a tooth then my dad make a hamburger a sonic drive-in uh but um my gosh when I was driving uh when I saw the university of phoenix online I think they started in 2004 and I think I had to watch it for five years before I started that but my god the pandemic is really um I mean online c has exploded I mean but hopefully stan you'll um you'll tell us about it now and someday make a online ce course for us yeah no we're we've been talking about that you know getting more involved in doing that and as well as eventually doing some hands-on training you know you're here uh at the practice so uh yeah because you you're starting that uh um you're calling it um an ensue what are you gonna um call it the um that the head pain institute well penises yeah so it used to be aztmj right we do too much more than just tmj right so everybody's like why you do sleep uh you treat all types of head pain and neuralgia neuropathies you know and all sorts of things like that so we even treat uh cervical dystonia because that's all part of uh what we're doing here so did you officially drop a z tmj I’ve always known you as a z tmj is it now the or the head pain institute so we're phasing out the aztmj and moving it into the headband institute and one of the reasons we picked the institute is because we're going to start publishing we've already started the process right because we're doing a lot of unique things that there's not enough papers on so we've got to put the papers out so that's part of it and then other people are going to want to learn what we're doing so we're going to start teaching them how to do these things so hence institute and that's what we're looking at but as far as the technology goes yeah I mean you know 3d intraoral scanning uh you know that's the wave of the future right and I noticed that a long time ago you know when a lot of the orthodontists I know we're doing it and some dentists were getting into it i'm like I gotta do that because i'm taking impressions all day right so let's do that and then I was you know using an outside lab and I was like wait a minute you know I do enough oral appliances and stuff why don't I have my own lab so we had our own lab and then we got into 3d design on the computer so we're taking the 3d images we're designing the appliances we're now 3d printing the appliances or milling them out of blocks of orthodontic acrylic and we're getting phenomenal appliances that require very little adjustment when you take it to the patient which is phenomenal because uh you know when I was getting stuff from other labs it was taking forever and because of the way that I design things and kind of uh prescribe the appliances I have certain thicknesses if i'm repositioning I got so many millimeters forward i'm moving people you know things like that so they're very detailed as far as my prescriptions for the appliances so just having that in-house and be able being able to computer design it with extreme accuracy has been uh you know phenomenal as far as that goes ultrasound for example so I didn't make that up you know using ultrasound diagnostically or for guiding my injections that's the standard of care and pain management and orthopedics and other areas of medicine they all do that they've been doing that for a while so I just took their courses uh and you know we got some good ultrasound equipment and uh just worked at it and I really developed some really good techniques in the head and neck which is good because you know when I was taking the courses with the medical people they didn't know what to do they're like you know how do you use ultrasound for tmj injection or any facial injections or you know some of the areas in the neck and I so I had to kind of develop that based on what I learned from these people and right now we're all doing that and it's phenomenal I wouldn't I couldn't imagine doing a lot of the injections that we do without the assistance of ultrasound right great well you know um when you start that handstand I want to tell the kids something really important like it's really easy when you get out of dental school um you know half the general dentist in america 150 000 general dentists that work 32 hours a week or more and there's 30 000 specialists that work 32 hours a week or more and it's really a common mistake to get out of dental school and say well you know I don't like muller endo i'm not doing milondo i'm going to refer that i'm going to learn all these other stuff like invisalign or something and that's all great but remember in dentistry the most important thing in all of the medicine is to get an a on the diagnosis and treatment plan you don't have to have to do it but you have to learn enough to triage this patient and that's why you know look at business deals um the fastest growing business uh um deal has always been one plus one equals three like if you took a hundred kids to a pediatric dentist a hundred moms are gonna say is little bobby gonna need braces when he grows up and you say oh well to answer that question here's a form and you need to go make another appointment at an orthodontist another place in time so now you see the business model is a pediatric dentist and an orthodontist two in one we both are out here where clear choice said well let's take an oral surgeon to place the implant with the prosthodontist with the lab tech let's put it all under one roof and now you got a 100 million dollar company from coast to coast it's been sold five times so when it comes down to some oral facial pain you need to go to the head institute um to at least learn what the hell is it if you can't diagnose enough to triage and send this patient on the right way then the most important specialty in my mind has always been dental public health and um you know everybody wants to talk about orthodontist and endodontist oral surgeons but at the end of the day we live in a on a planet with 8 billion people uh four and a half percent of them live here in the united states 331 million and at the end of the day when someone stumbles into your dental office you need to be able to triage them through 12 specialties I mean when you go to the hospital with a broken leg you don't ever hear well i'm sorry we don't do legs you need to go to the hospital on the other side it's like what the hell I thought there was a hospital I mean if you fall off your bike and get run over by a car they just take you here they don't tell you when you get there you can't do