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398 Three Hygiene Heroes with Andrew Johnston, Linda Douglas, and Daniel Lopez : Dentistry Uncensored with Howard Farran

398 Three Hygiene Heroes with Andrew Johnston, Linda Douglas, and Daniel Lopez : Dentistry Uncensored with Howard Farran

5/18/2016 12:02:23 PM   |   Comments: 0   |   Views: 376

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Andrew Johnston, RDH:

I am a Registered Dental Hygiene graduate from the Yakima Valley Community College Dental Hygiene Program in 2009. I hold three degrees including a Bachelors Degree in Business Management and currently working towards my MBA. First and foremost, I am a husband and a father to my wife and three children. When I have time to get away, I regularly lecturer at dental hygiene programs throughout the USA. I also speak at dental hygiene societies and associations. In 2013, I was asked to be a faculty member for DDS - Dental Development Seminars. My role includes mentoring and instructing dental professionals in technique driven delivery of local anesthetic. As the only hygienist on the faculty, I focus on being a liason between the dentists and hygienists to build trust and understanding between the two groups by helping ensure competency, accuracy, and confidence in the hygienist attendees.

I also write, blog, and am a regular contributor on Hygienetown.com. I write articles for a number of publishings including my own blog http://andrewjohnstonrdh.blogspot.com. I am a regular panel member for Mark Frias' roundtable discussions and have been interviewed by Dr. Howard Farran for his Dentaltown podcast. In the future, I hope to be lecturing at regional and national conferences on my local anesthesia review course. 

My "Charitable Dentistry" lecture is a compilation of many years of mission trips and charity work throughout the world. I have volunteered my time and efforts with local programs such as the Union Gospel Mission's dental office, YVCC sealant days, the Boy Scouts of America, and as a coach for the local parks and rec teams. Nationally, I have consulted for dental teams and offices interested in learning how to participate in charitable ventures. I provide research that is specific to the desires of the team at no charge to them. Internationally, I have been on mission trips in the Philippines, Guatemala, and the Dominican Republic. 

Linda Douglas, RDH:

Linda M Douglas graduated as a dental hygienist from the Royal Dental Hospital in London, England in 1982. After graduation she worked in periodontology before moving to Toronto, Canada where she has worked in private practice since 1990. Her desire to support patients with eating disorders has instigated in-depth study of eating disorders, and its effect on oral health.

Daniel Lopez, RDH:

Daniel Lopez is a dental hygienist currently working at the Callen-Lorde Community Health Center in New York.  He has extensive training in the management and treatment of HIV/AIDs patients.

Howard:

It is beyond a huge honor. I'm at the Townie Meeting 2016 in Las Vegas. In my opinion, seriously, the three most famous hygienists on Earth. I mean, you guys, you are, you're crushing it on. Hygiene town, social media, your own websites. I mean, if I ever see hygienist talk or do anything it's one of you three and so it's just an honor to be here. So I just want to go around the table. I'll start with you because you're right next to me. I'll hand you the microphone but I'm just going to ask you all the same questions.

 

 

What are you excited about in hygiene? What are you passionate about? What do you think that the hygienists or the dentists who has a hygienist working for him, what's got you excited? What's still got you enthused? What's hot and what's not in dental hygiene today? Andrew?

 

Andrew:

Well, my name's Andrew Johnston. I'm from Vancouver, Washington which is right by Portland, Oregon.

 

Howard:

Downstream from Mount St. Helens.

 

Andrew:

Down the stream yeah.

 

Howard:

Did you get a couple inches of ashes the last time she blew?

 

Andrew:

Well, I mean, I wasn't alive back then but I mean possibly.

 

Howard:

Am I that old?

 

Andrew:

I didn't want to say it but maybe.

 

 

You know right now in dental hygiene that gets me kind of excited is two things. One is restored of dentistry. I practice one day a week doing nothing but restorations. So placing fillings. That's really fun for me.

 

Howard:

So you're a dental hygienist doing expanded functions in Portland, Oregon, where they have passed expanded functions? How many states can you do that in?

 

Andrew:

Well, I have a license in Oregon and Washington. So I can do it in both of the states and I can do composites and [inaudible 00:01:40] in both states as well.

 

Howard:

And they just passed that in Arizona but the legislature passed that but they said well we have no place to treat them so they went to their two dental schools and told them to set up a curriculum and train them. But as soon as they train them then we're going to have that in Arizona. So what's that like?

