Dentistry Uncensored with Howard Farran
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376 Dental Harmony with Robert Arm : Dentistry Uncensored with Howard Farran

376 Dental Harmony with Robert Arm : Dentistry Uncensored with Howard Farran

4/26/2016 10:19:14 AM   |   Comments: 0   |   Views: 488

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Robert Arm DMD, is an activist for community health. He earned his dental medicine degree at the University of Pennsylvania in 1972. He completed a rotating dental internship with emphasis on oral surgery and oral medicine at the Philadelphia General Hospital and pursued additional training in hospital dentistry and certification in oral medicine and oral pathology, at Philadelphia General and at the Hospital of the University of Pennsylvania.

In June 2000, Dr. Arm joined a group of students, residents, attendees, and faculty from several universities who traveled to Hanoi, Vietnam to treat patients and to address students at the Hanoi Medical-Dental School.

He is also a Consultant for the Highmark Blue Cross Blue Shield Delaware, Former Program Director for the General Practice Residency at Christiana Care, Former Clinical Professor in Oral Medicine at Temple University and a Diplomate of the American Board of Oral Medicine, Special Care Dentistry, and Facial Pain.

Dr. Arm joined the Christiana Dental Spa team in December of 2011.

www.ChristianaDentalSpa.com 


Howard:

Well it is a huge, fun honor today. I'm in Phoenix, Arizona, and I saw my buddy Bob on Facebook that he was down here in Arizona watching some baseball games because Phoenix-

 

Robert:

Partially.

 

Howard:

Phoenix has, what, a dozen spring training camps?

 

Robert:

True. I first came down as part of the American Dental Association Commission of Dental Accreditation. For the first four days, I was with them evaluating some events, training programs that you have in the Phoenix area.

 

Howard:

For the American Dental Association-

 

Robert:

American Dental Association Commission on Dental Accreditation.

 

Howard:

Dental accreditation what? Accrediting dental schools?

 

Robert:

They accredit dental schools. I was here reviewing advanced general dentistry programs.

 

Howard:

Advanced general dentistry-

 

Robert:

Dentistry programs. the AEGD.

 

Howard:

Oh, AEGD?

 

Robert:

Which is very similar to the GPRs, General Practice Residencies, which is the one year to two years post-graduate.

 

Howard:

So there's AGED and you said it's advanced general education dentistry residencies? You said it's very common to what?

 

Robert:

A lot of states require a year post-graduate training. It is always a good idea to get the experience and additional knowledge you don't have in dental school. These programs are more than a fifth year, they really create the ability to become more independent. Occasionally, I go to do site visits, accreditation visits, to make sure the programs are really educating our future dentists.

 

Howard:

You said some states require a residency?

 

Robert:

Yes.

 

Howard:

Really? I had no-

 

Robert:

The state of New York requires it for licensure without an exam. It's in lieu of an exam in New York. In Delaware, we required since about 1940, but it's in addition to an examination. Delaware requires a hospital-based program.

 

Howard:

To be a licensed dentist in Delaware, you have to have a residency?

 

Robert:

Yes, or military equivalent, which is about three years, or private practice for about three to five years.

 

Howard:

Does Delaware have a dental school?

 

Robert:

No.

 

Howard:

It don't have a dental school. I had no idea. I have never heard of this before.

 

Robert:

Delaware's the first in the country to require the advanced training. Now, many states request it and some make it in lieu of an exam. Particularly with the concept of trying not to put patients through the ordeal of an exam.

 

Howard:

Well Bob, this is very exciting. You've been a member of Dentaltown since 2002, you have 5,000 posts, you're a consultant on oral medicine, oral path, medically compromised, facial pain, you're the past president of the American Academy of Oral Medicine, diplomat on American Board of Oral Medicine, American Board of Pain Management, special care dentistry, fellowship College of Dentistry, hospital dentistry, dentistry for the disabled. One of the most common questions we get every year from dental students is, "Should I do a residency?" What would you tell a young kid? How many dental schools are there now? 56?

 

Robert:

Something like that.

 

Howard:

What would you tell the 5,000 kids in 56 dental schools who are all thinking, "Bob, should I do a residency?" What would tell that kid?

 

Robert:

I would definitely state they should. There's enough residencies that have openings that people can get into. I guess you have maturity where they're not just doing what they're told where there's a faculty over them. They're allowed to think for themselves, work very closely with the faculty. There's always somebody there. While there's some requirements, it's really taught at an advanced level. For an example, the programs I went to in the Phoenix area, they did a lot of implants, a lot of surgery, impactions, so it gives them more maturity, more time to think of what they want to do in the future, and a lot more skills than they have in dental school.

 

 

From when I went to dental school, there was just so much we needed to know. Four years might've been enough, but now, with all the new treatments out there, four years is really not enough, and people have been advocating the fifth year. A residency is not a fifth year. It's separate from the dental schools. It may be affiliated with one, but it really gives a better handle on what's going on. Most residencies teach the medically complex, the special needs patients, where the dental schools would probably be the equivalent of an old dental office with a four story walk-up to get to them. If you're healthy, you were seen. If you're not healthy, you did not get seen. A lot of dental schools, they refer their advanced patients out to an AEGD or a GPR program.

 

Howard:

Now, a lot of these have a stipend for the students? Do any of them cost money?

 

Robert:

Most of them do. Some of them do cost money, but many of them have a stipend that's pretty decent.

 

Howard:

What are you talking about? What kind of range?

 

Robert:

Well, depending on what location, some pay over $40,000 a year, equivalent to the medical residents in a hospital setting.

 

Howard:

That's all an MD physician resident gets is 40 grand?

 

Robert:

40 some odd. $48,000, and that may [inaudible 00:06:13], but each program's different. Some of the AEGD programs, advanced general dentistry programs, they get equivalent to a little bit less. Some programs do require some tuition be paid, but you have the option of what you apply to and what you want to do.

 

Howard:

Are you at all involved with the accreditation of any of the dental schools?

 

Robert:

I could be a site visitor, but I'm mostly in the graduate programs.

 

Howard:

I just got back from Asia, and we went to Japan, Indonesia, Singapore, Malaysia, and it seems like wherever you go around the world, India, Brazil, United States, there's an explosion of new dental schools.

