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AUDIO - HSP #231 - David Shirazi
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VIDEO - HSP #231 - David Shirazi
•Bruxism and OSA
•What to do with bruxing patients
•Know when to treat and when to refer.
•Work with your local MD's
•Positive effects of cannabis oil
Dr. Shirazi graduated from Howard University College of Dentistry, in Washington D.C. in 2000 and earned a Masters degree in Oriental Medicine from SAMRA University in 2006 and is also a board licensed Acupuncturist. He has completed over 2000 hours of continuing education in TMD and facial pain, craniomandibular orthopedics, and sleep disordered breathing. He has also completed a hospital mini-residency in oriental medicine at the China Beijing International Acupuncture Training Centre which is the only organization the World Health Organization (WHO) has authorized to teach internationally on acupuncture and herbology, and another at Kyung Hee University and Medical Center, the top medical hospital and medical research facility in Korea. In 2011, he became a board licensed RPSGT, the first and so far only, dual degreed dentist and RPSGT. He is the founder of the Bite, Breathe and Balance study group, dedicated to the multidisciplinary approach to treating craniofacial pain and sleep disorders. Dr. Shirazi is the director of a state of the art private practice, The TMJ and Sleep Therapy Centre of Conejo Valley, that is limited to the treatment of TMD, craniofacial pain, Sleep breathing disorders, and craniomandibular orthopedics. His practice is part of the TMJ and Sleep Therapy Centre international family, one of over 30 Centres throughout the world, and is located in the beautiful hills of Thousand Oaks, CA. Personally, Dr. Shirazi enjoys hiking and camping in the state parks, traveling, and speaking. He is married to the love of his life Kimberly Shirazi, and have welcomed their first born, Maximus 2 years ago. They live in the Malibu mountains, where they are very close to nature.
www.tmjconejo.com, aka www.tmjandsleeptherapycentre.com
office: 805-496-5700 Fax:0805-496-5719
Howard: It is a huge honor for me today to be Podcast interviewing Dave Shirazi and I'm not even going to try to explain all the letters after your name. I'm just going to read your bio because man I am so excited to have you on today. Talk about a dental unicorn. I love to find unicorns. Everybody ... there's enough dentists talking about a filling, a crown, a root canal. You are as outside the box as they come.
"Dr. Shirazi graduated from Howard University College of Dentistry in Washington D.C. in 2000 and earned a masters degree in Oriental Medicine from S-A-M-R-A Samra University in 2006 and is also a board certified, board licensed acupuncturist. He has completed over 2000 hours of continuing education in TMD and patient pain, craniomandibular orthopedics, and sleep disorder breathing. He has also completed a hospital mini-residency in oriental medicine at the China-Beijing International Acupuncture Training Center, which is the only organization the World Health Organization has authorized to teach internationally on acupuncture and herbology. Another at [Koing Kayang Hi 00:01:14] University and Medical Center, the top medical hospital and medical research facility in Korea, I assume in Seoul.
In 2011 he became a board certified RPSGT, the first and so far the only dual-degree dentist in RPSGT. He is the founder of the Bite, Breath, and Balance study group dedicated to the multi-disciplinary approach to treating craniofacial pain and sleep disorders. Dr. Shirazi is the director of the state of the art private practice The TMJ and Sleep Therapy Center of Canijo Valley that is limited to the treatment of TMD, craniofacial pain, sleep breathing disorders, and crandiomandibular orthopedics. His practice is part of the TMJ and Sleep Therapy Center International family. One of over 30 centers throughout the world and is located in the beautiful hills of Thousand Oaks, California.
Personally Dr. Shirazi enjoys hiking and camping in the state parks, traveling and speaking. He is married to the love of his life Kimberly Shirazi and have welcomed their first born, Maximus, two years ago. They live in the Maldu mountains where they are very close to nature. I kid you not when I say this. I had Eric, Greg, Brian, and Zach and if I was going to have a fifth boy it was going to be called Maximus.
Howard: I kid you not. Now was that from the movie?
Dave: Yes partially it was stuck in my head for …
Howard: What is the name of that movie? Gladiators.
Dave: Gladiators, yeah.
Howard: Maximus what a strong name, it’s like Zachary, you know I mean?
Dave: Exactly, and in Latin it means the greatest and you know people live up to their names so …
Howard: Maximus in Latin means the greatest?
Dave: Means the greatest.
Howard: That is a great name, so give old Maximus a kiss from uncle Howard, and my God you are a dental unicorn, I don’t know of any dentist who studied in Beijing in Korea and the United States, that is amazing. Tell us about your journey what made you leave the United States and go to China and what was that like living in China and then to Korea, walk us through your journey as if we just met in a bar and we are having a beer.
Dave: Well I was in my last year of masters training in Chinese medicine and an opportunity came up, one to do the hospital residency in china and so in Beijing so …
Howard: How does a residency pop up to go to china, how does that pop up?
Dave: Well all of my instructors … I went to the first accredited acupuncture school in the US it’s called Samra, and all of my instructors were fresh of the boat from China and Korea and so as a student who only speak English, we would try to translate their Chinglish in English because it was very kind of hard to decipher, but because they had ties to their country of origin where they went to school, they were able to get some students over to do residency. We got to go there, I wanted to know if there was anything that I was missing out on, things that they teach in the US that they don’t teach over there back where I come from and actually I know this is going to sound odd, but it wasn’t too different in terms of the didactive training.
Because the country is communist, they have very regimental definition and outline of what Chinese medicine is and how it can be taught. The first Samra opened up in 1969, well after the communist took over, so when they opened up they had their curriculum, they actually brought them down from China because they are communist that just had to be that way. Their hygiene levels are different than ours, certain techniques that they do is different than ours of course the culture is very different from ours, the food is delicious by the way, I had you freaked out. The air is quality is I think the lowest you can find in the world right now, we were after just a couple of weeks, we were coughing out blood and stuff because the air quality was so bad.
