Dentistry Uncensored with Howard Farran
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165 Detection And Management Of Caries with Stephen Abrams : Dentistry Uncensored with Howard Farran

165 Detection And Management Of Caries with Stephen Abrams : Dentistry Uncensored with Howard Farran

9/25/2015 12:00:00 PM   |   Comments: 0   |   Views: 847




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What is caries? What is the structure of a small early lesion? What are the devices on market for detecting caries? Stephen Abrams, DDS shares a wealth of knowledge with listeners.

 

 

Stephen Abrams is a general dental practitioner with over 35 years of clinical experience. Upon graduation from the University of Toronto, Faculty of Dentistry in 1980 Dr. Abrams established a group practice in Toronto Canada, which has grown to involve both general dentists and dental specialists. 

 

Dr. Abrams has also been active within the profession. He has honorary fellowships in a number of dental societies including Pierre Fauchard Academy, Academy of Dentistry International, American College of Dentists and the International College of Dentists. He is a member of Alpha Omega Dental Fraternity. 

 

He has been very active in the Ontario Dental Association, chairing their Dental Benefits Committee for the last seventeen years; negotiating with the provincial government and local municipalities across Ontario on various government sponsored dental programs. He has dealt with issues of access to oral health care, design of dental programs and the value of preventive dentistry while leading this ODA Committee. In 2008, he organized a symposium at the International Association for Dental Research entitled “Designing Dental Programs for High Risk Children”. The outcomes from this symposium have been incorporated into submissions made to the Ontario Government on designing dental programs. 

 

In 1999, Dr. Abrams began working on a non-invasive laser based device for the detection and monitoring of caries and erosion with a professor University of Toronto Faculty of Mechanical Engineering. In 2006, he founded Quantum Dental Technologies to introduce The Canary System to the dental profession. 

 

He is a senior member of the European Organization for Caries Research (ORCA) and the International Association for Dental Research where he has presented a number of papers on the detection of caries using The Canary System. Dr. Abrams has published over one hundred papers in various international publications on topics ranging from early caries detection, caries prevention, removable dentures, design of dental programs and restorative dentistry. He has also given full day courses on the detection and management of dental caries. In November 2014, the University of Western Ontario invited him to deliver the Feasby Memorial Lecture on the caries management. 

 

In March 2014, he organized and chaired a symposium at the joint Canadian and American Association for Dental Research Meeting on the safety and efficacy of community water fluoridation. This was part of the process to engage the research community in dealing with this issue and provide the dental profession with the latest research on water fluoridation. 

 

In 1992, he was awarded Canada’s 125 Commemorative Medal for Community Service. In 2002, Dr. Abrams was awarded the Barnabus Day Award from the Ontario Dental Association for 20 years of distinguished service to the dental profession. In 2014 he was awarded the Alpha Omega Humanitarian Award for his work on behalf of the dental profession. He is one of the founding board members of ACCERTA Claim Corporation, a dental and pharmacy claims management company.

 

 

Web site: www.thecanarysystem.com

E mail: stephen@thecanarysystem.com

Phone Quantum Dental Technologies: 866 993 9910




Howard: It is a huge extreme honor to be interviewing Stephen Abrams today. Reading your resume, you should probably get the Nobel Prize in Dentistry. You have ... You are just ... My friends ... You practice in Toronto right?

Stephen: That's right.

Howard: My friends in Toronto, they can't say enough good things about you as a person, as a human, as a humanitarian, as a scientist, as a researcher. You've had your fingers in more things in dentistry from water floridation, to you're the founder of the Canary System, to ... You're just an amazing, amazing person. Thanks for giving me an hour of your time today.

Stephen: It's my pleasure. You've done some very interesting things as well too, so I wouldn't sort of undersell yourself. [crosstalk 00:00:55] It's a very neat place for dentists to share ideas and that's really important, in a very safe way.

Howard: Yes, well thanks. All I've done is made it possible for people to connect with people like you, not me. Not connect with me. But really, you're ... The things, the awards you've got. I don't want to read them because it'd take the whole hour just to read them. I don't think there's anything you haven't done or got an accolade for, whatever. 

Where I want to actually start is since we're both dentists, caries. Basically if you're a fireman. You signed up to fight fires. If you're a policeman, you're catching bad guys. We're dentists, we signed up to go out after streptococcus mutans causing cavities and P gingivalis gum disease, and now we've learned 28 years later there's more bugs than ... I hear they're discovering a new bug in the mouth every three months. They're discovering a new species of bacteria. 

What's new with caries? Furthermore, what was the early journey for you to get into the Canary System?

Stephen: Let's start with the early ...

Howard: I'm not going to spank you on this show for not doing an online CE course on the Canary System. I've wanted that since ... In fact, I think when we started online CE in 1994, yours was the first course I wanted to get on there because ... We put up like 325 courses and they've been viewed over half a million times. You're going to have to end this podcast by committing to an online CE course on the Canary System because you know so much about a caries. How did your journey start with caries? What has changed about your personal knowledge of a cavity or caries back in the early day versus now? How does the Canary System play into all this?

Stephen: My knowledge is basically as yours is. We're both ... I graduated 1980 from the University of Toronto and my training there was Extension For Prevention. That was the big mantra at that point in time. I had troubles with that because once you got to know your patients, really why did you have to make such extensive restorations to treat very small lesions. Then I became frustrated as time moved on with really the inability to find caries at the appropriate time. What was most frustrating was pit and fissure caries. How could I treat pit and fissure caries and how could I detect them.

The story behind the Canary System is one day in 1998, one week, I'd had a terrible week. I'd seen three patients in a row. Two I thought had pit and fissure caries, there was nothing. The third one had a large, large lesion. I realized I'd misdiagnosed in all three. Into my room walks a physicist who's a patient in our clinical practice. I shared with him the story and he says, "I've got the solution. I have technology that can image defects in crystal structure and are you interested?"

Again, I always end the story by saying I was told two of the biggest lies. It won't cost you any money and it won't take any of your time. From '98 to now this is where I am. The journey has been an interesting one because it's landed me in the arms of a number of very interesting people who are doing primary research in caries and epidemiology and in program design. All of which fit into where my head is at at this point in time.