 

Robert:

Correct.

 

Howard:

Like Malaysia went from 4 to 18 dental schools in a decade, and all the dentists are screaming that the oversupply is crazy. It seems like Japan's the only one who nationally got organized and said, "You know what? We have too many dentists, and we're going to cut back the number of dental schools and the number of dental school graduates." Now some people are saying in the United States that the American Dental Association is accrediting way too many private dental schools. What would you say about a comment like that?

 

Robert:

First of all, the Commission on Dental Accreditation, while it's part of the American Dental Association, it is separate. There is no restraint of trade. At one time, dentistry helped maintain itself, we did cut back from dental schools where about five, six dental schools closed.

 

Howard:

When did you get out of school?

 

Robert:

In the '70s.

 

Howard:

In the '70s? I got out of school in '87 and there was a whole slew of them. It was Fairleigh Dickinson, it was Emory, it was Northwestern, Georgetown. A lot of dental schools were closing back then.

 

Robert:

Again, it's supply and demand. Now they're looking at particularly the underserved. For example, one of the dental schools you have here in the Phoenix area in Mesa, Still University, the dean there is very proud that many of his students go into public health dentistry, into federally qualified community health centers, and really trying to meet the demand for dentistry that people do not have, do not have access to. The pay scale is low enough that they can afford the graduate students, and it gives an experience to the students, experience to the faculty because they're learning, these are private practitioners, and the patients really benefit.

 

 

The programs I visit around the country really have a triple win, where any volunteer or salaried attending is learning more because they're being challenged by recent graduates. The recent graduate is really learning a lot more and getting a lot more experience and speed, confidence, and the patients are getting a great deal. A lot of the corporations, I'm proud of a lot of our private corporations, are helping support these models so that people in need to get dental health back which helps in systemic health, and it also helps them get a good smile and gain self-esteem. Their self-esteem helps them get a job and get into mainstream of life.

 

Howard:

Am I biased? I always think that our dental school here in Arizona, A.T. Still with the Dean Jack Dillenberg, we all think he's the best dean of all the dental schools in the world. Are we biased here or would you agree? Name a dean that's better than Jack Dillenberg.

 

Robert:

Jack's unique. Jack's been brought up as a volunteer going way back when.

 

Howard:

You talking about Jack Dillenberg?

 

Robert:

Yeah.

 

Howard:

What'd you call him? Jack [inaudible 00:10:36]?

 

Robert:

No. Jack has been brought up in the area of volunteerism and he's worked at a lot of charitable organizations around the globe. He is that gives back desire and probably graduates the highest percentage of students that give back. The school started as a new concept, and it's working out very well.

 

Howard:

He is so neat. Also, he's so proud that the name of his dental school is the only one that has the word "oral health" in it. Is it the A.T. School of Dentistry and Oral Health?

 

Robert:

Well, it's oral health, some other others say dental health or dental medicine. It's all in different names, often meaning the same. We've had the concept of total health when they started the dental medicine regime going back a long time, but each school is unique also. Depending on what you want to get out of school, you have some that are very academic and geared to research, some that are very clinical and are geared to clinicians. Over here, Jack has made the school very much geared to public health and the well being of the total team.

 

Howard:

He is an amazing man. If someone asked you what your occupation is, what would you say? Oral medicine and pathology? Special care dentistry? What would you say, Robert?

 

Robert:

I am a dentist, number one. I specialize in diagnostic sciences, which includes oral medicine, oral pathology, facial pain, and be complex. It's very hard to describe myself with one tag.

 

Howard:

Right. You're a multipotentialite.

 

Robert:

Something like that. I'm more of a generalist in diagnostic skills. Instead of just going into salivary gland or soft tissue lesions or OR cases, it's a little bit of each.

 

Howard:

What could you educate all these dentists on today about oral medicine, oral path, special needs dentistry? What lessons could Bob share?

 

Robert:

Number one, if it's a problem you've not seen, you may want to think about referring, at least verbally, to see what recommendations there are. Diagnosis and treatment of diseases change and are constantly updated. Unless you do it a lot, it may not be best to handle it yourself the first time. Most university faculties are more than glad to talk to the private practitioner.

 

 

When I started, a lot of these patients were, quote unquote, a pain in the neck for the dentist. They're very difficult to treat, to diagnose, and often the dentist punted them. Nowadays, with dental schools teaching more and more, the clinician can do more, but often needs a little bit of extra help. Read, and often the knowledge is not in print yet. That's why the Academy of Oral Medicine switched from published clinician's guides to on the web. If somebody wants to know how to treat a particular disease, the AAOM has on their website how to treat and patient handouts on various diseases. The same thing with a lot of the other groups.

 

Howard:

What is that website? W-W-W what?

 

Robert:

It's aaom.com. On the tag there for patient's handouts, which is toward the top right, it does have handouts to give to patients to explain disease. It has also suggestions for the dentist for treating. Whenever you treat a patient, if your course of treatment is not working, take a break, take a timeout, think about what's going on, and rediagnose the patient.

 

Howard:

Very good. It seems like a robust website that I was not ... I don't think I've ever visited this website before.

 

Robert:

Well, I had the privilege of working with them on-

 

Howard:

They're out of Seattle, Washington.

 

Robert:

That's where the office is.

 

Howard:

How did that start out there? Was that affiliated with the dental school in Seattle?

 

Robert:

No, it started out in the Northeast, but the corporation that we've hired to manage it, the management corporation's there and handling it.

 

Howard:

How many members do you have?

 

Robert:

I should know that. There's over 500, I believe.

 

Howard:

500.

 

Robert:

I should know the numbers, being the past president and on the board, but I don't keep track of numbers.

 

Howard:

What are diseases that you guys talk about?

 

Robert:

For the oral diseases from a simple aphthae, a canker sore, herpetic lesions, to more exotic, like erythema multiforme, pemphigus, pemphigoid, as far as soft tissue lesions. As far as systemic, the biggest problem is xerostomia and burning mouth. Then the other gamut we have is the medically complex, the people on blood thinners, which become a headache. When do you treat? When must you alter the medication with the physician? With the new drugs coming out, you have to keep up to date. I guess the third area is which patients need to be treated in the more confined environment such as a hospital or an OR setting? That includes a lot of the major heart patients.