something and every dentist has to be a dental public health dentist first in order to know enough to get them out of pain like if you can't do the molar root canal well can't you access it and put some former crease on there can't you do something you know um and um and by the way when you go it the most embarrassing thing about me being in denison Arizona is always when you get the report that eight and a half percent of the emergency room visits rodontogenic in origin and we've all seen those patients what do they give every one of them 28 tabs of pen vk 16 tabs of vicodin and I kid you not when I tell people this they don't even believe the story I had a person walk in one time with a two foot by one and a half foot x-ray that they took of their head for a toothache and still end up just giving them pen vk and viking but um we got to be better trio so you gotta so I really hope you do this head um the head institute and I really hope you make a course on it because um it's great marketing I mean like pinky had a problem in dawson where they were trying to sell you to come down there for a week so they made a one hour course to summarize each week so you knew the difference and so um hearing about going to panky for a week or ross nash or scottsdale or coyce or you guys or whoever um it's nice to um deconstruct the well here's a flyer here's a course and a nice little hour in the middle like well what is this all about and stan if you did that that would be uh that'd be awesome um or if you both do it or what have you um so is there um is this something um do you use botox much like if you saw 100 if you saw 100 patients how many times would you use botox well we use it two to three times a day on patients I mean I mean that's I mean that's a lot right I mean if you think about it so I mean yeah I mean you know I think allergan loves me you know there are 100 patients right that we have 100 out of 100 kind of 100 probably 10 yeah you know I think 10 uh you know which I think I think is a fair amount right um you know it's funny because I have patients come in and they go I want botox in my jaws right and I go well let me do an exam on you and see if it's a good idea right and uh you know um you know most of the time they don't need botox you know we just do some normal treatment and I’ll tell them hey let's go ahead and try this but if you're still really tight and you can't relax your jaws and you notice you know we can use the botox to loosen things up but it's not a first line you know and I think I think one of the things that got out there I don't know how it got out there but there's a handful of dentists that that's where they first go right bam botox we're gonna botox your jaws right and yeah and it usually works right because you know if you if you decrease the muscle activity in the jaws you're probably going to get some improvement but it's not really solving the problem a lot of times you know because you're not doing a full diagnosis well it's like a lot of things in dentistry Howard you've seen red it got promoted as a profit center so again you can say anybody that has tmj and again I don't know what that is in my life anymore it's a horrible term it's like going to the doctor with leg pain and he says you have knee right so I don't know what that means either it's like go to the doctor with a leg pain and he said you have knee right so yeah I love that joke and I’ve never heard it awesome you heard that I did not create that gosh I have never heard that joke that is i'm stealing that right now oh you got it oh my god that is awesome well and as far as you know but one thing I do want to say about tmj I know that the endodontist don't like the term root canal so they're trying to get us used endodontic therapy the periodontists don't like um deep scaling deep cleanings they're trying to do periodontal therapy and the tmj people just point out that that just means there's a joint at least say tmd a temperamental disorder but the bottom line is what did I say at the beginning you know you take all these specialties and you divide it by the patient and you're patient-centered and when your patient comes in and says do you think i'm going to have her need a root canal or do I have tmj that's just their language so just learn to speak their language and I’ve also noticed that the most successful dentists were usually not the ones making 4.0 in the front seat of the class they were usually the guys in the back that were in fraternities and drinking and made c's but they could talk to people and I cannot tell you in the last 30 years how many dentists I told you'll really increase your treatment plan presentation if you would just get a job as a waiter or a bartender on Friday and Saturday nights because if you can't keep a table happy because they ran out of iced tea and butter and if you can't talk and if you're afraid of people I mean what better place than a bar where everybody's drunk I mean just learn how to talk to people and they use and they're going to use tmj root canals et cetera et cetera I agree with that a thousand percent communication is the key to successful practice and I want to ask you another question I mean we're in america and america I’ve lectured in 50 countries and this is a vastly different country in so many ways I mean number one our people eat half the prescription pills and when you're in america and you have a problem at least half of america is going to say well I uh obviously there's a pill for that didn't anybody study this disease and make a pill so I know they're gonna ask you well obviously there's some new fancy medication that will cure this are there any new medications that have got you excited uh did farm did pharmacology uh help you in any way migraine there is uh for oral facial pain I mean we use a lot of drugs that have been around for 50 or 60 years some of them we have evolved in pain treatment to use off-label you know indications for it so you have to be versed in what the side effects of those drugs are but in migraine they now came out with the first new class of drug in 25 years so they're called cgrp drugs so they work as an antibody or as a gating mechanism basically to help abort headaches and it's given hope to people who are resistant to medication improvement or migraine for their whole life so it's been a godsend for a lot of people and then off label with this medication people are having less pain pretty much everywhere yeah so I mean