 

Andrew:

I think it's fantastic because I think it answers a couple of the questions that are always relevant in dentistry, right, access to care. So you can work in the medicaid clinics, medicaid offices, and you can do more restorative work to get these people what they need. But the cool part about that, as well, is that you have a trained hygienist that is also giving good oral hygiene instruction during those restorative appointments, as well.

 

 

I know a lot of times, I mean dentists are great, but they focus on the preventive part of it like we do and so I feel that as we're placing a little duo filling in number of [inaudible 00:02:34] for Johnny over here and we're educating mom and dad behind us and saying "This is why they're getting a cavity because they're not doing this this this and this," while replacing the filling.

 

 

It's just something I'm passionate about. It's something I really love. I've been doing ti for several years and it's very fun.

 

 

The state of Washington, though, you don't need to have an expanded permit. All hygienists can do it as soon as you graduate and you take [inaudible 00:02:55] you can't have a license without being able to do it. So it's a little bit different than Oregon where you have to have an endorser for it.

 

 

The other thing I'm really passionate about is getting out of clinical. Not necessary for me myself because I do 50 hours of clinical a week, pretty much. I love it. But giving people, especially hygienists an opportunity to still be in the profession, still give the education to other professionals, as well, but maybe not wet finger dentistry - as they say.

 

Howard:

So can I move you to Phoenix if I pay all your moving costs?

 

Andrew:

I would love it but-.

 

Howard:

Seriously?

 

Andrew:

Probably not. I got a good thing going now so.

 

Howard:

Well, if you ever want to live in Phoenix, Arizona, I would so [inaudible 00:03:44] any three of you out. I mean, I know you're from Canada, you probably hate the United States. You're from New York, you probably think Phoenix rolls all their [inaudible 00:03:52]. I'd do anything for you three. I just think you guys are just amazing.

 

 

So what do you say about this because I know in Arizona to get hygienists have expanded functions, they were talking about that when I got out of school in 1987 so it's almost 30 years later before it passed and every old dentist I know thought the minute they let you put fillings in crowns the sovereign profession of dentistry would collapse and it would be over. Why do the old guys think that and what do you think about that? I mean, I don't even know if they do that where Linda and you are in New York. Is that the end of the world for dentistry?

 

Andrew:

Well, obviously not since we've been doing it since the 70s in Washington. So I feel like the vibrant states still with dentistry are not losing patients and no one's dying yet. I think that the biggest misconception, though, is that we're going to cause more disease somehow or won't be able to learn how to place. But I feel like fillings is a very mechanical process. Right? If it's in a mild gum, you're gonna put your band on, you're gonna put your wedge in, you're gonna condense like you normally do, you're gonna burnish. It's the same steps over over and over again. It's very very easy, I feel, to place a filling as long as you have the training and understand the anatomy and what to do if maybe that you didn't close that contact. What are you going to do in those types of situations? Or how do you get a contact that's really tight and really hard?

 

 

So, no, obviously it's not the end of the world and I don't know, I don't think it's that difficult to do.

 

Howard:

So I know you're wondering who this Linda Douglas is because I know you're thinking is that [inaudible 00:05:30]? I always, whenever I see you, I first think you're gonna start singing Smooth Operator but Linda, you're in Toronto, Canada, what's your hygienist, I think you're the most posting person hygienist on hygienetown.com. I'm a huge fan of yours. We've published you many times. You're really one of my idols. I think you're a rock star of hygiene.

 

Linda:

Thank you so much.

 

Howard:

I can't say enough about the great things about you. What's your passion about hygiene and when are you coming out with your next album?

 

Linda:

This thing on?

 

Howard:

Yeah.

 

Linda:

Okay.

 

Howard:

Are you [inaudible 00:06:07] start with that?

 

Linda:

No. I'm not. We're almost neighbors though.

 

Howard:

Are you?

 

Linda:

Well, we're both from London.

 

Howard:

Okay.

 

Linda:

But, yes, I'm really passionate about saliva and all its wonderful properties and also saliva testing for oral and systemic disease which I think is going to really grow in the profession.

 

Howard:

Explain in detail. Is there a company you're working with?