 

 

One of the big controversies we have that's on Dentaltown quite a bit is when you premedicate and when you don't. While both the American Dental Association and the Orthopedic Association have said you generally don't need to premedicate, but. The "but" is probably left up to the attorneys when something goes wrong later. For the most part, people with hip and joint replacements, knee replacements do not need premedication, but then they put a little asterisk with that. If they're systemically involved, like diabetes or lupus, you may need to. Most of the orthopedic surgeons still want to medicate, even though there's no indication.

 

 

On the other hand, the American Heart Association has cut down a lot of the patients we premedicate. When I was back in dental school, we used to have to give IV antibiotics for people with valve prosthesis. Anybody with a murmur we used to premedicate. Now they're just four criteria for premedication. That is a valve prosthesis, a history of endocarditis, a heart transplant patient with complications, or a serious congenital heart abnormality. The guidelines have changed also from going back to a few days before the day of, a few days after, to just one dose approximately an hour before.

 

Howard:

What would that dose be, a gram?

 

Robert:

About two grams of amoxicillin.

 

Howard:

Two grams of amoxicillin.

 

Robert:

The studies have shown that even if you premedicate from two hours before to about an hour to two hours after, you still have a pretty good level. The incidences are very low, but you still don't want to take chances. The complications are major.

 

Howard:

It's hard to get your mind around it, because they'll say, "We need to do that. Give him two grams an hour before to that patient." Then you got to think to yourself, well if that patient just went in their own bathroom in their own house and took an electric toothbrush and brushed their teeth for two minutes like the American Dental Association tells them and then flossed ...

 

Robert:

That's why they altered the guidelines, because studies of chewing with paraffin wax for the control have shown enough seeding just by eating normally. If you add some periodontal disease to the scene, almost 100% get seeding. Brushing the teeth as you mentioned will get seeding. That's why they really altered the regime and tied to make it more conservative, more realistic. The earlier studies show people who got endocarditis heart infections six months after dental treatment were considered dental related. It's guilt by association more than by evidence. It's the same thing with the prosthetic hips and joints.

 

Howard:

Is it guilt by association or is it the one million attorneys in the United States who bill out about $1 trillion of our $17 trillion economy just trying to get fed?

 

Robert:

Combination. Again, it doesn't have to prove causation, just enough to get the jury to decide.

 

Howard:

What advice would you tell these young kids? We hear this a lot. The first time they're dealing with these patients, they call the physician and the physician will tell them something. They basically get the feeling, "I called this physician, I called this cardiologist, no one's agreeing on what to do." I'll give you an example that was on the message board the other day, Coumadin. Some doctors are saying, "That's crazy. It's a tube, pull it, leave everything alone." Then they're looking at guidelines where that's not what the guidelines are. What advice would you tell a kid when you're working with multiple doctors and there doesn't seem to be ... Because the American Heart Association doesn't always agree with the American Dental Association.

 

Robert:

With cardiac they generally do. The safest thing is to leave the anticoagulant level alone. If it's kept within a reasonable amount, in the case of Coumadin, between an INR of 2 to 2.5 even up to 3, it's pretty safe using appropriate, as atraumatic as you can techniques. Coumadin, at least you have a level. The advertisement for these new agents sounds so great on TV. You don't need a blood test. Why? They don't have a blood test. Coumadin has reversal agents. One of the other ones now has one that just came out, and a lot of the things about diet, we know about Coumadin, it's been around many years. These newer agents we don't know totally about. They may allow better diet and not as many restrictions, like with Coumadin they say "no grapefruit."

 

 

Each of these we're learning more about. The half-life is different. In Coumadin it's about 48 hours. Some of these newer agents, the half-life is about 24 hours, so you can stop it for a lot shorter time. Again, you should check with the person managing the anticoagulant level, be it the cardiologist or the hematologist depending what reason. If you stop something, the risk is still there, be it the atrial fibrillation, the heart valve prosthesis. The risk is still there, and taking it off is a potential danger to the patient.

 

 

I'll give my own example. At my age now, with arthritis, my knees are shot and I do need replacements, but I'm on Coumadin. If I go off Coumadin, I've already before I started on it had a pulmonary embolus, had some deep vein thromboses, and I'm a little concerned about going off of it. We're working on levels, if I need the surgery and decide to go for it, how we could taper it and work possibly switching from the Coumadin to heparin and back again. Heparin is a very short-acting for our ...

 

Howard:

How old are you, Bob?

 

Robert:

69.

 

Howard:

Was your knees that go from an injury or does that go from sports? What made your knees go?

 

Robert:

Arthritis.

 

Howard:

Just arthritis?

 

Robert:

Yeah.

 

Howard:

Do you think that was genetic or just inflammatory in nature? Or just just comes with being 69?

 

Robert:

Probably a combination. I wish I could say it was from great football injuries, but I was never an athlete. Now I may qualify as a fourth line person with my weight, but no injuries that way. I do remember my right leg, which is the worst, had a trick knee for a long time. Again, probably long term abuse of the legs, long term extra weight, and finally the knees, even walking around a lot does affect me. Particularly with the pulmonary embolus I did lose quite a bit of lung function.

 

Howard:

Permanently?

 

Robert:

Well, yeah, because the lung with an infarct does die in part.

 

Howard:

Do you do much facial pain? Do you do TMD also?

 

Robert:

Yes.

 

Howard:

Give us some fatherly advice on TMD. There's so many theories, there's so many camps. Don't you think that TMD theory may be the most, I don't know ...

 

Robert:

Controversial.

 

Howard:

Controversial. Would you agree with that statement?

 

Robert:

That's correct. The first problem is diagnosis. Have your diagnosis. Work up the patients for parafunctional habits, see what causes the pain to get worse and better, and if it really needs to be treated. If it's just a pop or a click, many people pop or click in any part of their body and there's really no need for treatment.

 

Howard:

Not to interrupt, but I grew up Catholic. The difference between Catholics and Lutherans is Lutherans sit there for an hour and Catholics kneel, sit, stand, kneel, sit, stand, kneel, sit, stand, and their knees are cracking all day long. I used to always say to myself, "How come there's not TMJ people running around saying 'Hey, your knee clicked. You need treatment.'"