Then the opportunity came up in the same year to go to Korea and that was amazing that was one of the greatest experiences of my life, because their hospital system over there puts ours to shame there is no other way of saying it. Their system is so far advanced, in that hospital every physician that graduates is a traditional MD like we have here, but they also have a PHD in Chinese medicine. They had dual degreed every single doctor and they use traditional surgery, they use traditional drugs like we do here, but they also do acupuncture and they also do herbology there, but on a whole other level. Like so, they will extract the herbs and then run it through a liquid chromatography and make sure that the molecule they want is there and then they will make it into a topical or an injectable or a pill or powder or whatever and it’s just on a whole other …
For example while I was on rotation, there was a stroke patient that came in, had a history of a stroke. The doctor chose to treat them with acupuncture that day, so he goes on the main frame and looks up the MRI to see what the infarction was then does the acupuncture to match what’s for that infarction. I mean just on a whole other level, just on a whole other…
Howard: A lot of American, Americans always think they are number one in everything I mean the only thing America is number one in is self-esteem and confidence. Anybody who comes here with a different thought, they are going to get shut down. There is no one dental school, is there any dental school in the United States out of 56 that teaches one class in acupuncture or herbs?
Dave: Not that I know of.
Howard: Or herbs? Is it herbs [silent H] or herbs?
Dave: It depends how you want to say it, I say herbs [silent H]
Howard: Herbs? My name is Howard, so I want to emphasize that H. Explain … First of all I want to start with diet and dental decay in China verses Korea verses USA, is any of their diets more prone to decay or less to decay between China, Korea and the United States?
Dave: Well, when I was there which as in 2006, oh my God nine years already. When I was there [inaudible 00:07:38] they had actually mixed Chinese and western diet and Korean and western diet. The traditional Chinese diet didn’t leave much for decay, they didn’t have processed foods. In fact they were insects rodents and things like, that’s was part of their diet as well as herbs as well as fruits and vegetables. The less processing you have of food, therefore the less refined sugars, the less decay you are going to see I teeth. What was interesting in Korea especially Seoul they had, they love western culture, they love western cultures, so coffee bean …
Howard: In China and Korea?
Dave: No, Chinese hate American culture, but Koreans love American culture, and so they had McDonalds burger king, coffee bean, they had all that and they had a small epidemic of obesity. When I was there I actually spend a day doing a fat clinic rotation, which wasn’t a problem in China, but it was a problem in Korea, and basically it consisted of doing basic exercise and a traditional crane diet, that was their treatment.
Howard: Why did the Chinese … When you said they hate the American culture is that more with food, movies, politics, religion, what did you mean about that?
Dave: Kind of all of the above, I mean they welcomed me and they welcomed my class it was a total of 10 of us that went. They welcomed us because we were there to learn from them, and we were paying them for a service, but in terms of the cultural love of how we live our lives, there wasn’t, I didn’t see any affinity. Now secretly what they have loved to have that kind of freedom that we have? I think so, I think it would be naïve to think otherwise, but just like you said like any dental school think that … every American thinks we are the best in everything, they are the best in everything.
Howard: I noticed that I have gone to China and Hong Kong, I noticed that when you are in America and you just say name one president or prime minister or the top dog of China just name one, almost no American can name any, or if you say who is the president of China? They got no idea. Well name any president in China the last 10, 20, 30 years, they can’t name one. When I go over China and was talking to their dentist and everything, I didn’t meet one that knew any US president starting from George Washington or Ronald Reagan or Washington, o but I would ask all of them, what do you think of when you think of the United States? |They would only name prices, I say what do you, what do you think of United States? They say, “Oh, I love United /states,” I say, “What do you love about it?” they go, “Hot cheese, chocolate bar, brassies, coca cola, Pepsi,” and they would just name things that they bought from this country, but they didn’t just like over here no one knows who maudenzong over there no one knows who George Washington was. I saw a total … just product base, what do you trade?
Howard: Now it might have been different for you being I a university setting where everybody was highly well read.
Dave: Yeah and you know what’s interesting about everyone being around the highly well-read, medical school is free, the government covers it. In China unlike Korea where you do both, you do either western medicine or traditional Chinese medicine, so you take a test after high school and if you pass the test and you can choose to go through one training or the other, very interesting it really is a different way of life.
In fact one time I tell this is a really funny story, we were walking down the street with my group looking for a restaurant and we saw this group and let’s say party of five in front of us and this two I guess representatives from the restaurant started chasing them down and we didn’t know what they were saying they were yelling at them in Chinese and they were like following them for a block. Then at some point they all turned around and back and went and ate at the hotel and all I could imagine was that they being solicited, maybe they were possibly bargaining on the price I don’t know, but the whole concept of someone hollering at you as you were walking down the street [inaudible 00:12:16] the restaurant would not fly here, I’ll tell that you right now, that would not fly here.
Howard: What was the main difference between living in China verses Seoul Korea?
Dave: Oh my God, you cannot compare. Living in Korea and it was brief, but living there it didn’t feel like I was in a foreign country. I mean obviously everyone speaks Korean and very little people speak English, but you can get by the people are incredibly nice, everything was pretty clean everywhere I went the air was lovely. We rented a room in someone’s house, we each had a room sort of bedroom and it was a wonderful easy experience. China not so much, you got to be on top of your game in China, you cannot leave your wallet hanging around, you can’t assume that drivers on the street are going to stop for you, it’s a very different mentality.
Howard: Who do you think as far as living your life existence on the third rock from the sun, who do you think was the happiest and giggle the most in the three civilization you lived in. The United states, the Chinese, the Korean how do you rate them as far as the happiness factor.
Dave: Goodness well I heard such a small sample [paused] well China would be last between Korea and the US it really kind of depends on what town in the US because sometimes the town that I leave in Garry hills you know a thousand oats my offices I would say that would be above Korea, if we are talking New York I would say you know Korea goes well above [laughing] the people of New York it kind of depends
Howard Farran: I want I have noticed that in a country where everybody is the same ethnicity say you go to Poland everyone is polish you go to Ireland they are all Irish there are just not really melting parts at all you know but in the United States am noticing it’s just like the United States, Canada, Australia, England when you live in big melting pot people are nervous to ask any questions that might have to do with race because they don’t want to be called a racist or anything like that but I want to ask you a political racial politically insensitive questions that is some people teach that Chine…that Asians have more gum disease because their cervical knack is constricted, and the pure mechanics calcium and phosphorous precipitating out of saliva, that Asians teeth build more tarter and calculus and have more periodontal disease than the opposite extreme in African tooth, where the constricted cervical neck is the least constructive and often times [bobus 00:15:03] and they don’t really precipitate tarter and calculus thus they have less periodontal disease.