say that again so you know with medications there's the on label you know the effect that it's intended and been researched right that's on label right and it's off label like you know medication works for something but it's not really been studied and it's not the purpose of medication but it works right so same thing with this medication so we find that people who take these cgrp medications just have less pain in general you know because the cgrp is a pain modulator right so cgrp is a um this is all new for me on the cg cgrp migraine treatment and is that mainly what does this cgrp stand for calcitonin gene related peptide damn I don't even wanna I don't even know if I want to even ask my brain to remember that one right so that that's a new one huh and is it um do you like it is it successful yeah I’ve noticed that it's like phenomenally right successful you know exciting for us yeah big thing for you yeah uh my god you guys are teaching me a lot of this and another um another one they're gonna ask I you know I feel like I know my homies pretty good is uh um can you make a living at this I mean if you decide to be oral facial pain and i'm gonna rick that is yeah I get it that you can have a practice limited veneers if you're larry Rosenthal and appa in your downtown Manhattan where the metro's 10 million people but I don't think you could have a practice limited veneers in Eloy Arizona um do you need to be um we're in a metro that just passed 3.8 million people do you know could you make a living at this in Wichita Kansas where i'm from with 400 000 people or would you need 3.8 million people to do this full-time um it's still fair I think I think you need you need uh you know again because and I think one of the biggest reasons is education right not a lot of dentists and physicians know that we're available to refer to right and they don't always know and if they do they don't know well what else what do you do what are what are the types of things you treat they're not as educated on that and then the general public definitely doesn't know what we do you know what I mean uh and it's even more confusing for them if they type in like tmd or tmj and stuff like that because there's so many people you know physical therapists chiropractors dentists all sorts of people that are doing their own little version of how to treat it they wouldn't know that there's like a specialty that treats it right so educating the people has been a big issue so to get back to what you're asking um because of the lack of knowledge of what we do we need a larger group of people so I figured you know typically uh it'd be one of us per 1 million people right at this point but at some point like they're saying you know there should be 10 000 of us once I think everybody's educated you know practitioners as well as the public yeah the demand is going to be huge and you can open up in smaller communities but I think right now since you know it's not really understood what we do uh being in a larger metropolitan area is kind of where we have to stick to uh do you agree with that yeah I do I think just right now though because we just achieved specialty I you know I go back to what you said earlier Howard about numerators and denominators so we if we conservatively look and I mean conservatively at just oral facial pain problems so that not including headache generalistically in that or movement disorders in that just oral facial pain neuropathies neuralgias joint problems muscular problems that's easily three percent of the population so we're looking at 10 million people across the country with 250 guys right or gals so as this evolves up a town like Wichita at 400 000 absolutely I have no reason to believe or doubt at all that you could make a good living in a town like that because it's going to take a while to ramp up all those doctors if you get in now and start at the bottom of this field where it's fairly early as a specialty you have every opportunity to put yourself in a position where you can do extremely well in your life as a practice for a practice I think I’ve worked you know in an academic center I’ve had my own small mom-and-pop private practice with this field I’ve worked in a big group practice with multiple offices and now I’ve worked out here with stan and so I’ve done well on all of those practice types so uh there's no way that unless you don't practice effective treatments that you're not going to be able to do well the bigger the bigger the area that you practice in population-wise of course you're just going to draw more patients that's natural about anything right so yeah you can do that but you're not going to open as a general dentist in a town of 10 000 you know like you would there and be able to service the population because it's only a percentage of the population that needs your service so and I just want to say one other thing we're talking about terms you know these patients you know they call them um you know they call them root canals not endodontic therapy they call them I need a deep cleaning not um replaying curettage they call it tmj um is like calling uh how did you say well one last time it's like calling it's calling leg pain just you have knee but another term that I think confuses a lot of my homies and you got to think about it is um the word holistic because when holistic is used how I see it being used is they don't want to they went to the doctor they got a problem and he said take these pills I was talking to a lady um this morning and um her whole problem with the whole training plan is um she would need to take four pills and I said well if he told you could just take one pill would you done it and she said yeah so I was amazed that this lady shut down the doctor because it was four pills instead of one but to me the term holistic means is no i'm not gonna go take a damn pill I want to treat it other than a pill maybe they um had other diseases where the pill didn't do anything um but anyway so I and I’ve also noticed especially in san francisco where i'm talking about the most that if you put holistic dentist on your website on your sign on your seo people will drive an hour across town in fact one guy in san francisco I know he advertises on his website that he's the only dentist in san fran who's off the grid well we can do that in Arizona you can call srp and pay a little bit more money for your electricity just have it come from a solar field and he says it's so ridiculous