 

Robert:

Well, it has to be symptomatic. The same thing with some of the other pain entities like the cracked tooth syndrome, where it's basically a diagnosis by elimination. I've seen people treat cracked tooth syndrome where there's no pain, no symptoms, but they see a little crack, so they say, "Well, you need at least a crown, maybe a root canal and a crown." If it's asymptomatic, often you leave it alone until something comes up.

 

 

The same thing with myofascial pain. What's going on isn't all muscular. If you look at pain in other parts of the body, they treat it differently. With dentists, we have a handpiece, we see teeth, we treat the teeth, but the teeth are in contact just a little bit of the day. They're not really in constant contact. At night when somebody clenches or grinds, a night guard may be useful, but whether you clench against teeth or clench against the night guard, the muscles still are in spasm. Often, if it's more myofascial in pain, we treat it as a muscle spasm condition, and just try to eliminate most of the parafunctional habits.

 

Howard:

Another huge controversy, the old Peter Dawson occlusion camps. By the way, Peter Dawson's getting an award from the American Dental Association as one of the greatest educators out there. Then you have the newer camps, neuromuscular. Clayton Chan out of Las Vegas. What are your thoughts on those two occlusion camps? What camp would you be in?

 

Robert:

What is best and functional for the patient. The camps [inaudible 00:28:21] long centric and retruded, intercuspal canine guide and group function. Depending on who you speak to, that's the ideal occlusion. If you go to a different camp, that's bad occlusion. It's really what's functional for the patient. That's one of the reason I guess I'm not a big occlusionist. While I did teach occlusion at the University of Louisville, when I was at Penn learning with Marv Alderman and the facial pain team up in the University of Pennsylvania, we saw cases done by Morty Amsterdam, the periprosthesis guru, and they still had TMJ. How are you going to tell Dr. Amsterdam the occlusion is off, when he was one of the stars in that area?

 

 

There's a lot of other things going on. We first really need the diagnosis, the history, and see what's best, do no harm, don't do anything irreversible until you tried everything else. It takes time. Anybody with chronic fibromyalgia, they don't limit it. A good example might be, if you are more comfortable with your back slanted to the right, for an example like this, in treating back problems, they're not going to fix your spinal column so you walk around like this so it's comfortable, while in dentistry, we try to move the jaws to fit the pain. You have to get it to follow good anatomical relationship, but you also must consider the patient as a whole.

 

 

Another example, in my office we had a patient with submucosal fibrosis, which is from eating gutka, betel nut and mostly in India and some of the other Asian countries, the mucosa gets thick and they can't open, almost like scleroderma. The clinician who first examined without knowing what betel nut is decided that it was a TMD problem and tried to increase the opening. It's really systemic. You really need the diagnosis, need to know what it is. At Temple University, one of the patients came in and put down on his history RSD, and it's better. He no longer has pain in his legs and other areas, so they left it alone. RSD, Reflex Sympathetic Dystrophy or Sympathetic Mediated Pain could affect many joints of the body, many areas of the body.

 

 

When off his medication to treat all his others problems that are corrected, he developed facial pain. Just place him back on his medication, he got better again. After having about 10 root canals and occlusal adjustments, because now his pain was associated with his muscles of masticatory area. We really had to focus on the total patient. You've got to treat the total patient, and a lot of people don't do that.

 

Howard:

I have to seriously thank you from the bottom of my heart. You've answered 5,171 questions on Dentaltown. I mean, you've been a saint. I remember when we were in school, the instructors used to always whine about our textbooks because they'd say, "I want you kids to know it takes over 5 years to write a textbook, and then when our dental school buys the book, we use it for 10 years." Sometimes they get frustrated, they'd be saying, "I'm to the point where I don't agree with anything in this book."

 

 

Now, we're in 2016, so many drugs come out every year. My patients that are pharmacists tell me it's all they can do just to stay on top of every new drug that comes in. Then they're supposed to understand the complications this drug may have with another drug and another drug, and some of these senior citizens are coming in on 10 drugs. At times it's just overwhelming. I wanted to ask you about that. A lot of times these kids, they'll ... Grandma comes in. She's on 10 medications. Do you look up each medication? How is a young dentist supposed to come out of school, see grandma or grandpa walk in there on 10 meds and know how they could even interact?

 

Robert:

You don't have to know that many diseases or medications. You just have to know the ones that your patient is taking or has. Each patient's unique, and you should check on what they have, what the side effects are. Many times with the side effects, yeast infections, moniliasis, it's due to the medications they're taking. Often even facial pain or halitosis or taste disorders are related to the medication. You have to look up the medications. There are some cheat sheets that you can do that with, but often to check is one way to do that. I would not recommend to anybody wasting time like I do by reading all these pages, but just to review the ones that your patient has.

 

 

The physicians often don't know them. They don't read all the books. Just be aware, any changes ... Look at the etiology. When did it start, the onset? Was there any change in medication? Was there any change in the health of a patient? They could all be related. Again, some of it's guilt by association, that the patient started this medication, they now have this. Well, they also got a year older and it may be due to the aging process, but it may be due to the medication. A lot of times, they don't know the side effects until after the drug's been out for some time.

 

Howard:

Well, I remember when they came out with breast augmentation. They placed a million breast augmentations and all these lawsuits popped up that they caused all these things. A couple of these companies went completely bankrupt from lawsuits. Then 10 years later, the FDA found out that, well if a million people have breast implants, 30,000 are going to get this disease, 3,000 are going to get this disease, and now they're FDA approved. The FDA approved the silicone implants that cost billions and billions and billions of dollars of lawsuits.

 

Robert:

Risk, benefit. What is the risk to it? What is the benefit? If the risk is possible disease, the benefit is a psychological well being, you have to consider that. As long as people go in and know the risks, as long as you get informed consent, and I'm saying informed, not just consent on a piece of paper. That includes any dentistry we do. That a lot of things are relatively safe has to be reviewed and reviewed with the patient. One of the things that I'm happy in the office I'm in now, I'm now in a private practice situation-

 

Howard:

In Delaware?