This is being confirmed to me by pediatric dentist had practice around here saying, yeah, keeping a chrome steel crown on an African kid in Tanzania, this would be the most difficult, but getting it to snap into undercuts of a constructive cervical neck on an Asian child would be the easiest. Do you agree with that and do you think that and do you think that Asians have more periodontal disease and if yes, is it from the constructive cervical neck. Do you think Asians smoke more than United States? Do you love the fact that when I go to ask a question I just dump like 20 questions out there so you can just pick anyone you want to go after?
Dave: Well I have a thought to share and that is yes, there was a lot of people smoking when I was in Beijing, but then again that’s a small sampling, because even 17 million people in one city which was Beijing, it’s still a billion and a half people so I can’t speak for all Chinese. One thing that we do know is we see a lot of people with neuromuscular tone issues having sleep apnea. We are actionist and of course the more overweight you are it makes your airways smaller, more collapsible and therefore you can get [inaudible 00:16:23]. Asians have, just like how they have the shovel shapes incisors, they have very shovel shaped airways, very, very flat and they are actually slightly predisposed to sleep apnea because their airway is so small to begin with.
There are studies that have correlated bruxers, which I want to talk to you about later the correlation between bruxin and [inaudible 00:16:44], that have more periodontal problems and more severe periodontal problems.
Howard: Okay, my job is as to make question, just to make questions that our viewers are airing, explain the shovel shape, you said shovel shaped incisors …?
Dave: Well I mean flat, you know what shovel shape and sizes are, they look like shovel, they have a kind of flat and all that. Their airway is very flat in longitudinal [fashion 00:17:08], and their mandibles are relatively small, so when they lay back to sleep, it’s very easy to close an airway that’s very thin. Does that make sense?
Dave: They seem in terms of treatment with Oral Appliance Therapy , they seem to respond the best with interior repositioning because their airway is so flat and this plain, that when you bring them forward, you do indeed increase their airway, because not everyone is like this, sometimes people airways are like this shape and when you bring it forward you actually close the airway. The same thing with the Asian, if you have a [long streamed 00:17:47] area like this and you bring them forward, you will get to a point where you keep bringing them forward if you don’t course a TMJ problem first, if you keep bringing them forward you will start to make the airway smaller.
Howard: Did you see any differences in incidents of [paranolysis 00:18:03] between Seoul, Beijing and United States and any difference and instance between TMJ?
Dave: I’m genuinely not qualified to answer that because when I did my hospital residencies, it was purely on Chinese medicine, I didn’t look inside their mouth. Even in practice today, its limited to pain in sleep and functional orthodontics I don’t really do periodontal exams anymore.
Howard: Do you have a [hygenous 00:18:32], tell us about your practice …?
Howard: You don’t have a hygenous?
Dave: No, no, it’s just me. I have seven people working for me, three of them are just for medical billing, I have my office managers, we have six operatories, 3,000 Square feet. At night my office becomes a sleep lab. We take the chairs, we don’t have dental chairs, half of my chairs are sort of massage chairs and the other half of the chairs are all surgery chairs, only because you can recline them so I can do acupuncture. When we are doing the sleep study, we have them on sliders, so we just push them off into the corner and we have they’re called cabinet beds. It’s a queen sized tempurpedic bed shelved into a cabinet, tri-fold and so when it’s time to be at bed, you open up the cabinet, the walls of the cabinet becomes the frame of the bed and it becomes a queen-sized tempurpedic bed and then we do our research, we do our sleep studies.
Howard: How long have you heard this practice?
Dave: In this location with this sleep lab, two and a half years.
Howard: How is the going?
Dave: Great, it’s really great. When we were in our previous location was a block away, we had 2000 square feet and three operatories and we just needed the space, so we went out and of course I’m very passionate about research, about studying it, meeting it, doing it and this became a great opportunity to do research.
Howard: I think you should create an online CE course on Dentaltown and start educating these dentists, I mean you are so …
Dave: I would love to.
Howard: I would love that. That is amazing. Where do you want to start this, bruxism and OSA? Explain OSA.
Dave: Okay so Obstructive Sleep Apnea, so 90% of apneas are either apnea physical blockage or hypopnea which I’ll explain and 10% is sensual sleep apnea where the CNS just tells the boy not to breath. That’s a whole other subject I can answer that for you if you like as well. In the apnea category, we have apneas which is where there is a physical obstruction in the airway, on the upper airway, are 10 seconds or greater in duration. A hypopnea, is when there is a shallowness in the breathing the … sort of breathing that courses 3% or greater oxygen desaturation. Medicare decided to make their protocols for hypopnea, 4% or greater desaturation, but I don’t take [inaudible 00:21:16] so I just call them 3% desaturation.
You can have what is called a RERA. A respiratory effort related arousal, which is essentially like in apnea but it didn’t take [tarters 00:21:28] but it caused an arousal. An arousal, this is something that’s never talked about, but arousals are incredibly important. What they are is when someone is in a deep stage of sleep, will be at [inaudible 00:21:44] stage three, stage two and they have an airway events whether its snoring, whether it RERA, whether it’s the apnea or hypopnea and it kicks them out of that deeper stage of sleep into a lighter stage of sleep, and that’s very, very important because just having those arousals, you can have a diagnosis of insominia.
You can have all the symptoms that you can get from stay back, little depression, little anxiety, hypertension, the type two diabetes that is all it takes to raise your inflammatory markers up. When I first started doing this, a lot of … When I talk to dentist about how they follow up with their patients, they would have their patients do a lot, like they were at that, last night I slept great, felt great when I woke up, [clients 00:22:33] is fine, a little bit of jaw pain, et cetera. When I ask them, “Don’t you do a sleep study, even a home sleep study?” They would say, “No, this is fine, maybe one day I will send them in back to the lab to do in-lab study.”