 

Linda:

No. No. But there's a company that does the [inaudible 00:06:45] for oral cancer so if you see a suspicious liaison you can test the saliva for the bio-markers for oral cancer.

 

Howard:

So I've always noticed in 20 years of doing this that they have thick ropy saliva they got a high decay rate and if it's thin and watery they got a lower decay rate. Is that too crude and rude or do you think that's true?

 

Linda:

That puts it in a nutshell. The more abundant watery saliva has a lot of minerals and buffers and also enhances the self cleansing mechanism. So that's all conducive to good oral health.

 

Howard:

So when you touch saliva like under the tongue, you put your glove finger on saliva and pull out, how long should that string be? When that string gets too long, how long would it be before you said something's wrong here? You're out of wack.

 

Linda:

Oh, I would say that there are studies on that actually. There's a whole study on the length and it's called "[inaudible 00:07:54]." That stringy quality. I don't remember the exact length but I would say if it's more than about two centimeters then that's too long.

 

Howard:

Now, I'm an American I've never heard of a centimeter or a meter.

 

Linda:

Oh, excuse me. Let's say one inch.

 

Howard:

One inch, okay, now I'm communicating with you.

 

 

So you also you talk and write a lot about eating disorders.

 

Linda:

Yes.

 

Howard:

What are you thoughts on eating disorders?

 

Linda:

Well, what I've studied is a real eye opener. Actually, ten years ago, one of my patients said to me that her daughter is recovering from an eating disorder and could I be vigilant for signs of a relapse? I said of course and then I realized that I didn't know that much apart from erosion which everyone knows about with bulimia. So I decided to do more research because I wanted to find the more subtle early signs before the erosion manifests because it takes about six months after onset of bulimia or purging anorexia for the erosion to manifest. Eating disorders the highest mortality rate of all psychiatric illnesses.

 

Howard:

That is true.

 

Linda:

Yeah.

 

Howard:

I'm in Phoenix and Arizona has all the houses for addiction and alcohol, drugs, eating disorders, sexual addiction. They have all those places. I was surprised when I read that, what percent of anorexic nervosa actually will end up dying from their disease?

 

Linda:

About 10% die within 10 years of onset.

 

Howard:

Yeah that's just so sad.

 

Linda:

Yeah.

 

Howard:

Here's a guy whose been on a diet for almost all 53 years that I've been alive and here is something that dies and they would just not die if they eat a sandwich. The mind is an amazing thing.

 

 

So then, [inaudible 00:10:01]? Let's say I just went in the bathroom and I just purged. So to get that out of their mouth they're gonna go run and brush and now their teeth were soften from acid they're putting toothpaste and abrasion.

 

Linda:

Exactly.

 

Howard:

It's the worst time to brush is after you've soften your teeth with vomiting.

 

Linda:

That's right.

 

Howard:

So how do you counsel an anorexic that's still purging?

 

Linda:

You can advise them. Well first of all, you can make them a mouth guard to protect the teeth during purging. Some clinicians do that. But not very often. You can advise them to neutralize the acid by rinsing with a solution of baking soda and water. Teaspoon of baking soda in a glass of warm water. Or you can use, actually, Colgate enamel repair paste neutralizes the acid really well and MI paste.

 

Howard:

Now, talking about that, what is MI paste? Because you see that posted so many times in hygiene.

 

Linda:

Yes.

 

Howard:

So what is MI paste?

 

Linda:

MI paste is for remineralization and it's a treatment that you apply after brushing and you leave it on for at least half an hour. Or you can leave it overnight. It's derived from milk protein. So it has Casein Phosphopeptides. Is that right? Calcium, phosphate? Yeah, that's it.

 

Howard:

Who is making MI paste?

 

Linda:

GC America.

 

Howard:

Okay, GC America and that's a big product now.

 

Linda:

Yes.

 

Howard:

So I venture to say to the thousands of dentists right now that have never heard of it. So GC America which stands for General Chemical which is out in Japan.

 

Linda:

Yes.

 

Howard:

Even though they just moved their headquarters over to Germany for tax purposes. So talk, when did this product come out and why did they bring this MI paste to market?

 

Linda:

This product has been around, I think, around ten years, a little over ten years. Basically it's because we've been using fluoride for a long time in the profession but fluoride alone, we haven't eliminated [inaudible 00:12:37], fluoride alone is not working because if your saliva doesn't have enough Calcium and Phosphate then you cannot form fluorapatite. The fluoride is not going to work.