 

Robert:

In Delaware, called the Christiana Dental Spa, where the owner of the practice Dr. Linda Nguyen had the concept more from California, total person, total relaxation. For an example, while somebody is waiting for a [inaudible 00:36:38] crown, better get a facial massage or a body massage taking the total patient. The patient has to know there's going to be a delay. The patient has to know, what are the potential side effects of doing things on the same day? A lot of new ideas we have in dentistry are creating problems, but the informed consent is key. What are the risks? What are the benefits? What are the risks of doing an implant? What are the benefits of doing an implant?

 

 

Nowadays, the time and course of doing a endodontic treatment, crown lengthening, crown, build up crown, they cost almost the same, and the value rate is there, so an implant may become a better choice. It was not that way when we were in school. Everything is risk, benefit, and knowledge of patient.

 

Howard:

When we were in school, the people who placed the implants were considered hacks and butchers and quacks.

 

Robert:

In some parts of the country.

 

Howard:

In Kansas City, I was there '84 to '87, and the one oral surgeon that was out there placing them, the other teachers openly called him quack, nut. I mean, ramus bars, subperiosteals, they've really come a long way.

 

Robert:

Again, what we're calling experimental today is going to be possibly common practice coming up, but might be refined. I hate being the first to use a medication, but I don't want to be the last either. I delay getting my hepatitis vaccinations until we knew they were safe and they worked, and I was dealing with hepatitis patients all the time. I want to see the data. Show me the proof, not the speculation.

 

Howard:

I waited forever on the eye surgery. First it was radio keratotomy where they made scars, then it was lasers, the 4 millimeter. I waited, I think 10 years until they had the 8 millimeter before I did that, and that was one of the greatest gifts I ever gave to myself. The other one I'm looking at now is ... What's that when chicken pox comes back?

 

Robert:

Zoster.

 

Howard:

That new vaccine. First they said that you couldn't get 'til you were over 60, and now they've released that. Haven't they lowered that to, like, 50 now?

 

Robert:

Yes. Well, you could actually get zoster at any time.

 

Howard:

Well, when it first came out, I tried to get it. They said, "Oh no, you've got to be 60 and over." That was year one.

 

Robert:

Except if you're medically compromised, the first guidelines for zoster, if somebody who got zoster, look for an underlying systemic disease because your immune system was altered. It was a lot younger. We saw teenagers with zoster, but often related to chemotherapy or cancers. There's no such thing as an absolute.

 

Howard:

Have you gotten that vaccine?

 

Robert:

No, I have not.

 

Howard:

Are you going to get it?

 

Robert:

Probably.

 

Howard:

What are you waiting for?

 

Robert:

Time.

 

Howard:

To see if it's safer?

 

Robert:

No. Just time to do it.

 

Howard:

Oh, just making time to do it. I always wonder what genetic components are a disease. My dad's brother had that and it was just life-changeingly horrible. I thought, okay, well my dad's brother got that, then there might be something in my genes. I'm pretty sure the only good jeans I ever got was a pair of Levi's, so I'm banking ... I want to ask you another thing. You mentioned Louisville, and I was just wondering, is that where you fell in love with baseball out there? I can still remember my first baseball that was a Louisville slugger. It reminded me of ... When we were little, the most common magazine was Reader's Digest. Every grandma and grandpa had it up on their nightstand. All my grandmas, grandpas, mom, dad.

 

 

When we had just got out of school, there was a Reader's Digest article where a journalist from Reader's Digest took a set of study models and a set of x-rays and they went to 25 different dentists, and one of them was the dean of the Louisville dental school. He literally got 25 different treatment plans, and I remember the backlash from the dental communities that Reader's Digest was horrible, and how could they do this, and it was a slam on dentistry. I'm looking at this thinking, this is excellent journalism. Then I look on Dentaltown, there's 210,000 dentists. You couldn't get them all to agree that today is Saturday. I was wondering, how many years have you been practicing dentistry?

 

Robert:

About, oh great. About 45 years now.

 

Howard:

My absolute question is, going back to 45 years ago today, is dentistry still half art, half science? If it works in my hands, it works, if it doesn't work in your hands, it doesn't work. 45 years later, is it more science or is it still half art science? If that Reader's Digest guy went and took an FMX and a set of study models and photos to 25 dentists including the dean of Kentucky, would he still get 25 different treatment plans in-

 

Robert:

Probably, because there's a whole gamut of acceptable ranges of treatment plans. That's why I'm very big in post-graduate education that now you have a chance to treatment plan more cases. In dental school, one of the biggest drawbacks is the number of treatment plans you do, the number of patients you comprehensively work up. You don't take into account medical problems, and financial problems, and time problems, and the ability of the clinician, the desires of a patient. A treatment plan is something that is agreed upon by the clinician and the patient based on all of these needs, desires. There's no one absolute treatment plan.

 

 

When I first went to Delaware, they had an essay treatment planning part. You basically had to do three treatment plans, as we do in most graduate programs. What's the ideal for this patient if they could afford a fortune, had a lot of time? What's the minimum acceptable that you could do to get them a decent masticatory capabilities and spend the least amount of money? What is best for the patient someplace in between? Automatically, each patient minimally has three treatment plans. When you add different concepts to replace missing teeth, implants, partials, sleeve copings. You can go on and on with different techniques. We haven't changed, they're still doing gold foils in California, and gold foil is still a good option if you don't traumatize the pulp too much.

 

 

There's a lot of different areas. Some things fade away, like silicates. I think you were in dental school after silicates saw the exit, but silicates were great for the radiation patients because they had a lot of fluoride in it, and you very rarely got additional decay. Even in doing the treatment plans, what additional chemotherapeutic aids? Does a patient need chlorhexidine? Does the patient need supplemental fluorides? What else might help him maintain his mouth? If he has arthritis or psoriasis, is a normal toothbrush, an electric toothbrush, or a toothbrush in a tennis ball the best way for him to maintain hygiene? It's a team effect, and you really have to work well with the patient and his other health team. There's still going to be multiple treatment plans. I could come up with many. Doing a residency, we spent most of our time doing treatment plans.

 

Howard:

If you were a kid and you just came out of dental school and you really needed help treatment planning and you're sitting in a community, who do you think the best treatment planners are to go sit down with if you needed some help and you were going to call someone? Which of the nine specialties would you say probably could help a complex treatment plan the best?