The problem with that is you can have a patient that had a lot of arousals prior to Oral Appliance Therapy, you treat them with Oral Appliance Therapy, their arousal index goes down and their brain is mentally sleeping better, but they are still having an oxygen problem and apnea problem, but you would know that because all you have to go on is their subjective answer, that’s why sleep studies are so important, whether its home or in-lab.
Howard: Talk about the pro and cons of a home or a lab, like you’re doing them in your own office.
Dave: I offer both, I offer in lab and home and I have no bias, I would tell the patients what is in their best interest. I’ll tell you what, the bottom line comes down to this, because obviously a PSG, which has 20 leads on the patient that we’re measuring the brain wave activity, their muscle activity, their airway flow, their thermos, thoracic inlet and outlet, lid movement, so you have everything covered and there is someone watching them, there’s a sleep technologist watching them sleep, so if they have a cough, that’s going to make their EKG go crazy and is going to make their brainwaves go crazy, but if you didn’t know that that was an [autofact 00:24:01] then you might score that as a possible event of some kind, so that’s obviously the best test.
Home sleep studies are between four and above leads; usually we don’t do less than five. Type four is they only do four, that’s like a watch pattern, but the way I approach it with my patients is I tell them, “Look, when you go to a hotel on vacation, how do you sleep that first night? Can you just flip the lights switch and you are out because you are just so tired from travelling and what have you or does it take you to three days to get used to that bed?” If they say it takes two to three days to get used to the bed, I’m gone a notch closer to getting home sleep study, because I want something that’s more realistic of what the … and not a typical night sleep is for them.
If they tell me, “Doc, you know what, you turn off that light switch I’m out, it doesn’t matter what I … “ My wife could sleep on a bed of nails on her face, she has no problem sleeping. She would be someone, and I have done before, but she would be someone that you would do a full PSG on.
Howard: Explain what PSG is?
Dave: Polysomnogram is the sleep study where you go into the lab and you put on those 20 leads like EEG, EMG, ECG and et cetera and a sleep technology that watches you sleep the whole night and scores it and a physician interprets it.
Howard: A very common question that I’m seeing a lot from the … everybody is talking about sleep medicine now, what about the three-year-olds, do you do pediatrics patients with this, I mean at what age would you be concerned about a kid having a sleep apnea?
Dave: Birth, sleep apnea is much more problematic and costly the younger the child is, and the reason is as adults, about 25% of our sleep is REM, where we do our memory consolidation and a mental rest, and about 15% 10-15% is Delta which is stage three. Stage three is where over 90% of growth hormone is released, so it’s incredibly important. The younger the child the more their sleep is predominantly either Delta or REM. For example, for adult white men, if they have five episodes of either apnea or hipopnea per hour, that’s actually considered within normal limits. If they are five to 15 per hour, that’s considered mild, 15-30 is considered moderate and anything over 30 is considered senior.
The way they got that number was, after they did sleep studies on these patients, they looked at their health history and if they noticed diabetes, hypertension, stroke et cetera in their history and they looked at their score they all on average which had about 30. The numbers went up; I have treated people that are 127, so these numbers go way up. When they notice that people that have 15-30 category, if they noticed that these patients had three diabetes, three hypertension, right on the border. The mild category, again this is white males only, they found they had mostly excessive daytime sleepiness every time. Now coming back to the child, if a child, then let’s say younger than 12 has an HI of 1.0, 1.0 or greater, that’s severe, that is severe, because you are interrupting so much up their good sleep.
Howard: What percent of a pediatric dentist would you say have ever ordered a sleep study for a pediatric patient?
Dave: Pediatric dentist.
Howard: Those are 210,187 dentists in United States, 80% on general dentist, California has the most dentists at 33,242 and Ramon has the fewest at 297, but for our periodontist friends, how many of them do you think do sleep apnea observations, sending home at [inaudible 00:28:15], I mean if it’s so important, it’s so much important with children with their growth, but what percent of pediatric dentist do you think are on top of this?
Dave: Very low, I don’t know what the numbers are but I suspect that its extremely low, because as you know every time new insurance that … not insurance, I’m sorry, new research comes out or new guidelines and protocols comes out, it takes a while for people to change their ways and move forward, so it’s only just recently where the American Academy of Pediatrics, I’m sorry, American Pediatrics Association, just announced that every kid should be evaluated first time.
Howard: When was this announced?
Dave: I believe this year; I believe this study that protocol just this year.
Howard: Wow, I did not hear that.
Dave: Of course, of course you didn’t, its brand new, it’s brand new. I’m sure even most of the pediatricians in my area haven’t hear about it either, so there is going to be a little bit of a disconnect before you get from the changes to the actual change in behavior to it trickling down to a [peda 00:29:21] dentist and the people they are going to know about it are only the people that dedicate their lives to it.
Howard: I think it funny how peda dentist get very mad when you call them peda dentist, they want to be called pediatric dentist and then my old school peda dentist said that, “I just think it’s cute that they find offense by that, it seems so harmless.” Dentistry is way behind the curve, oral cancer is surging with HPV that they won’t … dental insurance committees won’t cover oral cancer screening on most of them warned out of state boards or let us give an HPV vaccine as a public health dentist, I’m not even allowed to give a flu shot but a pharmacy tech can [inaudible 00:30:04] into a CTS, but I know some of the first things you open up with is that you had seven employees and three of them were medical building.
Howard: Is that kind of the wall you had that dentistry is not on top of sleep apnea and so we just … you just had to focus on medical?
Dave: Well oral sensual pain, cranofacial pain and sleep disorder breathing as it pertains to a dentist are all paid for by a medical insurance. It’s usually not covered by dental insurance, that’s why we do a medical insurance. Now the reason why I have three is because I see as many people as I do and medical insurance is far, far more challenging to work with than dental insurance. Far, I mean it’s not enough far as for me to tell you. When I have people complaining about dental insurance, I just role my eyes, I don’t even say anything, I’m like okay.
Howard: I know and they always complain about Delta, and Delta sells, they are $105billion industry, I mean Delta is selling 20 billion of it and all they do is complain and then they get the American Dental Associates is a thousand dollars a year and then they don’t sell dollars worth of insurance and you are right, dealing with Delta compare to dealing with medical, I mean, like say there is no word for us to describe how much difficult medical insurance is. Dentist actually have a sweet job, they work four days a week, 32 hours, they make on average three combined average household income where everybody working in a house bringing a paycheck in a hat, they average three combined houses of income a year. They have three day weekends and they still complain.