We as dentists really treat diseases, and I keep saying that to government and to patients and to my dental colleagues. We don't fill teeth, we treat disease. The big diseases that we treat are caries, periodontal disease. We treat parafunction. We treat diseases because of erosion, because of exposure to acidic environments and we treat a variety of different orofacial injuries. Those are our diseases. As soon as we get that messaging out, then patients don't look at us as if we're mechanics, "oh can you fix this tooth?"

I'm not fixing that tooth, I'm treating one part of the endpoint of that particular disease process and that restoration won't treat the disease, it treats the effect of the disease. You, the patient, have to work with me and my team to treat the disease. If we don't treat the disease, you'll be back in for more restorative work or whatever we're choosing to do. Caries is a disease and that's really, really critical in my head.

Howard: It just seems like the older I get and the more I read, the less I understand. It's far more complex than we realize. You're not born with that bug. You probably picked it up from your mom when she kissed you. There's so many factors involved. I'm sure hereditary genetics has some effect. It seems to grow wild in some mouths and ... It's crazy. There might be someone listening right now early on saying what is the Canary System? Explain that so they ...

Stephen: The Canary System came about as a means of detecting changes in the crystal structure of the tooth, because caries as a disease results in the destruction of the tooth, the crystal structure of the tooth. What it does is it uses a pulse laser and measures the changes in the crystal structure on the surface and beneath the surface. 

Quite simply, if you drop energy into any object it wants to get out. If I put a red laser on and I shut it off, that red laser, if there is no defect in the crystal structure, will just diffuse the tooth and just disappear. If there's a small hole, caries, crack, defect in a restoration, it'll absorb the laser energy, becomes tracked, as soon as the laser is shut off it radiates and comes back out. We measure the reflected heat and what's called luminescence from the tooth and we convert that into a Canary number on a scale of 1 to 100. 

Depending upon the surface that you're looking at you can then decide what you need to do in the realm of treatment. Treatment can be something as simple as I'll monitor that, just placing a sealant, to beginning to put them onto a remineralization program where where a brown spot may be. You can harden those up and measure the changes to the replacement of a restoration or what happened to me yesterday in clinical practice. Patient came in, diffuse pain lower right hand side, right wing radiograph, nothing present. Cold, all the rest of it. 

Picked up my Canary, scanned a small stained groove on the marginal ridge, there's a crack. I removed the restoration, there was a big crack, but it was early on to the process and so we placed a bonded restoration with the possibility that it may require endodontics and a crown in the future. But here, this diagnostic was able to help me where others couldn't. 

Howard: You're saying it's purely a diagnostic instrument. '

Stephen: Yeah. [crosstalk 00:07:56]

Howard: What if someone's saying well what is the difference between that and a DIAGNOdent? 

Stephen: DIAGNOdent, there are a number of ways of measuring or trying to measure tooth decay. DIAGNOdent uses florescence or glow, so the laser light is on all the time. Then we say, well what is glowing. What glows is stain, bacteria and restorations. DIAGNOdent does measure those things. Does it measure caries? No. Unfortunately it doesn't measure caries or if it does it measures very near surface changes, very very near surface.

Howard: Is it an over ... Is it an ethical over simplification for me to tell my patients I just convert the Canary number to the percent of the way that it's to the nerve? I think I get their attention when I say, "okay right now you have a $250 cavity. If it grows deeper and hits the nerve it changes over to a $2500 root canal and a crown. If you can't afford that ..." Because I'm in Phoenix, I'm in Phoenix. Twenty percent of my 5 mile radius does not even speak English. I'll say, "If you can't afford that $2500 root canal and a crown, we're back to a $250 extraction. You pay me $250 now and you walk out the door with a tooth. You walk out that door and don't fix it, you're going to be back here in a year or two and then you're still going to give me $250 but I'm going to keep the tooth." Is it unethical for me to show them that number and say that's the percent of the way towards the nerve?

Stephen: One of the things that we found is that we use a description that's very simple. We say that the scale is 1 to 100, anything under 20 is healthy. Then as we scan the Canary has a voice so you hear the number. What's amazing is that the patients will ask, "Well what does the number 40 mean." We'll say, "On that tooth with your level of risk, there is caries there. There's decay." They say, "Then how do you treat it?" The discussion is a very different one than showing them an x-ray and showing them a spot on an x-ray. 

They understand numbers and what's amazing is that they also remember the numbers. They'll come back and say, "Geez when you're checking that tooth, I remember it was a 50, now it's a 40." The discussion is yeah that's right, what did you do, how did you bring the number down. We also prepare printed reports when we're doing some of our scans and the patient can leave with a printed report or they can look at that report on our Cloud. The report records the worst number on that tooth. 

Again, they then understand numbers because they have their blood work, they have their PSA's, they have all the other things that one would be looking at. They understand that you can go up or down the scale, it depends upon what they as patients can do. We never tell them, "oh, if you don't do something now." They say, "Oh it's a 40, doc what do you think I should do?" The discussion then becomes a 40 means this, this is where we go.

Howard: I've been trying to tell dentists my entire career that dentistry, you make something, sell something, watch the numbers. All they want to do is learn how to make fillings, crowns, and root canals. But if you don't sell something, I tell them, are you really a good dentist. Because the average close rate in dentistry is 38%. If you focus on selling dentistry more to fight this house on fire, this catch this bad guy. How many times have you seen two practices, identical rent, everything's exactly the same. They both have 1000 active charts and one dentist has got an 80% close rate and is doing twice as much revenue as the dentist that's doing a 40% close rate. 

The bottom line is I don't how you can be a good ... Call yourself a good fireman if you don't put out 6 out of every 10 fires in your neighborhood. I just think a dentist that puts out ... That can get 8 cavities fixed versus 4 cavities out of 10 fixed is just a better dentist. I think a lot of this is about how to sell something. You got to get the patient involved and they got to hear the sound and you got to engage them.