 

Robert:

First of all, I would recommend that extra year of advanced training. There, you get several different attendings, practitioners, and they each go over treatment plans with you. The whole year, you see so many more treatment plans that you're doing, your fellow residents are doing, that you really had that wealth of knowledge. In the private sector it's going to vary, you have to ask your colleagues, because some people you go to are excellent, but they have a slanted opinion towards their treatment. It really is going to vary based on the neighborhood you're in, and often it's another super generalist. Not a periodontist or an endodontist, because I guess if you have a hammer you use a hammer, so you have to see which specialty you may want to use that will give you an honest opinion, not just what they do.

 

Howard:

You're so wise in so many areas for so long. I want to ask you some huge problems we see in dentistry today. One that no one talks about is, when grandma goes to the nursing home, they're averaging one new root surface decay per month during the nursing home. After she's been in there one year, she has 12 cavities. A lot of times they bring them to the office, you fix these up, and I swear Bob, six months later it looks like termites got them all. How do you tackle that type of an issue that is getting more and more common every day? I look at the data. Fastest growing population in the United States is women over 100. Second fastest group is women 90 to 100. Third fastest group is women 80 to 90. It's just going to be a much greater problem every day that goes by.

 

Robert:

It has been a great problem for a long time because while Medicare states there must be dental care, they don't fund it. Most nursing homes do not provide it, except if there's an emergency situation. At the hospital that I was at for 33 years, we used to get phone calls stating, "This patient is an emergency, you have to see them tomorrow." Of course, like most facilities, we had a waiting list. Then the funding, if there's an emergency, the nursing home is responsible. We tell them that, "Oh, it's an emergency? You're funding." "Oh no, you have to charge the patient." "According to federal laws, if it's an emergency you're supposed to fund that." "Oh, it's not an emergency then."

 

 

First thing to prevent that, I would start with more education in nursing schools, in medical schools, where there's almost no dentistry whatsoever. I taught at a graduate nursing program, and they have to recognize the disease. A lot of that has to do with their medications. They get xerostomic, with the xerostomia they get class 5 lesions, the root caries, and it's really the percent caries. You get that with young people due to lack of oral hygiene, and the nursing homes they often do not provide oral hygiene. Maybe a fluoride rinse would be good for them. Maybe chlorhexidine rinses would be good for them, but nursing homes unfortunately are not necessarily there for the patient's best health, but to make money.

 

 

At the nursing home we had affiliated with our hospital, we did an annual survey of all patients like they're supposed to have, and we tried to treat every patient that needed it. Most nursing homes don't really have that annual survey.

 

Howard:

Is chlorhexidine your favorite mouth rinse for root surface decay? Do you think it's effective on root surface decay?

 

Robert:

That's on periodontal disease, chlorhexidine. Some of the fluoride rinses would be good, and really very-

 

Howard:

Any over the counters?

 

Robert:

Some of the over the counters may work. It really depends. The real thing is to get the patient to do it, get the team to do it. Often, a nursing home would not even want to take out a denture at night or clean the denture. It's whatever works. "I've tried something and the taste was not nice," you try something else. It's based on what do you get the patient or the caregivers to give, to use?

 

Howard:

I like to stay dentistry uncensored. I like to stay with all the controversies. One of the biggest controversies is pain medication. There are doctors out there, I swear Bob, there's 125,000 [inaudible 00:50:43] dentists. There's thousands of dentists who, if they pulled 100 sets of wisdom teeth and 100 molar root canals, everyone would get a scrip of amoxicillin and a scrip of 20 Vicodin. There are other doctors who will not give a scrip of antibiotics unless there's some form of infection or swelling. What do you say to the doctors out there who after every molar root canal give a scrip of amoxicillin?

 

Robert:

It's not indicated unless you see sepsis, and then the question is, do we do same day root canal or go back to the old theory that worked nicely? If it's signs of infection, maybe do a two visit to make sure the infection is gone. I go back to the days where they used paper points to put in take cultures, and you didn't fill the tooth until the cultures came back negative. Sometimes it seemed like it took two years, at least until you graduated, to get them negative. It really depends on the patient, what systemic disease they have. We overuse antibiotics so much. That's why the American Heart Association and the American Dental Association altered the regime. We got more resistant bugs.

 

 

One of the best antibiotics now for oral infections is tetracycline with the right groups where you don't get tetracycline staining, because we don't use it that much. If it's not somebody developing teeth, tetracycline is very good for periodontal disease particularly. Again, you want to limit the use of medications. Pain medications, new studies have shown a combination of acetaminophen and ibuprofen work very well. I think they said something like 600 milligrams of ibuprofen or 3 tablets over the counter and 1 of acetaminophen over the counter works as good as some of the narcotics.

 

Howard:

How much acetaminophen? How much Tylenol?

 

Robert:

About 500.

 

Howard:

500? I think Vicodin is one of the strangest drugs out there. It seems like when you give Vicodin, seems like if you gave it to four people, one would tell you they slept for three days, the next one would tell you they couldn't sleep for three days, they were wired. The next one will tell you they were completely constipated and hadn't had a bowel movement the whole time they were on it, and the fourth one said it works right. Prescribing this drug for 20 years you're like, this really only works on a quarter of the people. How weird is it that you have the most common pain pill and it only works 25% of the time?

 

Robert:

It works more than that on the pain. I'm going to go back to a research study on a drug that never was released. It was the old NSAID Zomax, which was taken off the market during the Tylenol scandal. It was made by McNeil. They took it off because there were six deaths really from allergies and people never should have taken it, but McNeil had to come back and said, "We really care about people, and we're concerned about death after the Tylenol poisoning." When we were doing a research study with that plus coating, it worked better than Percocet. It's the combination of the NSAID plus narcotic.

 

 

Another good drug without doing that, without the constipation and all is Ultram, tramadol, which is a non-narcotic but works like a narcotic. You still need a DA number for that. It depends on the patient's history. Whatever works for the patient. I have a form that I give out to patients. The best thing to try is the over the counter, the ibuprofen and acetaminophen, possibly for the gingival pain that you do get in trauma some benzocaine ointment or gel around the tooth area, and that works pretty good. For the practice, we have about five dentists. My cellphone is the emergency number for everybody involved in that.