Dave: Well, I was sure that my medical billing to [inaudible 00:31:54] they will change this turn up.
Howard: I wish you would do a course on this, because I think the most interesting content is thinking outside the box and I think man, what a fun unique selling proposition you have, are you are getting most of these patients with internet, do they tend to be more recycling, not to be weird or offensive but I’m thinking in California you think of tree huggers and going green and recycling and more new age. Is acupuncture and herbs and what you are doing you think more popular in California than say Arkansas and Nebraska and Oklahoma?
Dave: Yeah, I think that’s a fair assessment, I think people who are more holistically binded are a bit more favored here in California Los Angeles area. Particularly and let’s said Arkansas, yeah for sure, no question about it. There are those who just want the traditional [drug 00:32:50] that would the only way they’ve been treated, and so if that’s what they want, that’s fine, there is plenty of docs around that do just that. When it comes to sleep, I don’t know if holistic falls onto that category, but when in terms of pain, I think I’m the only dentist that’s told to do it as acupuncture.
Howard: Okay, just stop right there at acupuncture, first of all explain what acupuncture is, because I’m sure a lot of you would just think, no you are putting a pins somewhere and like this voodoo or this is ancient that goes like a thousand years no research but you feel it’s an absolute science, so explain acupuncture and how it works, and why you feel it’s a scientific or say dentistry or dermatology or …?
Dave: Its far more scientific than anything in the western culture and the reason I say that it’s been around for 5,000 years but for about 25 or 2,600 of those years was it actually formalized in a way of teaching and of course there is so much [inaudible 00:33:57] behind acupuncture. We have facts about how they work but we don’t really know how they work. Functional MRI, like for example, functional MRI’s have shown patients with knee pain, when they do an acupuncture that’s furthest away from that area, they’ll actually see endorphins and enkephalins being triggered in that part of the brain where we sense knee pain, we see that. We are not sticking the needle in the knee, but we see the result there. Western medicine on the other hand is about 200 years old. About 200, 250 years old, so it comes back to America. Where we think we have the best of everything.
Howard: We’re number one in everything.
Dave: We’re number one in everything right? The danger in thinking like that is you could miss out on something very, very good, because if you think it’s all there is.
Howard: Well, explain now how acupuncture works?
Dave: We have meridians that flow through our body which are like electrical currents like the electrical wire, and the pass through our organs and they pass through the [inaudible 00:35:06]. In my lectures, I teach in all lecture acupuncture course for general dentist because …
Howard: How long is the course?
Dave: It’s the whole day; it’s a eight hour day course.
Howard: You should put that eight our day course up on Dentaltown because we put up 350 courses and they have been viewed over half a million times, because they don’t have to shut down their practice and travel and spend a lot of money, it’s just we are making India education easier, faster, or cost.
Dave: I actually have the video tape but I did it as a Webinar.
Howard: Awesome, can you put up on Dentaltown?
Dave: I will be happy to; I will talk with Ryan afterwards.
Howard: Actually I am Howard@dentaltown.com but the guy that runs the online continuous educations Howard Goldstein, so his email is Hogo, so just H-O-G-O@dentaltown.com and I am Howard@dentaltown.com, but yeah, you can cc my son Ryan at …
Dave: [inaudible 00:36:05]
Howard: You should make yourself a Dentaltown email, it’s a lot easier.
Dave: Yeah, but the course I teach, because the device, the electrical device doesn’t break the skin, we technically not doing acupuncture so its within your scope of practice, and because you are going to use is for symptoms of the head and neck, like dental oral head neck TMJ, and then that again is within your scope of license, scope of practice. Going back to that there is electrical currents that we have throughout our boy and the energy that flows through what we call Qi.
Dave: Well, it depends how you want to spell it, so some people spell it C-H-I, some people spell it Q-I, but it ends up the sound is CHI. In Korea, I’m sorry, in Japan they call it Ki like K-I, but it’s the same name. in Chinese medicine we say when there is a pain, or even a paresthesia or numbness, we say that there is a blockage of the Qi, and It's our job to go up and well, where is it originally coming from and what are the points that are related to the area that I’m trying to treat that will resolve this issue. It’s very organic, they look at things have being in excess or deficient; things have been cold and hot and dump and dry. It’s a complete 180 from the western mentality, complete 180.
Howard: Well I noticed is you deal with the more higher educate, like I will give you an experience that I just had yesterday at the gym. Somebody thinks they have injured they road header cuff and someone said well here is the name of my neurosurgeon and this is the very successful, older 50 year old person. He says, “Hell no, I’m not going to neurosurgeons, the only way they make money is to flay me open. I’m first going to go to Dr. Angie because she’ll try everything minimally invested, so she will exhaust everything non surgical and I want to give my body a chance to heal.”
I already see in America, that the highly breeding, literate and most intelligent people are starting to become afraid of surgeons and pharmaceutical companies, I mean they just see all the side effects, they see all the surgeries, they are like, “I want to slow down spanking and there are going to be a last resort. Taking a pill and getting flayed open is now becoming a last resort and what you’re doing is the up and coming … I would almost call it minimally invasive dentistry, you know what I mean?
Dave: It is the same mindset and I do want to adjust what you said because indeed, every doctor should have the mentality, let’s treat this as conservatively as possible. Not just financially conservative, but let’s be as conservative as possible so that we don’t do anything that’s irreversible, because once you have surgery, there is no going back. There is no going back from surgery.
Howard: I will give you an example, like treating the worn dentations, what do they do when the teeth have worn down. To repair that will file the whole tooth down till it looks Ike a grain of rice and then put a crown on it. To treat well, the first thing we do is to sharp the tooth on a pencil sharpener and we crowned it to prevent more destruction of the enamel. I’m pretty sure you know what that means … The mindset is changing.