because everybody that comes to him drives their car like an extra 45 minutes to go to the dentist off the grid it's like okay well how much petroleum did you burn extra in gasoline to go to the dentist so um I think holistic is a big term because um if you say you're a holistic dentist I think at least I don't know what percent of america but I think it'd have to be a significant quarter would think well good I want to try him because I don't want to go somewhere where they're just going to write give me a pill so remember talking to patients is very uh difficult there's a lot of slang and then you know when um when I’ve been in a like japan Korea Vietnam every person in japan is Japanese when you go to Korea everyone's Korean when you go to Vietnam everyone's Vietnam but in the united states you got 330 million people from all 208 countries there's a lot of slang so when you're coming out of school don't have any of these words just shut you down when someone says holistic or I don't want you know I don't want to go to a surgery my sister had surgery and that butcher ruined her well okay well that's where we're starting you know we're starting with a human being and this is what how they're thinking and uh I just love it so I can't believe we went over an hour that was the fastest hour in my life um was there anything stan and um that you and bob were thinking that you wanted to talk about that we didn't talk about or didn't get to or everything I mean it sounds like I mean what do you think yeah absolutely no it's fine yeah I think it was a huge honor that you guys would take the time out of your busy day and um bob um thank you so much for 4 000 posts on dental town on all things oral facial pain and dental sleep medicine uh that was the only thing we really didn't talk about why would that just be your final deal um your practice says practice limited oral facial pain and dental sleep medicine at the head pain institute we didn't talk about dental sleep uh medicine so why don't you both just finish with that stan give me your rant on oral facial pain and dental sleep medicine yeah so I mean the dental dinner the sleep part of it it's probably you know very similar to what a lot of dentists are familiar with right there's the dental part of sleep medicine and there's the medical part but the medical part comes first right because if somebody has sleep apnea which everybody thinks is like you know this huge thing it's not that big it's like four to five percent of the population most people have snoring you know I think it's around 30 have snoring that's more popular but there's a there's a misconception that people who snore have sleep apnea which is not necessarily true obviously statistically um and a lot of dentists are being you know kind of like uh let down the path that like you got to get into this sleep thing there's tons of money in sleep things it's great everybody's got sleep you know I don't know how true that is I you know when I talk to dentists that are getting into it they're like yeah it's not as big as they said it would be and i'm not really getting reimbursed by insurance like they said it would be and now being that I’ve been doing it for as many years as I have and I guess is as far as you it's part of the practice it's you know it's a good part of the practice but it's maybe five to ten percent of the practice right so really it's head pain and all this stuff and tmd that's most of what we do but the sleep stuff what it comes down to is we do an analysis on them if they have a sleep study grade if they don't we get a sleep study because you know one of the questions is do you have sleep apnea or is it just snoring you know what's going on right or is it one of the other you know 70 sleep disorders that exist right um so it it's you know it really comes down to determining um what is it from a medical standpoint that you have that's due to sleep do you need to see a sleep physician whether it's a pulmonologist or a neurologist right and uh if you've already been through that route and you can't tolerate the cpap machine right then we're gonna say okay are you a candidate for the oral appliance right and we have ways of figuring out if that's you know appropriate and if it is we tell them look this may or may not work right we'll go ahead and do it for you and we are able to get it usually reimburse their insurance because we deal with medical all the time uh and that's it and we and I think because we're really good at uh determining whether or not we think they're going to be successful with an oral appliance the success rate's pretty high right and um and we've got a few appliances that we work with and that's it so it's not it's not too complicated you know it's just a matter that the complicated part is figuring out you know is an oral appliance are they at that point where it's appropriate and if it is do we think it's gonna work and then as far as you know ordering it and fitting it and adjusting it that's pretty straightforward well my last and final question is stan is uh how can you say you're born in Toronto and you went an hour without saying hey well you know I’ve been here that long but I’ll tell you when I go back to this apology no I know I apologize sorry so there you go I’ll tell you every time I go back and visit family I come back and i'm back i'm back in the swing you know yeah oh my god like it's like I gotta re-adapt back into the us and how do you morally justify a Canadian dentist um choosing their number one sport to be hockey which knocks out more teeth than any other sport isn't that kind of uh mixed values that you're a dentist and you like to watch people it's good you know it's a job security right it's an annuity you know it's like having a bowl of candy at the front desk right so do you like the new uh general the new uh coach they got at the um hockey team here the Arizona coyotes I don't know you know I gotta I gotta say something I gotta be honest is it Canadian I don't follow hockey as much as I should oh my god they got a new guy who uh everybody thinks he's gonna get us uh a big Stanley cup but uh again I know you guys are busier than a one-armed dentist thank you so much for coming on the show today uh it was just an honor to podcast you and very informative thank you so much thanks for the ask Howard good to see you it's been a pleasure all right have a great day take care thanks guys  

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