Stephen: That's exactly it. We need to shift because patients are not dumb and they want to know what's going on. A lot of them know a lot more than we know ... That we think they know walking in. Once you engage them in a discussion where you have a scale to measure disease, you can then begin to tell them it gets worse or it gets better and here's how you go ahead and treat it. I don't think of things in my head in terms of close ratio. I think of things in terms of here's the diagnosis, here's the range of issues we found in your mouth, and here are the things we're recommending you do and then you decide what you want to do. 

Howard: Now see ...

Stephen: Inevitably they say, let's go for it. 

Howard: To our listeners, the reason Stephen can say that his patients aren't dumb is because he's Canadian and I'm American. I can't say that in America. No, I'm just teasing. I want you to address this. It's 2015. We landed on the moon 45 years ago in 1969 and you keep seeing these dentists, they just walk out there with this metal hook, a Shepherd's hook, and then they go in there and then they just write down a W, a watch. Really? Why don't you be a pirate. Why don't you wear a pirates patch with one eye with your little hook to a [inaudible 00:13:31]. Don't you think we've grown past an explorer and a hook and writing a W in a chart? Really? You're just going to write a watch when you could digitize this. You've got digital x-rays. You've got CAD/CAM. You've got 3D x-rays and you're still just going in with a hook and writing a W. You can quantify that so much better than a hook and a W. 

Consultants have told me something that everybody's aware of and everybody's trying to get their hands around it, but it seems like as a dentist writes more and more watches, they seem to be headed towards more and more depression, disease, dysfunction. Because if a fireman showed up at a house on fire, he jumps out of the truck and puts water on it. Then a dentist looks and the hygienist goes yeah, I got a stick on #3 and he just looks at it. Takes his little monkey hook, pokes around and says, ah watch it. That's kind of a sign of low energy, kind of depression. There should have been more excitement. There should have been a measurement, a discussion, pull up a digital x-ray, get out a Canary, the [inaudible 00:14:39]. You know what I mean?

Stephen: Yes.

Howard: The high energy person ... It takes higher energy and Karma and good will to convince this patient hey let's zip this in the butt now. Let's not let this grow into something bigger and more extensive. I really think every dental office should track their watch rates just so they can confront the doctor saying ... You also see it on doctors who work 5-1/2 days a week. We're all seeing that in the consulting business, where it seems like the dentists who go in three days a week have the highest energy because they're off for four days and rest up. 

But as the doctor keeps dragging out their schedule longer and longer and longer, they just start slowing down. Yeah, they're going to run a marathon that week but they're going to crawl it. Where some people just wake up Monday morning and run their whole damn marathon in four hours. What do you think of the watch? You've got 7000 people, dentists listening to you right now. What would you say to the dentist who just sits there and does watches? Just says well we'll just watch it.

Stephen: First thing I would say is we changed the word from watch to monitor. Monitor is a different word. Monitor means I recognize there's pathology there and I'm going to monitor it. You can monitor it using visual, which isn't great, or you can monitor it using caries detection devices, the Canary being one that I recommend. But watching it is, what are you watching. You're waiting until it blows up. Then in your monitor, you can then say to the patient there are a number of lesions that I am monitoring that are early on. They're white spots visually or, in the Canary world, they are spots where you're seeing numbers in the range of 25-30-40 depending upon the surface.

You then turn to the patient and say let's see what we can do to harden these lesions. Let's not watch them. Let's monitor them and let's talk about your home care. That becomes then providing them with product. You can suggest to them the over-the-counter products that are available. 3M makes a Clinpro toothpaste, Clinpro 5000, which is very good. We've done some work with it for remineralizing early lesions and that's available through dental practices. That provides them with a high concentration of calcium, phosphate and fluoride and it will harden the lesion. Now you have a patient who has a number assigned to a tooth surface and a treatment and you're monitoring it. There you are. 

If you want to go further and say well I want to do something in the office, well then have your dental assistant or dental hygienist apply a fluoride varnish, especially in patients at higher risk. Application of fluoride varnish quarterly along with dispensing a home-based therapy provides you with a good preventive program. There you're not watching. You're actively involved, doing the right thing and you're making sure, if you're measuring the lesions and again our recommendation is with Canary, you're then making sure that the lesions are not getting larger but they're getting smaller and you're measuring the changes which are happening beneath the surface. Something that you can't see visually and, if it's on smooth surfaces, something you can't see with a radiograph. 

Go one step further. I look at an adult or a child, deep pits and fissures. Do I do a preventive resin restoration, place a class 1 restoration or place a sealant? Well, what's the fissure like? I don't know, I can only see a little stain. Pick up a device, in this case a Canary, place a sealant once you know that that fissure is free and clear of caries. You say to the patient, you're in high risk of developing decay in these pits and grooves, would you like a noninvasive solution for treating it. They say yeah. Here are the numbers, let's put on the sealant. 

Then you say, well I can't tell what's going on beneath it. We have data from our company and some other research that's been done that shows that we can monitor decay between opaque and clear sealants. You can then place that sealant and scan it on an annual basis to make sure that it's still doing fine. We just released data in July at a caries conference at looking at detecting decay beneath clear resin infiltrants such as Icon. One of the challenges with Icon is where is it and can I see beneath it because the surface is clear. With our system, you can do that.

There are a number of modalities you can do to treat lesions that you would traditionally, as I say watch but you're not really watching. The other thing is, let's say you have a patient who has no disease. That's great. In our office, it's celebrated. Look at what you've done. Look at what we've done together. Those patients are wonderful ambassadors because they leave saying I went to the office. I've been going to see Dr. Abrahms for many years and I'm healthy. 

Howard: Basically what you said in a nutshell is you've got to take that W ... If you turn a W upside down it's an M.

Stephen: Yep.

Howard: You've got to go from watch to monitor. Just flip that W upside down, an M, get a Canary System. I highly recommend it. How much is a Canary System?

Stephen: Right now, the Canary System is available, the list price is $13,995 and there are convention specials at each of the conventions.

Howard: They would find that at the CanarySystem.com?

Stephen: That's correct.

Howard: The Canary, I've always assumed a Canary in a coal mine, the song with the Police, that they would take a Canary down in the coal mine and when gas would start coming out the little birdie would die first and they could see the bright yellow canary in a coal mine ...

Stephen: That's right.