Dave: Yeah, and I hope so, and I hope it does change because in that same case, because we all we see these cases in these patients coming in with this close verticals, you can’t even see their lower incisors they are so collapsed in. when we see these patients we should be thinking, why have they worn their teeth then, why are they in my office today, and if their video is that lost, what is their judgments that lack? That should be their mentality, not you know what, I’m just going to protect these teeth with bruxzin crown, so that he can’t wear them down. Why is he bruxing, because he’s trying to keep his [inaudible 00:40:19] open? Because that is a known thing. If it is, well just covering it up with a [zachonea 00:40:26] crown isn’t going to really help the patient in the long run.
Howard: Do you think you can seize a [patient 00:40:31] grinding and make them oral appliance, a night guard without doing home sleep test?
Dave: Okay, I will tell you exactly how I feel about that, my local dental society who I love very much. When I first came into this community 19 years ago, they asked me to do an editorial on TMJ, like a full page sort of thing and then use that. I did it, they loved it, it was fantastic. Can we do one on sleep too, and said I would love to, are you kidding I love education, and so I wrote it and in it I put dental, that in the future I foresee that if a dentist sees bruxtism in a patient and just doesn’t refer out for a sleep study of any kind or to a sleep specialist of any kind and just sticks and NTI in their mouth or a night guard, that would be seen as malpractice.
When I put, they wanted me to remove it and I wouldn’t and so they didn’t publish, which I understand. They don’t want; we don’t want to get … they are our brothers and sisters in trouble, obviously, but it’s important to get the word out there that you don’t just do it. I remember you heard that Dr. Steve [Olmoson 00:41:46] here and he was talking about the great study out of Montreal where with Dr. [Gilivin 00:41:54], where he took patients that had sleep studies and had sleep apnea and didn’t wear their Cpap but had their night guard, so then he said, “Alright, wear your night guard and then let’s do another sleep study and see where you are at.” 40% of those patients there acting got much worse, by wearing the night guard, versus nothing.
The worse their apnea, the worst it got with the night guard. We could postulate that because the initial opening of the mandibles rotation and the translation that initial rotation actually brings the mandible back, so when you put a night guard in someone, not really doing their airway any favors, we can postulate that, but the fact remains, no one looked, no one did an x-ray of their airway, no one did an x-ray of their jaw when they made them a night guard. In fact most people, most dentist that I see make night guards, they don’t even take the jaw position, they just have their assistant take them in the malls, they send it out to the lab, the lab goes, “That’s okay, I read about that looks about alright, I don’t think its interpolation I’m just going to put it in there,” and its completely [inaudible 00:42:58], does that make sense?
Howard: Absolutely, so what kind of x-ray do you like, are you doing a two dimensional panel, you are doing a three dimension CBCT?
Dave: I’m doing CBCT, not panels, I mean two dimensional dentistry is quite over, is quite over. There are so many other aspects to look at.
Howard: What CBC I you get? The dentist always tell me be specific, they are always saying, “Be specific, no generalization.” What CBC did you pair?
Dave: The[ ica nexgen 00:43:29].
Howard: The icanexgen?
Howard: the icanexgen, and where is that made out of, where is that come out of?
Dave: Out of Georgia.
Howard: That’s out of Georgia?
Dave: Imaging sciences, yeah.
Howard: Imaging science out of Atlanta?
Dave: I’m thinking yeah, it’s an American company.
Howard: What’s that?
Dave: It’s an American company; the others are Korean and Italian.
Howard: What are the other ones you like?
Dave: Goodness Howard.
Howard: What’s the Korean and the Italian one?
Dave: I don’t know their names, I’m sorry. The Korean one, I just know it’s a lot cheaper, the Italian one is a lot … its extremely more detailed than the I can, but it’s a lot more radiation, a lot more and the patient lays flat on the table which I don’t like because the mandible can flop back, so it doesn’t work in for most dentist, maybe it works for neurosurgeon.
Howard: What about the sleep home study, which season you like?
Dave: Well, I’m biased, I like Somno Medics, because …
Howard: You like which one?
Dave: The brand is called SomnoMedics.
Howard: Spell it.
Dave: Somno S-O-M-N-O medics, MEDICS.
Howard: what’s Somno stands for?
Howard: Sleep, S-O-M-N-O?
Howard: Mean the whole word it means sleep?
Howard: In what a different language, Greek, Latin what?
Dave: I think its Latin.
Howard: Somno is Latin for sleep, I did not know that.
Dave: It sounds like Spaniard.
Howard: I was an altar boy; I should know all my Latin.
Dave: Its sounds like Spaniards [inaudible 00:44:59] Somno Spanial.
Howard: Yeah, in Spanish?
Dave: Yeah, Latin [inaudible 00:45:04].
Howard: Do you speak other languages?
Dave: I speak Farsi and Spanish yeah.
Howard: Farsi and Spanish, so neither of those helped in Beijing?
Dave: No, unfortunately nothing helped, no. English was my best bet.
Howard: English is your best bet?
Dave: I have to tell you something about that and China. You know how there is a stereotype that French people are very arrogant with their language and if you don’t say it just right, they get all up in arms? No, I’ve been to France many times, if you try to speak their language, they love that you try, they are very nice. In china, no matter how much you try, no matter how many times you humor them, they are always correcting you and they are not nice about it, you are always corrected, no you said that totally wrong and it sounds exactly the same what they say, but yeah, just told the side note about the language.
Howard: I think that’s the one thing I cannot do. I think I’m mis-wired on something as the happiest day of my life was not the birth of any of four children, it was the day my mother told me I no longer had to take piano lesson and my piano says that I couldn’t carry a tune in a lunch bell and the only D I ever made, was in Spanish and Sir. Martin the teacher told my mother that I was linguistically retarded. He said, I just said [inaudible 00:46:24] 10 times in a row every time he comes he goes I don’t think his ear is connected up to his mouth, okay and so I have a piano teacher and Spanish teacher saying I’m not gifted in sound and one of the two is going to right. That’s … but Somno. Tell me, how much is that Somno Medic?
Dave: It I … if you are getting it purely for HST it’s about …
Howard: Explain what HST is?
Dave: Home Sleep Study, if you are using it just as a home sleep device, at the time that I bought, which is several years ago was 5’000, now I will tell you the reason I’m biased towards it is because in my opinion they make the best in lab equipment. If you get the in lab that that cost 25, 000 for the whole shubeni and …
Howard: You have that in your office?
Dave: I have multiple ones of those in my office, yeah because I got three beds.