 

Howard:

Let me give you a more specific pin down on Dentaltown. The United States is a very diverse country. I don't really like the term "The United States of America" because when you talk about Europe, nobody compares Germany to France, no one compares Finland to Greece or Portugal. They see it as a collection of countries. I see the United States as really a dozen different countries flying under a flag. You can't compare Manhattan to Alaska, you can't compare Florida to Kansas City.

 

 

When you're on the message boards, there's a lot of very conservative areas of the country. I don't want to mention any names because I don't want to offend anybody in Texas or Alabama or Mississippi. Some of them put out the feeling out there that dentists prescribing Vicodin for root canal pain, extraction pain, that you're raising your community's addiction levels. There are just dentists out there that just will not prescribe a narcotic and I don't care what they do. Do you think the disease of addiction can literally start by going to a dental office and getting a prescription for a wisdom teeth removal or a root canal? Do you think we're contributing to the pain pill addiction in America? Or do you think addiction is a totally different issue?

 

Robert:

Overuse we're contributing to, but again, being very active in the pain groups, the International Association for the Study of Pain, which will be in Japan, the American Pain Society, and a few of the other groups, you want the patient out of pain. You don't want them to suffer. I'm using the word "suffer" because pain is a perception. You want them to use something that is appropriate, and that can range from acupuncture, acupressure, to different therapeutic regimes. You want them to avoid it. Often the best way is to premedicate. For an example, if they could take an NSAID before you do an extraction, before you do the root canal, you're already starting an anti-inflammatory effect beforehand.

 

Howard:

What would you give them, Motrin 400 milligrams? 600? 800? What would you give?

 

Robert:

Depending on the height and weight of the patient, but I have no problem giving 600 is the average dose before the procedure, and start that before they start pain. If you get ahead of the pain, it's a lot better. Years ago, there was a concept of giving pain medication Q4H, Q6H, and the patients really had pain before then, and then they really needed more to catch up. Then they had in a lot of centers, give pain medication PRN, but just watch the dose. Every patient's unique. You have to see their profile. One of the studies with patients with psychological problems, that if you cure the pain then they have nothing to blame for their failure except themselves, and they might become suicidal. That we did in one of our pain clinics in Louisville at the time. Each patient's unique and different.

 

 

Nowadays, you cannot call in strong medication. The only thing you can really call in is acetaminophen number 3, or there's tramadol 50 milligrams. It's very hard, because patients can get acute pain, you can get a flare-up, and your hands are just about tied. You have to try to work with the patient. The best way to avoid pain is prevention. Go back and have them come in every six months, I'm just using that as a number that's been around for a long time. Some people need it every two months, some may not need a checkup more than once a year, once every other year, but prevent disease, prevent decay. Watch out what systemic disease they have, and what's the interaction. Is the pain from the tooth, or is it from trigeminal neuralgia? Is it from the tooth, or is it from the vasculitis associated with lupus? You're treating a whole person, and you have to really check on that.

 

 

One of my rules is if the patient's getting pain medication for one problem, I communicate with that physician and one person's the captain of the team with pain medication. I've had very good luck working with physicians and get a lot of referrals from physicians. Even though I'm not full time at the hospital anymore, I'm still on the staff, and we get a lot of patients referred.

 

Howard:

We're out of time. We went over our hour. I just want to ask you one question overtime since you did said, "I have a little extra time." You might not want to answer it, it's a big can of worms. A lot of dentists, the patient has anxiety. Sometimes they think they want to write them a prescription for a little something for the appointment. Maybe a Valium, maybe Xanax, maybe Ativan. What are your thoughts about that to dentists out there, when to use pharmacology to treat anxiety?

 

Robert:

If they know what they're doing, it's very good and very safe. If they don't know what they're doing, stay away from it. One of the things, while I ...

 

Howard:

Tigger! Tigger is being very mean to me because I've been gone for 18 days.

 

Robert:

He just wants attention.

 

Howard:

I've been gone for 18 days, so when I came back after 18 days, he's punishing me. Now he's warmed up.

 

Robert:

One of the concerns I have with questions asked on Dentaltown is people are asking how can I do this? My comment is, if they don't know how to do it, maybe the best thing is to refer or to go to a colleague and see how to do it and then do it. You don't experiment with a patient. Anti-anxiety medications are around, there are a lot of great courses to use. Nitrous analgesia, maybe with a little bit of relaxant, we do that in our practice. Often, I'm the one who's administering it.

 

 

While I trained in IV sedation, I do not currently have a license for that, do not want a license in that, and generally nitrous analgesia and maybe a slight relaxant, but I'm very keen to the wording. A lot of people use medications that are very good for this, but it says in their product guide "sedation," not "anti-anxiety." If the product guide for the company's specific section says "sedation," I would not use that for an anti-anxiety medication while it works. I have no problems using an appropriate amount of Xanax based on their history, and nitrous analgesia.

 

Howard:

You're saying if I'm afraid of the dental, that a prescription for anxiety would be better than a prescription for sedation?

 

Robert:

Again, each person is different. Some people need to be under a general anesthesia. Each person's unique. You really need, again, that workup, that assessment, that interview. Most of the time with patients that I spend with my chronic pain patients or lesions, is taking that history. They generally give me the diagnosis, they generally give me how much anxiety they have by their history. What makes it worse? What makes it better? Each patient's unique, so there's no one answer for everybody.

 

Howard:

Right. Well, my last question. Did you catch any fun baseball games in spring training?

 

Robert:

When I go to spring training, I want to see the practice sessions. Minor league games have not started, they won't start until about the 15th or so, but I saw the minor league practices. In Delaware we do have a minor league team of the Kansas City high A, so I went to the Kansas City camp.

 

Howard:

Kansas City Royals?

 

Robert:

Yeah.

 

Howard:

Who just won the World Series?

 

Robert:

Yes.

 

Howard:

I was in dental school when they won it the last time. I couldn't believe during the World Series they were saying, "They haven't won for 30 years," and I'm like, wow. Was it really 30 years ago?

 

Robert:

Yes.

 

Howard:

You're a Royals fan too?

 

Robert:

I'm a player fan. For an example, we house play- My daughter got older. When she was about 14, we thought housing a baseball player was not a good idea. Before then, we housed players, particularly minorities from Latin America, South America. We became a family. A lot of these players we still keep in touch with with the-

 

Howard:

Kind of like a foreign exchange program?