 

Howard:

So it's got fluoride and what else has it got in there?

 

Linda:

It's got, I can't remember the names off the top of my head, I think it's Casein Phosphopeptides and I'm sorry I can't remember but it's basically Calcium.

 

Howard:

But is it toothpaste for the patient or?

 

Linda:

Yes.

 

Daniel:

It's Casein Phosphopeptide and Amorphous Calcium Phosphate.

 

Linda:

That's it! Amorphous Calcium Phosphate.

 

Howard:

Okay and this is a B to C, this is a consumer product to be brushing their teeth with daily?

 

Linda:

No. It's only available through dental offices and it's a treatment that you apply after brushing and you leave it on.

 

Howard:

So this is something that you sell to the patient?

 

Linda:

Yes.

 

Howard:

So when they get done brushing their teeth they put this on their teeth?

 

Linda:

That's right.

 

Howard:

How do they put it on their teeth? Is it like brushing?

 

Linda:

No, it will mostly stick to the brush and get wasted. So it has this quality, you know how milk sticks to the side of the glass? It's made from milk protein so it sticks to the teeth really well. So you can apply it with your finger or you can put it in a tray.

 

Howard:

Why don't you guys get GC and make an online course about these things?

 

Linda:

That's a good idea.

 

Howard:

We came out with a Dentaltown app. So now they got these on their smartphones. This icon down here is E. We put up 351 hour courses and they've been viewed over half a million times.

 

Linda:

That's amazing.

 

Howard:

So you guys should know, a course you can do like an hour each or all together whatever but like all these things they don't know. It's so much more. You know, the old days I got to close my office. I lose $5000 in production. I gotta fly from my town all the way to Kansas city. All that stuff. Now, they can just sit their on their iPhone and their wife is watching Beverly Hills Cop and they're not really into it so they just put on this [inaudible 00:15:06] and they listen to it. You could be explaining to this.

 

Linda:

Yeah.

 

Howard:

I mean, it's really overtaking hands on courses. I think that would be a phenomenal course.

 

Linda:

Yeah.

 

Howard:

Do you guys think you would want to do that together or separately?

 

Linda:

I think that would be super.

 

Andrew:

I'm good for whatever.

 

Linda:

Yeah.

 

Daniel:

Yeah.

 

Howard:

Because I think we do on DentalTown, I do feel embarrassed, we do way too many courses on root canals and filling. What I call drill, fill, and bill.

 

Linda:

Yes.

 

Howard:

With my four kids and my grandkid I don't want them to get root canals and implants. I want to prevent disease.

 

Linda:

Yes.

 

Howard:

That's my office motto. I just want to have a dental office where I want my granddaughter to go.

 

Linda:

Yes.

 

Howard:

I mean, I don't want my granddaughter to go where they have economic incentives to do [inaudible 00:15:49] under their gums. I don't want them to go to a dental office where they have all these economic incentives to do crowns instead of fillings. I want my granddaughter to go where it would be the best dentistry for my granddaughter.

 

Linda:

Yes.

 

Howard:

You guys should teach that.

 

 

So what else has got you passionate?

 

Linda:

Actually, I love everything about hygiene. I like taking care of people. But my forte is the saliva and dry mouth management which is really increasing.

 

Howard:

Well, dry mouth is getting huge because every time they come out with a new prescription pill there's one more grandma now that's going to live to be 112 that's not going to have any saliva.

 

Linda:

Yes.

 

Howard:

How do you deal with dry mouth now?

 

Linda:

There's lots of options out there. When I first graduated, there was nothing really. We had to ask the pharmacist to compound saliva substitutes for us and dry mouth lozenges. But now there's so many over the counter products. Of course everyone knows about Biotin gel.

 

Howard:

I think that's a big assumption.

 

Linda:

Yes.

 

Howard:

How many thousands of people, there's some that don't know what Biotin gel is.

 

Linda:

Yeah, this is a saliva substitute gel base.

 

Howard:

Biotin gel.

 

Linda:

Yes. It's a good saliva substitute. The patients find their mouth feels a lot more comfortable.

 

Howard:

So is it a gel, a tablet?

 

Linda:

It's a gel. It comes in a tube.

 

Howard:

And they squirt it in their mouth?

 

Linda:

Yes.