Howard: You paid 25 grand per bed, for three beds from Somno Medics?
Dave: That’s correct.
Howard: Where are they out off?
Dave: They are out of Germany.
Dave: They are out of Germany and for their PSG, all the best universities use it for their research, Stanford, NYU Arizona, they use Somno Medics and the reason why I think and the reason why I like it …
Howard: What is the PSG stand for?
Dave: Polysomnogram, that’s the in lab study. The reason why I like them so much is they are the only product now where you do the in lab study and they are not tethered to the night stand, so the head box in more like let’s say Alice equipment which is about 10 grand a room, you have all your EEG leads plugged into a box that’s on the night stand, so you are tethered, so you have to sleep on you back, you can’t move, otherwise you pull the leads out and the lab techs got to come back in and re-plug them in. with the Somno Medics, their head box is on their shoulder and the unit is entirely wireless …
Dave: You role around in the bed, if you have to go to the bathroom you just go and you comeback and you go back to sleep, there is no re-plugging in nonsense.
Howard: You could take a date to their home for the study?
Dave: If you wanted to you could.
Howard: That is nice, wireless; I mean that is just an obvious. When you do that … so when you send at home, this machine goes 5,000, what do you charge for them to take at home?
Dave: My sleep lab charges $450 night.
Howard: For them to sleep in your dental office?
Dave: No, not office, much more to sleep in the dental office. For the home sleep study, I charge $450.
Howard: Your patients pay you $450 on their Visa or do you bill their medical [inaudible 00:49:07]?
Dave: Usually both. By the time we’ve done it, we’ve already received authorization, we have an idea of what they are going to pay and we know what the patient’s portion is going to be, so we charge them. We charge them just a portion.
Howard: What does that usually come out to be, of their portion verses the insurance?
Dave: Well, if the insurance covers 80% then we charge them 20% of 450 which is 90 bucks.
Howard: How many times … Do you sense of a home with this everyday then?
Dave: Almost every day, we are doing a sleep stud of some kind.
Howard: Then they bring back and then you just download this to your desktop computer and it shows a report?
Dave: Yeah, it has an autoscore feature but because I’m a sleep technologist, I score it again, and I go and send it to our medical director and have him do the interpretation.
Howard: You have a medical director in house or you send it out for a study?
Dave: We has one in-house, up until earlier this year, but now we chose someone that’s up in Northern California.
Howard: Interesting, and does he work with dentists and physicals and sleep, [inaudible 00:50:19]?
Dave: Yes, and the reason I like him and I liked my previous medical director is neither of them own their own dental lab. Physicals that own their dental lab, they make their money from doing sleep study in the lab; they make their money from selling C path equipment. They don’t like the other options, they don’t like the ENT counsels, they don’t like the oral plants option, if they don’t do it, they don’t like it. When they do their interpretation they would say recommended treatment, Cpap It’s a real shame. Now the ones that are not owning their own sleep lab, they are very open to all possibilities in an intelligent manner, and they are open, like so I has one of them send me a patient and then said, “This patient can’t handle the pressure of their Cpap, I want you to do a combination like an appliance with the Cpap because I do that a lot.
When I evaluate and when I listened to the patients complaints, I called the doctor up and I said, “If you switch his machine from a Cpap to an oral path, I guarantee you he won’t need an oral plan, so he’s going to be just fine.” He goes, “Okay, I’ll do it.” Now the reason why most physical don’t like to do an oral path does a sleep study do the patient every single night and insurance companies know this and don’t like to pay for multiple follow up sleep studies if the device is doing it, justifiable. I like working with doctors that are open minded and don’t have a financial interest.
Howard: So many times you can summarize every decision. I’m always telling my kids and you’ll hear they say, why o you think this happened, I said money is the answer, what’s your question. Pretty much sums up about 80% of all question when my boy sees something that doesn’t make sense.
Dave: I would be [inaudible 00:52:19].
Howard: Crazy, I know that. I don’t know, do you think America does that more or less, or do you think it’s a global problem?
Dave: Well it depends, if you are coming from a country that has their medical and dental paid for by the state, then there is less of that in their industry, but when it’s a more private sector, we see more of that.
Howard: How was dental paid in China and Korea, o you remember that?
Dave: Dental pain or pay?
Howard: No payment?
Dave: I have no idea, I know that Chinese medicine acupuncture and herbs is a covered medicine under the …
Howard: You have an all day Webinar on this?
Dave: On a lecture … Chinese medicine or lecture acupuncture that treat oral facial pain, exactly.
Howard: You are thinking about putting this up on dental town?
Dave: Absolutely I’m flattered that you invited me.
Howard: Oh my God, like say I look for dental unicorn and you are a dental unicorn an you are a neat guy and I love those things you … I’ve only got you for several more minutes and we haven’t even mentioned herbs, do you mind going into herbs for a little while?
Dave: I don’t mind at all, I don’t do too much of it in my practice because for example if …
Howard: Because I have some experience in herbs, I smoked something in college and …
Dave: Drug. I’ll tell you the research on Cannabis oil, is in the treatment of a host of medical condition, nearly every cancer, breast cancer, brain cancer, the research, the evidence for it is frankly overwhelming and overwhelming pleasant.
Howard: Yeah I still … I think the most hope I have about the future of civilization is for them just look back at a snapshot of civilization every 100 years back all the way to the great wall, it just seems like we just keep moving forward and I never would have guessed when I walked in a college some day, marijuana and gay marriage should be legal. I think a lot of people listening to you that are 40, 50, 60, 70 are thinking, that’s crazy, and a lot of kid that are 40 to 30 to 30 are thinking wow this is interesting, my school didn’t teach anything about any of this. I just think that younger kids have open minds and I think they think that old people should o is try to have open minds a play like children. I look at my three-year-old granddaughter, they wake up, they don’t need coffee, they don’t need a cigarette, they don’t need a cigarette, they don’t need, what are those energy drinks called?
Dave: Monster drinks [inaudible 00:55:04]
Howard: Monster drinks and red bull, they just get up and play, and they are always giggling an laughing and they are always open minded when they are playing and I always look at my Taylor and think, that’s what you need to do at 53, you need to get up and play and giggle and have fun and if anybody is listening to this and their hair on the back of their neck standing up saying that’s not they taught me at the University of Arkansas city, that olds school, you know dude, there is more than one … Talk about herbs, I’ve only got you for five more minutes, talk about herbs.