Howard: When that yellow little canary died, everybody ran out of the mine. Is that where the name came from?

Stephen: That's where the name came from.

Howard: Was that after you saw the movie "The Coal Miner's Daughter" or what or was it the Police song? Which one introduced you to the canary in a coal mine?

Stephen: The story was we had hired a marketing firm before we launched our product a number of years ago at a research meeting. We were all researchers at that point of time. They came in and said, "Here's what we're calling your product." We said, "Oh you know, we want to call it [PTR loom 00:20:44]." They said, "No, this is it." I said, "Do we have another choice?" He said, "No, it's called the Canary" and that was it. It just stuck. I really like it, but I wasn't thinking about that.

Howard: You've opened up a big can of worms because I know my dentists, because I've watched them talk on Dental Town at least 4 hours a day, 7 days a week since 1998 and man when you say the word sealant, the claws come out. Because half of the dentists out there think sealants work, they're valuable and they use them. The other half can show you a ton of PDFs that say half the sealants fail in year one, the other fail in year two, and if you think a sealant lasts longer than two years, you just don't have any research to stand on. Address that.

Stephen: There was a conference, a pre-conference at the European Organization for caries research a couple weeks ago in Brussels that I attended. This was one of the discussions that went on. There's some very good data that a number of the Danish and Swedish researchers have shown that over a 10 year period sealants do stay in place, but they also suggest that you monitor them very carefully because they can be lost. They do feel, and Dr. [Fitz 00:21:54] is very, very clear in her work that they will stay and they do actually prevent caries or prevent the lesions from growing. 

She says select your patients properly. When she and I have spoken privately it's also been make sure that the fissures are relatively clean and that's what the Canary can do for you. You've got to place the sealants ...

Howard: How can ... The Canary's a diagnostic device, how can it clean the pit and fissures?

Stephen: Well no, make sure your pits and fissures are clean. It's a diagnostic device. You may want to use air abrasion or the fissure may be clean enough once you've used a flowable etch to get into that area. You've got to make sure too that you keep the area very isolated so that you don't get any moisture in the area. But her work and the work that was presented at this meeting really brought me to think again about using sealants in my adult population in order to try and prevent caries, especially in some of the young adults under the age of 30 where there are deep pits and fissures but where the decay rates are very, very low. 

Howard: Decay rates are ... I still can't believe the United States subsidizes corn farmers to make high fructose corn syrup. I still have witnessed at least every six months someone standing at McDonalds or Circle K or 7-11 or whatever, and two young kids in front of you. One will order a bottle of water and the kid next to him will say, "Well the 64 ounce thirst buster is cheaper." How can a bottled water be 99 cents and the big old 64 ounce Coke be 69 cents. How can we have a society like that? That's why you would have to do sealants on adults. 

What I've heard is that last year was the first year that America drank more calories than it ate. It consumed 51% of its calories in liquid and it just doesn't ... Plus, you're in Canada where ... I'm in the desert where it's 117 today, so people drink a lot more fluids. We even saw that in the water fluoridation research where you need a lot less fluoride in the water in something like the desert than you do up in Northern areas where they don't consume as much water. 

You said the word fluoride varnish. A lot of pediatric dentists on Dental Town talk about that. That is one of the most underused technologies out there. Nobody can figure out why are so many people not in love and use judiciously fluoride varnish. Talk about fluoride varnish.

Stephen: One of the problems is that we as clinicians are trained in the fact that fluoride gels are a good way of applying fluoride in your patient population. Fluoride varnish provides you with a very high concentration of fluoride that, when you apply it and you let it alone for about an hour and a bit, you will absorb it into the outer surface of the tooth and it will provide the protection that fluoride gives you. There's a lot of research coming out now that begins to question the value o topical fluoride foams and gels. In my opinion, there's still a role for topical fluoride foams and gel, but there needs to be more and more use of fluoride varnish in your patient population.

In my clinical practice for example, if I'm seeing a patient for restorative dentistry and I'm having to see them for 2 or 3 lesions, at the end of the appointment I'll turn to them and say today's give is fluoride varnish and it's the best gift you'll ever get from me. That becomes ... It's applied then and we'll apply it at the re-care visits as well too in order to increase the fluoride content, especially in the areas where I'm placing the restorations. 

Howard: Don't you thing that the fluoride varnish is sticky? We talk about sugars, there's a difference between a liquid sugar and like a sticky honey or a raisin or something. Don't you think the stickiness has to really change the outcome since it's sticking to the tooth?

Stephen: It is sticky and a lot of the manufacturers have been moving towards varnishes that don't have that tactile feel to them as the older one's done. I would encourage you to look at the varnishes that are on market. We're a big proponent of the 3M Vanish Varnish. It's got a good flavor to it so you don't get any push back from patients, Oh I don't like the taste of it or it tastes too bitter. We don't get that tactile feel. "Oh my tongue gets really upset when ..." I don't get that feedback from them. It's an easy varnish to apply.

Varnishes are different today than they were a number of years ago, but they do provide at a high concentration of fluoride and they are good for patients, especially those where you're having to do restorative dentistry.

Howard: The over-the-counter toothpastes are basically 1000 part per million fluoride. The Clinpro is 5000 part per million. What did you say the 3M name was? 3M what?

Stephen: It's Clinpro 5000. It's a ...

Howard: It's a toothpaste, but what's the name of their varnish?

Stephen: Varnish is Vanish. 

Howard: Vanish. Is that also 5000 part per million or ...

Stephen: I think it's a bit higher. I don't have the number off the top of my head. It's much ...

Howard: It's a bit higher. I always think of you as the leader in public health dentistry or preventative dentistry. Some dentists are out there just ... They master drilling, filling and billing faster and easier. It seems like you've spent your whole career trying to actually prevent disease. You're the fireman that's out there putting sprinklers in everyone's home, not trying to get the biggest water truck out there. You just ... You're also big into water fluoridation. Have any of your views changed in water fluoridation over the last 30 years on preventing?

Stephen: One of the things that I did, which was really a lot of fun to do, was a couple of years ago when water fluoridation was becoming a heightened concern in my area of Canada is I approached a number of my research colleagues and said, "You know what, it's time for you as researchers to revisit the research on fluoride. Why don't we hold a symposium at the International Association for Dental Research meeting and revisit the research, revisit how to apply it, and then I think go out and tell the dental community look we've taken a look at it. 