 

Howard:

How often?

 

Linda:

You can do it as many times as you need. Really. But.

 

Howard:

Because Daniel told me that Budlight will do the same thing.

 

Daniel:

About 30 seconds when you're sipping it.

 

Linda:

Yeah, eventually it will have the opposite effect.

 

Howard:

So last I heard 860 different prescriptions cause dry.

 

Linda:

Yes.

 

Howard:

Is that about what you're hearing?

 

Linda:

Yes. That number is growing all the time.

 

Howard:

You see, I don't have to worry about that because I'm a man. We just drop dead. When I look at the data, it's basically 4.6% of American women will spend their last years of life in a nursing home. For every 100 women in a nursing home there is only one man named Lucky. So most likely I'll die of a heart attack in my kitchen. It'll be you that's in the nursing home.

 

 

I want to ask this question because I think the most under addressed issue in America. I assume it's the same for Canada. It's, we spend our whole life fixing up mom and six month cleanings and everything's great and then when she's finally sent to a nursing home, they average one new root service cavity per month that they're in a nursing home.

 

Linda:

Oh.

 

Howard:

So after grandma's been in their for one year. She has 12 cavities and as a restorative dentist, they will her in there and you fix all those cavities and they bring her back for the six month cleaning and they're all back. It's crazy. It's almost like she's being eaten alive by termites.

 

 

What are you thoughts on root service decay and nursing homes? Furthermore, I have gone into a dozen nursing homes [inaudible 00:19:13] I don't want to say their names. I don't want to get people in trouble; where I sit there and I've seen how they're brushed. They take a brush, they dip it in the dixie cup, they put a pea size toothpaste, they go ting-ting-ting-ting-ting, then they tell her to spit in the cup and they're done.

 

Linda:

Yeah.

 

Howard:

That poor little girl is making about $11 an hour. She's a certified nurse. CNA certified nurse. She has nine months of school. She makes $11 an hour and she's got 22 people on her wing. She's got to get them bathed, to the bathroom, to feed, this and that. She's not going to sit there and brush and floss 32 teeth.

 

Linda:

No.

 

Howard:

So how do you address that nightmare?

 

Linda:

There are two things that come to mind immediately. One is xylitol. I think we should use more xylitol for seniors.

 

Howard:

What brand? Is it true that some xylitols are not high enough in concentration and others are better?

 

Linda:

Yeah.

 

Howard:

What xylitol do you think?

 

Linda:

I like the [inaudible 00:20:24] products.

 

Andrew:

They're made by Xlear?

 

Linda:

Yes.

 

Andrew:

Xlear is the company.

 

Howard:

Xlear.com

 

Linda:

There's a Canadian brand called Xyla.

 

Howard:

Okay, well, we're Americans down here, Linda.

 

Linda:

Oh, stupid me.

 

Howard:

We're not going to be sponsoring any of these Canadian people. There's people that live upstairs in the loft. Just looking down at crazy America wondering what's going on with Trump and Hillary. It must be embarrassing being a neighbor to America. Do you ever look down at America and think "God, why can't I live North of Brazil or Germany or."

 

Linda:

Well, I just think that my American colleagues are very welcomed to come together if Trump becomes President.

 

Howard:

Okay, so answer this specific question. My grandma is in a nursing home. I'm listening to you now. I'm a hygienist. My grandma's in there. I see the math. I see that she's going to get one new cavity a month. What would recommend for her home care? That she should do a xylitol candy three times a day?

 

Linda:

Yes.

 

Howard:

What would you specifically recommend?

 

Linda:

I would say any exposure to xylitol three times a day. It can be granulated in their drinks. Or it can be a candy. That's fine. Any form that they can get it is fine.

 

 

The other thing is in Canada we have a product called prevora. It's a [inaudible 00:21:58] that's been developed to prevent root caries. So it's been used a lot for seniors.

 

Howard:

Okay, tell me if it's true or not, a lot of people like the [inaudible 00:22:10] the [inaudible 00:22:12] because it's a sticky oil that sticks to your teeth and implants. They think the Listerine, the alcohol based, the chlorine dioxide is very very short. They like the sticky [inaudible 00:22:24]. Do you think that's true or false?

 

Linda:

Yeah, I think that's true that [inaudible 00:22:31] has this quality that makes it more substantive.