Dave: In my field as it pertains to pain and sleep. I’m not doing herbs too often. The times am using herbs are if the patient can’t tolerate any medication. For me the medication route is something I use for acute cases and for cases where I still have a working diagnosis going, and to help me with everything else am doing; you know, Orthotic Therapy, Acupuncture Therapy, Cold Laser Therapy and et cetera. If the patient says, you know doc, I can’t put my lips on any medication, I have a bad reaction to almost everything. I go, okay fantastic let’s do the herbal route.
Because I have to be honest, even though I’m here in California, not everyone comes to me and says, “Hey can you treat me with herbs and acupuncture?” They still want the conventional and I have to give them the options and why you can have the conventional but I don’t recommend them for you. For example for that patient then I would do an herbal concotion. I don’t do that as a traditional herbal way of treating it is, you give someone the dry herbs and they cook it at their home and they stink up their entire house and the can’t the pot and pans smell like those disgusting herbs and they plug their nose and try to down it for a week. The way I would rather do it is I put it in a solution of alcohol, about 40% alcohol, very strong and they take just like a dropper full and wash it down with some orgy and that’s it. Sure it tastes bad, but so what, it’s just like a few seconds, unlike drinking a whole part of this …
Howard: You see I admire so we’re used to that because Jameson Whiskey and now you have to got to slam that too, that doesn’t go down very smooth. You know what, a holistic thing that I have seen in my own personal life no names mentioned, family member, morning, guard, and you know I’m a dentist and you see guard and all these positions, they want to give you these pills and this and that, nothing is working and then a holistic website says if you take a shot of vinegar,apple cider vinegar before bedtime …
Howard: Raw and so got a shot glass, shot boom and it just work like turning it off like a switch, and I’m like, how come none of the physicians, and when you are talking of physicians, like where did you learn that from, from the internet? Dude! They had no problem writing a script for something that had 20 side effects and cost a lot of money and insurance. Then now my buddy is drinking a shot of apple and vinegar and morning [inaudible 00:58:18] and then when he falls out of the habit and doesn’t do it for two or three or four days, boom its back.
Dave: It’s back yeah.
Howard: Its back, that’s what is sad about it because nobody is making money out of vinegar, so nobody is going to be talking about it, there is not going to be many commercials on TV.
Dave: The thing is, the more specifically, you are actually right. They are not making money off it, so they are not paying for a research study on good patients without the cider vinegar. when you see, what is that called, the purple pill, I can’t think of it right now, but when you see that commercial, there was a pharmaceutical company that said, “Hey we could sell this, lets pay for some research, let’s go through FTA one, two, three, four trials and let’s get this out to the public and let’s make money out of it. There are very many people that are testing things that are all natural.
Howard: What really, I thought was the most un-American thing that I ever heard in my life, is the lady on my street that wanted to try this new chemotherapy for brain cancer, and she is not even allowed, they are not even allowed to give it to her, and I say so she had … with brain cancer 70-years-old, had to sell her home in Phoenix and move to Scandinavia, just to have the freedom to take a pill. I mean the fact that our government, they talk about [inaudible 00:59:35] and free trade zone. The fact that there is no free trade zone, maybe they do where they have casinos, maybe there should be a free trade zone where we can say hey this is no FDA territory and you shouldn’t have to move to Denmark to try something that you are going to die anyway, and why didn’t she have the legal right to decide and select. All the doctors say I’m going to die anyway, it’s my life, I want to try this and the government says “No, no you have to leave the country.” That is just sick.
Dave: I’ll tell you what in terms of medical training, that is just a drop in the bucket, the whole concept that alcohol and cigarettes are legal and we know the kind of ramifications from using that an something in herb like you said like marijuana, which has very few, I mean the side effects of marijuana are: it makes you happy, sleepy and hungry. That’s basically it. Very, very few side effects but the list of medical uses is off the charts, it’s like nothing was good, but if you can’t package them into a pill right, so because it’s illegal to package food as a drug. You can’t do that. That to me is much more of a side of medical and you think about our mindset, that we would think that an herb that comes from mother nature doesn’t have its own ability to like take care of itself and not be too much and not too little, whereas something artificial like cigarettes and alcohol, we know lungs are may [inaudible 01:01:05] a little jumpy a little slicy and et cetera, is quite aligned and quite lethal.
Howard: What is interesting is that cocoa leaves, were known for hundreds of years to curb or being an appetite suppressant and here in America a third of the people are obese and there is not a chance in hell that we will ever sell cocoa leaves to chew on like a gum for an appetite suppressant in a country where one third can like myself, I have a hard time to stop eating. You know what I mean?
Dave: On that note speaking of herbs, a fantastic research study came out; I think it was it was even sweet in Switzerland I just read it last month. Where they found five grams of spinach whether its powdered form in a smoothie or wherever is as powerful appetite suppressant as anything.
Howard: Well I love spinach. I don’t look like popo but I love spinach.
Hey we are out of time. My brand is an hour, that’s the average can be of my listeners. I have to drive to work and I just want to say that this is way too much information. I almost look at this as Dr. Dave Shirazi just pulled over Dentaltown at 30,000 feet going 600 miles an hour on a747, and the only thing I get in this is slow down spunky if have got an all day’s program on this I bet a lot of kids would love it, it open their mind, it make them think, I think You are amazing, you are calmer, you are adorable. I hope to see your all day, I’m serious, I hope to see your all day course and outline you guy and thanks for spending an hour with me today.
Dave: It’s been my sincere pleasure. Thank you Howard.
Howard: Alright, I look forward to that Webinar I will watch you right on my big screen all day. By the way the new apple TV that is coming out, you will be able to do an internet search to find Youtube, and videos in Dentaltown and so. Within the apple TV youths will be able to search for Dentaltown, pull up your Webinar, and boom watch it right there on your big screen on your big daddy chair.
Howard: Alright buddy.
Dave: That’s great. Thank you so much.
Howard: Thank you, buddy, very much.
Dave: Bye bye.