I gathered together Jay Kumar, Angeles Martinez Mier, Barb Gooch, and Gary Slade. It was a fabulous experience for me. They looked at water fluoridation. It's safety, it's effectiveness, and how to use it within the community. The end result of that particular symposium was yeah it works. A lot of the things that we're hearing from the anti-fluoridationists don't make any sense at all. Angeles Martinez-Mier, who's at the University of Indiana, has been into some very interesting studies looking at tissue samples and tying them between fluoridated and non-fluoridated communities. Her work that she presented, and I just spoke to her a couple of weeks ago, there's no tie-in for all the claims that we're hearing from the anti-fluoridationists. 

For me, doing this had a number of reasons. One, it helped to validate my comfort level with community water fluoridation and we're now looking ... We're just waiting now to get this published in one of the journals. The outcome at the meeting was, it makes sense and it's very good to use.

Howard: It's silly that in the United States only 70% of the towns use it and 30% don't. I want to ask you for help on that because on Dental Town, one of our 51 sections, one of them is community fluoridation. On any given day, there's a bunch of poor individual dentists who have to go talk to the City Council or to their Mayor or whatever, whatever, and they just haven't spent their whole life on top of this like the people you're mentioning. I hope you could deliver some of those names to me to do a podcast. I would like to on the water, community water fluoridation.

Stephen: They are fabulous. I tell my patients, could you imagine your favorite topic in the whole wide world, I said mine was water fluoridation, and you get the experts to sit in a room with you and they talk to you and they go out for lunch and they talk to you more. That is what the experience was. Here are these four very bright individuals who have various areas of expertise. My job was to bring them together and to translate the research into language we as clinicians could understand, but it was a really wonderful experience and it validated it. 

Our big challenge now is how to take this information and move it to the community. That's really ... We have to look to the ADA and the Center for Disease Control in the United States. You do have very good tool kits for them. Here in Canada, the CDA, the main dental association, and the Ontario Dental Association along with both in Canada and the United States, the public health dental sections to help us get the message out. The message is the same from community to community. It really is. It's just a matter of how do we train the people to deliver the message properly.

Howard: Did you film any of those meetings?

Stephen: They were filmed. The IDR has the rights to the films. You can see them on their website if you are an IDR member. We've gotten summaries done and we're just waiting for publication now in Journal Canadian Dental Association.

Howard: Tell them if they want to put any of those on Dental Town, we'd love it or if you want to e-mail me at HowardatDentalTown.com and cc anybody to do a podcast on water fluoridation, I'd like to interview them on that. The last time I just debate ... I did it in '89, worked on that in Phoenix and then we had to do it again just a couple years ago. 

Now that I'm 53 and I did this 20 years later, I'm absolutely convinced that at least 20% of all Americans are completely bat shit crazy. I mean the conspiracies and listening to them ... Like when you say Centers for Disease Control. "Oh government, government." They just don't have any trust for the government. When you come to them and I say so you think 15,000 people work at the Centers for Disease Control and they're all in a conspiracy with the government against you. You don't think these people have dedicated their lives to help you have less disease. They say no. 

They literally think ... When you say the word government, they grab their shotgun, their NRA membership, and they just stop believing you. They would look at me in the eyes and say well you want this because you're a dentist and it's going to weaken the teeth so you'll make more money. It's like, are you kidding me. They really, they seriously really believe that. I believe 20% of Americans have 0.0 trust for the government and when the government shows up and says I'm here to help, they just run.

Stephen: I'm going to tell you ... This is a Canadian perspective. When I tell my patients one of the things that the US government should be extremely proud of is the tool that you have called PubMed. The National Institute for Health has taken it upon itself to gather literature from any peer review journal and it's available to anybody, anybody. Log on to PubMed.com, type in five key words and you get the latest research. That's not offered by any of the other countries in the world. The US government has taken it on and it's a fabulous website. It becomes the entrance for anybody doing research. I've said to them occasionally, who do you think put that up there and how much do you pay to access it? You pay nothing to access it. The US government is the one that established PubMed. It's an amazing tool. If this was a government that wasn't interested in providing evidence based to anybody they'd never put the tool up.

Howard: I actually saved ... I think I'm at 5000 ... The main use I use for that is community water fluoridation, but I think I've read 5000 citations on water fluoridation in the last 20 years.

Stephen: You've never paid for it.

Howard: Yeah I know.

Stephen: Who's ... You not me, US taxpayer are paying for that. When you take a look at the research community and they want to do let's do a med analysis on implants. The first thing they do is go to PubMed. Let's to a med analysis on Zirconia crowns, do PubMed. This is a fabulous tool. If the US government had a secondary agenda, they wouldn't have put that up. I'm taking us way off ...

Howard: No, no, no. [inaudible 00:34:49] In 1992, you got Canada's commemorative medal for community service. In 2002, the Barnabus Day Award from the Ontario Dental Association for 20 years of distinguished service. In 2014, you were awarded the Alpha Omega Humanitarian Award for your work on behalf of the dental profession. This has been your whole career. You're seriously a public health legend in dentistry.

Stephen: I like dentistry. It's been a wonderful part of my life. [crosstalk 00:35:16]

Howard: I want you ... Based on all your humanitarian awards and like say ... Everybody I know that knows you just thinks you're just a ... There's nine specialties recognized by the American Dental Association. I think a lot of dentists forget that one of those specialties is public health dentistry. We're all in public health dentistry. We all should be in the schools taking about preventative dentistry during February's Children's Health Month, working to get our water supplies, community water fluoridation. I don't want to touch politics, sex, religion or violence because you can't go there. Really, why don't 150,000 dentists ask the government to stop subsidizing corn farmers to make high fructose corn syrup when dental decay, obesity, and diabetes are exploding and it's cheaper to buy sugar now than it was before they started subsidizing all this. It's just crazy.