 

Howard:

Then, I'm going to Daniel. Daniel, you're in New York City and it seems like [inaudible 00:22:50] anything of you that you're doing blogging, YouTubing, it's about HIV patients.

 

Daniel:

Yeah usually.

 

Howard:

Is that a big part of your practice?

 

Daniel:

Yeah, I work in a FQEC a federally qualified health center it's called.

 

Howard:

Say that again, what?

 

Daniel:

A federally qualified health center. It's called [inaudible 00:23:05] health center. We were one of the very first advocacy groups for HIV so the roots of my clinic go back the early 80s. It was a community project that was originally established to get people into care, with people who were in a crisis, people who were dying of aids. Eventually, it got more funding and it became a primary care clinic through the 90s. Around 2002 or 2003, we moved into a very big building and became a fully established health center that included mental health, primary health, social health like social welfare.

 

Howard:

And this is in New York City?

 

Daniel:

Yeah, right in Manhattan.

 

Howard:

Manhattan.

 

Daniel:

And dental care. Full general dentistry [inaudible 00:23:43] of procedures.

 

Howard:

What percent of your patients are HIV?

 

Daniel:

90%.

 

Howard:

90%?

 

Daniel:

Yeah. In total, we have 20,000 patients for the whole center and dental clinics sees about 9000 of them.

 

Howard:

So this is your core confidence meaning?

 

Daniel:

Yes.

 

Howard:

Most of us out there we just have a dozen patients that are HIV positive.

 

Daniel:

Probably more. They don't know.

 

Howard:

We'll talk about that. What percent do you think? Tell us.

 

Daniel:

It's hard to ball park a percentage. We know who is in care. We know who is the anti viral regimes. But it's interesting that the people who are typically in care the people who are medicaid-ed and leading healthy lives now, they're not the ones who are spreading the disease because the ones that are spreading the disease are the ones that don't know they have it because they have an extremely high viral, they're very very infectious during unprotected sex. Those are the people that are not going to take any precautions because they have elevated risks of certain disease, they're the ones that are going to be the real infectors for it. They're not going to be the ones that are going to tell you they're HIV positive because either they don't know or they just haven't sought care and they're afraid to say it.

 

Howard:

I just got back from luxury in [inaudible 00:24:56] South Africa and and South Africa has a 25% HIV positive rate.

 

Daniel:

Yes.

 

Howard:

Unbelievable.

 

Daniel:

Yeah and it's very interesting to see the roots of HIV prevalence over there versus HIV prevalence over here because over there people will absolutely refuse to use any sort of contraceptive. There's no birth control because it's frowned upon by mostly the Catholic church that did a lot of missionary work there. They kind of squashed any sort of contraception. They didn't allow them to use condoms and there's just no education either. We can't really fault them for the lack of education and also an adherence for very strict religious guidelines. But it's having that impact on there where some areas it's up to 50%.

 

Howard:

Where are those areas?

 

Daniel:

All around. I mean, Congo. It's hard. Like Sub-Saharan Africa is really where the epicenter of HIV epidemic and over there it's a heterosexual disease whereas here in the United States often we see it as a homosexual disease.

 

Howard:

Is it still a homosexual disease in the United States?

 

Daniel:

It's a human disease. It's human infinity.

 

Howard:

What are the percentage for like homosexuals versus IV drug abuse versus heterosexual?

 

Daniel:

The highest percentage would be, the very very highest percentage would be, not specific to homosexual but we would say men who have sex with men because not all of them identify as gay. Men who have sex with men who are of African American descent who come from a low socio-economical status will be at the highest risk of up to 60% of [inaudible 00:26:27] converting to HIV.

 

Howard:

So if you're in America, and by the way my brother's gay and he's my best friend, he really is. So if you're a Black man who has sex with men and are below the poverty status, you're saying 6 out of 10 would be -?

 

Daniel:

Yes. Over half.

 

Howard:

Over half would be tested [inaudible 00:26:49].

 

Daniel:

Will acquire HIV at some point in their lives. At the current rate that it's going or 50% of men who have sex with men regardless of socio-economic status or racial background will be HIV positive.

 

Howard:

Half of gay men. Half of men who have sex with men in the United States will be HIV positive?

 

Daniel:

Right. The current [inaudible 00:27:07] statistics.

 

Howard:

Are you serious?