 

Robert:

Yeah.

 

Howard:

They would come up and play on a minor league team, but they'd live in your home?

 

Robert:

Yeah.

 

Howard:

Wow, that is amazing.

 

Robert:

They really get to appreciate it. It's like watching your kids play. With my daughter living with us still and we're helping her with her 7 year old child, we haven't had the room to bring a player back.

 

Howard:

Your daughter's living with you now with a 7 year old child?

 

Robert:

Yeah.

 

Howard:

Is that a gift, having your granddaughter ... Is it a granddaughter?

 

Robert:

Grandson.

 

Howard:

Is that pretty fun?

 

Robert:

Keeps us young.

 

Howard:

Keeps you young? Yeah. Hey, again Robert, you go by Bob. I just think you're an amazing man.

 

Robert:

Thank you.

 

Howard:

I've been a fan. You've been on Dentaltown since 2002, 5,000 posts, you've been answering questions. You're just one hell of a smart guy, a great guy.

 

Robert:

Thank you.

 

Howard:

You've educated so many tens of thousands of dentists for a decade on Dentaltown.

 

Robert:

Thank you. Unfortunately, I've cut down more recently because of time. This trip out here just came up about a month ago when they needed a visitor come out here. I'm the type of person never says no. As you've been to Asia, I've been to Asia, more the developing countries and more into the rural areas, in Cambodia we helped them with a prevention program throughout the country. I still want to go back, and now that I'm cleared for the long trips, I'll probably do some more traveling. I'm invited to a lot of the countries, but I want my wife to come with me. Raising a 7 year old, that's one of the drawbacks. It's hard to get her to come with me to the, I guess they're no longer developing, developed countries. Some countries I've been invited to that most people wouldn't want to go to, I still want to go to. We may not consider that the friendliest country towards us, but ...

 

Howard:

Which country is that?

 

Robert:

Let's see. According to some of the presidents, the worst two enemies we have in that area.

 

Howard:

North Korea?

 

Robert:

Being one of them.

 

Howard:

What's the other one?

 

Robert:

Iran.

 

Howard:

Oh, really? Are you going to Iran?

 

Robert:

I have not planned to. I've been invited there by some of the dentists. The University of Pennsylvania had a strong relationship with Iran going back ...

 

Howard:

I would go.

 

Robert:

I want to go with my wife. I've been to a lot of these countries without her, I've seen so many things, and so many different concepts of dentistry. They do things one ... I guess I lost a fortune on. In Vietnam, I saw patients with migraines wearing little patches on their forehead and wondered what it was. I tried it for some of the arthritis I had on my thumb, and it worked great. Brought it back, brought it to the hospital pharmacist, he checked what was in it, and it wasn't in this country. Now if I was an entrepreneur, I would've brought it in and that's Salonpas, which is a very big selling product now. I'm not the entrepreneur, and there's a lot of other ideas they do that we don't do.

 

 

I've been in Vietnam when they had SARS going there, I was in China, Szechuan province, when they had the avian flu. I never go to teach. I go to exchange knowledge. I love that so much, particularly going to some of the rural areas. It's an exchange, it's a passion. To me, I'm not working. This is a passion I love, and dentistry is a hobby. It's fun. I do what I want now, even in private practice. The owner, Linda Nguyen, has allowed me to work with the oral systemic, with the hygiene as they come in. A lot of the medically complex I deal with and speak to our full time dentist there. One of the people you probably know, Danny Bobrow, I've worked with him with Climb for a Cause and other areas. I'm used to going out. I was one of the first VISTA volunteers in this country back about 100 years ago I guess it was, in the '60s in VISTA. I've never stopped volunteering.

 

Howard:

I tell you, I've been following you forever. I think you're an amazing man. It's fun to have diverse hobbies and well diversified ... It really scares me. I'm just going to ask you that. Some of these dentists, it really scares me. They're 30 years old, they're 40 years old, and they're already burned out and they're on Dentaltown already counting the years 'til they retire, and they're in the financial section saying, "How much more money do I have to put in my 401k so I can retire?" Why do guys like you and I, why will we love this 'til we drop dead, and why are others burned out and fried at 40? What advice would you give to a guy who's burned out?

 

Robert:

I think it really depends on the mentors you had. I was gearing to one way in dentistry when the dean at Penn at the time, Dr. Lester Burket took me under his wing when my brother was very sick, my younger brother was very sick. I followed in his footsteps. I've been mentored by excellent people. In pain, I was able to work with Dr. Janet Travell, who did a lot of myofascial studies and trigger points, and I could name person after person that mentored me to go on and I would say a lot of these students at Louisville that I mentored have never left dental school. There was a few deans in that, there was a few associate deans, and once you teach dentistry as not just a profession, but a lifestyle and fun to help people, you don't get bored with it. Every day is a new challenge.

 

Howard:

That's what the young kids keep telling me, that the reason they went into dentistry and one of the reasons they love it is because they feared working on an assembly line or working in a cubicle and doing the same task over and over. The one thing you can never complain about dentistry, it's not a boring job, it's not a monotonous job. Every patient's different. Either their tooth is different or their brain is different, the patient's different, and you can't ever learn it all.

 

Robert:

We have to be a lifelong learner. For an example, you mentioned in the beginning about the dental school over here and its dean. That's why most of his students go into community health, volunteerism, and he's teaching an excellent concept. He's a fun person. Each school's a little bit different and ...

 

Howard:

When you call him a fun person what he's really saying is Jack Dillenberg is a leftover hippie from the '60s.

 

Robert:

Correct. He did cut off his ponytail.

 

Howard:

He is one hell of a fun guy. Amazing guy, and you would never guess he's in his 70s.

 

Robert:

You're as old as you feel.

 

Howard:

Old as you feel. That guy is my idol. What an amazing man, and you're an amazing man.

 

Robert:

Thank you again.

 

Howard:

Thank you so much. You probably could've seen another Royals practice this morning, but you came by my house to do a podcast. Thank you for all that you've done for dentistry, for Dentaltown, for volunteerism, Climb for a Cause, the list would go on and on and on. Thank you, Bob.

 

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