Give a lesson to these dentists out there about why they shouldn't just be taking all these courses in bone grafting and implants and root canals and why they should ... It's their duty and their called honor that dentistry is not an occupation for money, it's a vocation. My two older sisters that are nuns, they never got paid money to be a Catholic nun. It's a vocation. I've always thought dentistry was a vocation. Do you think it's an occupation or a vocation and do you think all dentists are really public health dentists?

Stephen: I think that we're all public health dentists because we're all interested in our practice and our practice is a small community. In my travels in talking to dentists, the sense that I have is that we want to do the right thing. Doing the right thing doesn't mean doing it for free. I don't think that that should be an expectation of us, for us. But, doing the right thing means reaching out to the public to make them understand what the value is of the things that we do. 

How valuable is preventative dentistry and how valuable is implant dentistry and how valuable is endodontics or any of the other things we do. The most important and valuable thing that we can do is set up a dental home where our patients and their families can come in and access services at one point of contact with the dentist being the quarterback. Then from there we can then decide which of the services you require. That's really my vision. 

Where government fits into this, is government should be funding the dental home. What we should be doing with government is working to get the population to access oral health care. If we look at publicly funded dental programs in Canada and the United States, the access is poor, even if it is free for the people receiving it. Why is it? Why isn't oral health care valuable? Why aren't providers compensated properly? Why don't we have dental homes where people feel comfortable. 

You don't go to a clinic for poor medicine. Poor people don't have a clinic for medicine because they're poor. You access private practitioners, community health clinics, but they're there to engage you. We as dentists can then during Oral Health Month or during the year, go out and engage the population and talk to them about the value of oral health care. That then will take apart the fructose boys, the corn syrup guys. As soon as you get patients and people to value oral health, they'll then begin to see that oral health impacts upon nutrition. It impacts upon employability. It impacts upon all sorts of things. It's a valuable component of living. That's found in a dental home and a dental home resides in a practice or in community health clinics where dentists are there as quarterbacks. That's my vision.

Howard: You sound like Winston Churchill after World War II where he said we're going to take out this war money and put it in healthcare and education because a country with uneducated sick people has no future. 

Stephen: Yep.

Howard: By the way, when I listen to you, I think you must have a twin. I don't know who's more eloquent and poetic about public health, you or Jack Dillenberg. Do you know Jack Dillenberg, the Dean of the Arizona Dental School in Arizona? 

Stephen: No. 

Howard: You two could be twins raised apart since birth. He talks as eloquently about the big macro, big picture of public health dentistry like you do. I want you to address this question. We just had 5000 graduates walk out of school in May. They're the biggest consumer of my podcasts, these young kids. They have their iPhone, they Bluetooth it into their car stereo. I don't even know how to do it. I can't even listen to my own podcast in my Lexus because I'm not smart enough at 53. 

I know what they're thinking. They're saying, well you know I graduated with $250,000 in student loans so I don't have $1400 bucks for a Canary System, but some day I want to put that on my list to buy. What would you tell that kid, $250,000 in student loans owed in practice, why they should invest money in the Canary.

Stephen: First off, I'm going to tell the kid ... When we started in clinical practice many years ago, we also came out with student debt and buying a practice and building up from the ground up was difficult. The first thing we say is, the most important person in your clinical practice is the patient. It's the most important person. The second most important person in that practice is the patient's family. If you establish those relationships ... I look back in my practice now and I'm blessed. I have three and four generations coming in and it's really kind of neat because I'm seeing kids getting married and now it's grandkids, and I've known these families for 35 years. 

Has it been good for me economically? I don't think about that. When I look back on it, yes it has. Did I sell them everything they needed to get sold the day they walked in? No. I treated them. We set up a treatment plan. We set goals. I didn't have Canary in the beginning, I do now. We were able to engage them in their own healthcare and they are comfortable and they come in. Sometimes they don't follow what we recommend and sometimes they disappear off the face of the earth for a couple years and come back sheepishly and we welcome them with open arms and begin to take care of them again.

If you would take that approach, then you're using technology to provide optimal care. In my opinion, Canary provides the optimal diagnostics for doing caries detection and caries management. Why should I buy it? Because I want to do the right thing. I want to find caries. I want to measure caries and I want to provide a modality of treatment. Why should I do other stuff? Because I want to do the right thing. Then, why do I go out and buy it? Because I then go and look at the research behind that particular technology. What is it measuring? How does it measure it? Is it repeatable? Are there studies? Are there good studies?

We did the same thing when we went out and put digital radiography into our dental practice. We did the same thing for composites. The same thing for implants. It's learning all about them and finding the right way of doing things. But it's the patient and the family that are most important. 

Howard: You've had a macral view of it. You've had a world view of dentistry for 35 years. What do you ... How do you think dentistry changed from 35 years ago to today? Looking at the changes, you hear things about ... Some people complain about corporate dentistry, but then other people like myself will say, well yeah but dentistry was kind of tough during World War II, World War I and the Civil War too. We all have our issues. How do you think dentistry has changed in the last 35 years? Talking specifically to these new graduates, what is their future look like for the next 35 years? Do you think the profession is going good and strong? Do you think it's coming into headwinds that are going to destroy it? What are your thoughts?

Stephen: The profession ... First off, where has the profession come from 35 years ago until today, a number of things have happened. The first off is what we call evidenced based care, which is something that showed up around 1985, '86. The next thing is the internet and the use of the internet by patients in order to understand the care that we're providing. The third thing is this whole emphasis on looking at management of disease, which is what the third party carriers are talking about, which is what the dental schools are starting to treat and which we need to get involved in as well. 

What's the profession going to look like 10 years from now? Our profession needs to step back and become the quarterback. There really isn't a need for a dental therapist to provide care in a practice unless it's under the direct supervision of the dentist. There isn't need to fragment off dental care so that you have independently practicing dental hygienists. You need to have one comprehensive look see at what the needs of that patient and the family are and that's what we should be doing. So that when you see a family and you see the kids and you see the mom in your waiting room, you begin to understand what their needs are and you can address those needs. Just not how many fillings the kid needs, but why does the kid need the fillings. Why is mom drinking [Pompa 00:44:51] in your waiting room with the kids. 

Howard: I know. In my office it's Mountain Dew and Funions.

Stephen: Yep.

Howard: I'm like really. 

Stephen: I'll share with you a story. I always like to go out into my reception area to see patients because the first thing that we do is I watch the way they are dressed. I watch how they look and how they walk. I was taking care of this really nice old elderly gentleman, his late 70s, early 80s. He came in, it was wintertime and he said, "I slipped and fell on the ice". I looked at his pants and I realized he hadn't been able to get food into his mouth. The pants and his belly were covered with food stains. I said, "So how'd you fall?" He said, "I fell on the ice yesterday and I broke my front tooth." 

I said to him, "Okay, show me your hands." He lifts up the hands, there's no bruise on them at all. I said, "You've had a TIA." He said, "No I haven't." You looked at his pants and you realized there's something going on. I said, "I'll restore the tooth", right, because that's the fix it part of me, "and then you're off to your physician." What he found at his physician, he had a TIA. What was my role? My role was to look at the entire human being, treat the areas that I could treat, but also diagnose what, where, when and why. 

Howard: It's interesting, going up in Kansas. I was born and raised in Kansas. When I got out of dental school in Kansas, I went to Phoenix which is about 100 miles from the Mexico border. You said something interesting to me. You said the first priority is your patient, the second priority is the family, and I love the Latinos and the Mexicans and the whole Latin America the most because when a Latino child comes in they might bring with them 5, 6, 7 people in the waiting room. It's a family event. To me it's just so romantic. 

Then a lot of the non-Latinos will drop a kid off and then they'll go run errands or go to the grocery store and pick up their dry cleaning and all this stuff. It really is a family affair in dentistry. During this last 2008 recession, a lot of dentists were asking me, where you getting all your new patients? I said, from all my old patients having babies and kids. It really is a family affair. 

I want you to give a father/daughter talk. Let's say your daughter just graduated from dental school. She's driving to work right now. Since you've done this three and a half decades, what advice would you give her to her future? Then play into that, what if she doesn't necessarily feel right because she's working for a corporate chain. Which I don't really see why, when I got out of school it was a really great experience to go work for the Army, Navy, Air Force, Marines. I said I'm going to go work in the military four years, get some experience. Now some of these kids they'll go work at corporate dentistry and they're like well is that bad? I'm like, it's experience but ...

She's driving to work right now. She works at a corporate chain. She doesn't like the way they do things. She'd like to have her own place. What advice would you give her? How can she ... I doubt she's ever going to get all these awards that you got some day. I mean you've got honorary fellowships and Pierre Fauchard Academy of Dentistry, International American College of Dentists, International College of Dentists. Let's not shoot that high, but what advice would you give her?

Stephen: First off, in reality I do have a daughter and she wants nothing whatsoever to do with dentistry. She has come to all the ... In the summertime, she comes with us to a lot of these caries conventions and knows a number of the researchers. I keep saying to her ... What advice would I give to her if she suddenly changed her mind and decided to become a dentist and ended up in a situation she wasn't comfortable in, is build the practice you want. If you build the practice you want either within the confines of another practice or on your own, they will come. Because patients, people, are looking for clinicians that want to take care of them. Not their teeth but them. 

If you think about it, who does a patient see more in healthcare? The physician or the dentist? It's the dentist. If the dentist is the primary touch point then you have a chance to begin to look at other issues that these patients bring in. They'll talk to you. We spend 5 minutes at the end of the visit just getting caught up. How are things doing? How are the kids? Where are things at? If things are going sour, we talk. I always phrase it as a friend to friend because I'm not trained in psychology, but then it allows me to push them to see X, Y or Zed. We're looking at the whole individual. If you do that, you'll build a practice, because then people then feel that you care about them and you honestly do.

Howard: With all of your research background and all of this stuff, I still get young kids asking me all the time, do you think they'll ever vaccinate decay? We vaccinate mumps, measles ... What is there, nine vaccinations we give a kid before they're two. What would you say to a young dentist who said I'm $250,000 in debt. Are they going to vaccinate decay?

Stephen: According to the last discussion we had a couple weeks ago, no. The problem is is it's a very, very, very broad biofilm that lives in your mouth. There's a huge number of bacteria. If you wipe out two of them, others will show to the fore. Our approach, my approach, has always been to say they exist. How do I control them and how do I control what they do to teeth and other oral tissues? You don't need to vaccinate them if you can get your patients to do adequate home care. You won't need to vaccinate if you watch your diet. You see where I'm going? 

Howard: Yes.

Stephen: Instead of wiping out a whole pile of bugs and finding new ones come up, there are ways that we've been able to control caries. 

Howard: What are you saying to the pregnant woman in your chair, when you say you're looking at that baby inside her tummy and you're realizing that when that baby's born it's not going to have streptococcus mutans, it's not going to have P gingivalis, it's not going to have the human papillomavirus, it's not going to have any of those bugs in the mouth. Just like at the other end, it's not going to be born with syphilis, gonorrhea, AIDS, herpes, whatever. Do you think it's just like trying to clean up the ocean by taking one floating piece of trash out? Do you think there's any chance that someday we will not pass this on to our children? We will not kiss them on the mouth. It'll be almost like an STD to where ... Do you plan to go your whole life without catching HIV? Do you think someday it's reasonable in 10, 20, 100 years that a child will be born and never get contact with streptococcus mutans or P gingivialis or HPV?

Stephen: No. I think they're going to get it but I think that the one thing that we don't understand yet is how aggressive is it. Are there different forms of it. Yeah, it's all right to kiss your kid, but it's also good to have really good oral health before you kiss your kid. If you have really good oral health, you may not be passing on the most aggressive forms of it. Again, this was the debate a couple weeks ago at a pre-conference meeting about transmissibility. Is it transmissible? Should we be messaging it this way? 

My opinion is that it's a good idea. You got to kiss your kid, just make sure you've got a good clean mouth. Make sure your oral health's in good shape.

Howard: Now you're talking loading dose. We know with like a water poisoning, I mean like diarrhea from cholera. They now think that you need to swallow 100,000 cholera to actually have a successful diarrhea and infection. What you're talking about is not only loading dose kissing your kid but also you're saying that in bigger colonies there's more aggressive forms of these bacteria.

Stephen: Yeah. That's right. One of the things that we I always talk to government about is that if you're going to design a dental program to treat kids, you should treat mom and dad too. Because mom and dad's going to pass this on. How do you treat mom and dad? Look at the type of preventive measures you have to do. Look at engaging them and actually taking care of their dentition. Taking care of their oral tissues on a daily basis. 

Howard: I want to ... Since I got a research junkee on my show, I want to ask you the most controversial question in all of dentistry. You have, on Dental Town, 202,000 registered dentists who have posted 4 million times. If you want to say the controversialist craziest thing in the world, a bunch of them, maybe a third, will say these amalgams, the research shows them lasting 38 years. They're made out of metal. The ingredients mercury, silver, zinc, copper, tin. They're all antibacterial static. Our studies on our amalgams, the worst studies showing them lasting 14 years. 

You composite freaks over here are using inert plastic and there's not antibacterial. There's no antibacterial properties to them. They're plastic and your best research is showing that posterior tooth surface composites are lasting 7 years. You tooth colored freaks, bacterial static, 7 years max, and you're always dogging on our amalgams and our worst research shows 14 years and we can show you papers showing our stuff lasts 38 years. 

Now I'm going to throw you under the bus. I'm telling you, of everybody listening to this, they're going to love you or hate your response. You can't win. There's nothing you can say to win over all the viewers with whatever comes out of your mouth.

Stephen: It's interesting because we have this debate in clinic as well to with the other guys that I work with, it shouldn't be guys, the other guys and gals I work with. In terms of materials, I think that amalgam has it's ... Amalgam yes does last longer. It's not pretty. It's much more difficult to monitor its marginal integrity. Composites I think need to be improved. The one positive of composites over amalgam is initially they've got very good early bond strength to tooth structure. Over time, I think we need to study how the bond strength deteriorates. 

There is work being done out there on composites that are nano particles, better filled, that release fluoride such as some of the glass ionomers. There are others things that I've been listening to confidentially which are really, really neat and will be coming to the fore in the next couple years that are improved. That do have the properties of good bond strength. That do release antibacterial, antimicrobial and fluoride as well too, but they're still well away from market. Those are the ideal materials. 

Is composite better than amalgam? Your observation is the same as mine. Those 38 year old, 35 year old amalgams are still hanging around in good healthy mouths. Once it changes, you have perifunctional activities, they don't do that well.

Howard: In my mouth, I have seven restorations that are all gold because ever since I got out of school in 1987, the only dentistry that I ever saw that was 50 year old dentistry back in '87 was the gold work. I would see gold foils ... My eye could see the gaps in them but there's something about that gold, was bacterial static because it just seemed like bugs just didn't want to live there. You'd see some of the gapping gold foil classified and they all worked. Well, not all worked but they just last longest. Do you think there's something. CapTech said it too. When they came out with CapTech they said our porcelain to the high energy gold that the high energy is not an environment for streptococcus mutans, doesn't want to live there as much. Do you think gold has bacterial static properties by its nature of its high surface energy?

Stephen: May have better marginal adaption. That's what I'm thinking. 

Howard: You think it's the marginal adaption not the high surface energy?

Stephen: Step back for a second. Look at what we're doing. Look at where we're placing materials. If you look at the environment, we're taking a material and we're sticking it in water for 30 years and the water gets warmed up, it gets cooled down, and we can then grind on it. We put a lot of force on it depending upon where it is. It's an acidic environment and we're expecting this material to live. Then I go back to my research colleagues and say how do you simulate that in the lab? How do you simulate ...

Howard: Right.

Stephen: In the lab? It's like, I don't know. Actually it's really interesting. One of my colleagues, there are a couple of them. There are a couple of artificial mouths that are being used and we've used those to simulate early lesions. We work with [Del Amici 00:44:51] at the University of Texas in San Antonio, and he has an artificial mouth that he's built with teeth, with plaque, with saliva. He feeds, he brushes and all the rest of that stuff. That's getting close for us to simulate demineralization and remineralization. But for materials, how are they being tested? 

As soon as you put a material in water for 30 years and expect it to stand up, that's a really touch environment no matter what you're using. Then all those other things on top of it. That's why I say to my patients, the best material is enamel. 

Howard: Fantastic words. I'm out of time. I want to ask you a couple things. I've done I think ... Ryan what number is he going to be? We've released 130 but what number is this? I think you're number 153. I would love ... You're so connected. If you have other smart people like you in these worlds, send them my way. I just think your mind is amazing. Also, what my peers want to know now, can they ever expect to see an online CE course from you on the Canary System? 

Stephen: We'll get together and get that going. I apologize for young biotech I get torn in every different direction.

Howard: I think it would be great also for the dentists listening to this on their way to work is to be able to play this ... The reason we do one hour times, is because it's the perfect staff meeting. The dentist could watch this and the hygienist and the assistant and everybody could get on board. Bill Rossie calls it equilabrating the practice when you all learn together and you all get on the same page. Thank you for a wonderful hour. You've got to share with us living in Canada, what is your funniest American joke.

Stephen: Not going there. 

Howard: You're not going there. 

Stephen: I'm not going there. No. 

Howard: My gosh. I always view Canada as the, you know when you walk into a condo and they got the loft upstairs.

Stephen: Yeah.

Howard: I always see Canada is the loft upstairs where the smart people are looking down on us and saying what a crazy circus you live above. You probably walk out your door everyday and ask the crazy Americans to keep it down. Thank you for an amazing hour and thank you on an amazing journey. Thank you for all of your humanitarian awards, your community service awards. You're a legend to dentistry and I hope everybody listens to this. I think every dentist needs to hear more from you.

Stephen: Thank you very much. I had a lot of fun. It was a lot of fun to just talk to you. It really was.

Stephen: You said something that another guest already said. [inaudible 01:00:43] said the best filling material for a tooth is the pulp and the best dentistry is preventive dentistry and that's what I associate you with. Thank you for all you've done for preventing disease instead of just drilling and filling and billing. Have a rocking hot day up there in Canada.

Stephen: Okay thank you.

Stephen: Bye-bye.

Stephen: Bye.

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