 

Daniel:

Yeah.

 

Howard:

50% of men who have sex with men will end up being HIV positive.

 

Daniel:

It's projected as that, yeah.

 

Howard:

In the United States?

 

Daniel:

A large reason for that is because medications are so good now, it's so effective, that the face of HIV is not the face of HIV as it was in the 80s and the 90s. People are really not dying of it anymore.

 

Howard:

So do you think that now it's not like this instance death sentence, like "Oh my God I'm going to die" that that's causing them take riskier behavior [inaudible 00:27:41]?

 

Daniel:

Yeah that's right. We're seeing the younger generation between 18 to 25 years old that just doesn't associate that sort of risk or morbidity with the disease.

 

Howard:

I can see that because if I'm going through the drive-thru at Dairy Queen I'm thinking "Well, they do sell Insulin."

 

Daniel:

Yeah just a drizzle on your ice cone.

 

Howard:

Let's change the subject to this, so the bottom line is you're talking to the thousands of people who are not like you or have the whole population HIV positive [inaudible 00:28:09]. So these people, the average practice in America has about 1850 patients so of those 1850 patients, how many do you think are HIV positive that the dentist knows about and how many are HIV positive that don't know about and are there any hygiene implications or words of wisdom you can share with the dentists and things they should look for, things they could be better in serving this population?

 

Daniel:

Yeah, well, documented it's assumed there's about, this is one number I'm not totally sure of, I think it's two million people who are living with HIV in the United States.

 

Howard:

So that's not even a full percent.

 

Daniel:

Right.

 

Howard:

Because if there's 330 million people and two million so it -.

 

Daniel:

It's less than one percent.

 

Howard:

So it's less than one percent.

 

Daniel:

Yeah.

 

Howard:

So probably, if you have 1850 patients you probably have 15 patients or a dozen.

 

Daniel:

Yeah it could be somewhere around there but also depends on your geographical location. It's going to be more prevalent in urban areas. It's not very prevalent in the Midwest. You're going to find it in epicenters of -.

 

Howard:

So say that again. It's more prevalent where? It's not as prevalent in the Midwest.

 

Daniel:

Just like high urban areas like New York City, San Francisco, LA, Miami, the real epicenters of very mixed populations, mixed in with very low socio-economic status, you know living in the city, people are very close to each other.

 

Howard:

See, I would have thought it would be all Canadian.

 

Daniel:

They've got their epicenters as well.

 

Howard:

Toronto and Montreal.

 

Daniel:

Yeah, Toronto and Montreal, especially.

 

Howard:

So, are there any words of wisdom like on treating these people?

 

Daniel:

Yeah, this is more of a clinical issue, but one of the bigger things that I run into that really needs to change is that, I conduct a lot of surveys, SurveyMonkey.com is my best friend, I ask hygienists their opinions on different things. One of the things I ask hygienists is do you use Ultrasonics on your HIV positive patients? An alarming number said no they don't. Then, I would ask them to provide a reason for that. The reason largely being that they were taught in school that using an Ultrasonic on a patient who has HIV will create an infectious aerosol that contraindicated the whole process. So this is actually not true at all. You can actually look this up on the CDC website. They address creating aerosols in dental practice and that it is not a vector of transmission for either HIV or hepatitis.

 

 

So, anybody that chooses with this knowledge, and as we know lack of knowledge in something does not hold up as committing malpractice, it's your responsibility to know the concurring guidelines and regulations, anybody who is willfully abandoning this highly effective and what I see as necessary treatment for people who are at risk for perinatal disease and [inaudible 00:30:45]. You're committing willful negligence. It's just not fair. It's actually a violation of the Americans with Disabilities Act because HIV positive is a qualification as a disability.

 

Howard:

So, I'll just a selfish question for myself, one of the problems I have is when you treat them that they seem to have a lot of problems with yeast infections and mouth [inaudible 00:31:08], what is your go to [inaudible 00:31:11] when they come in and have a yeast infection in mouth?

 

Daniel:

So we are seeing less and less of that because of the great medications that we have now so I actually see that very rarely in my practice. When we do -.

 

Howard:

So if you see someone like that it might be an indicator that they're not getting treated?

 

Daniel:

Yeah candidiasis is clear indicator that the T cell count is dropping and something isn't quite working and when I see that, I'll literally walk them two doors down to their doctor, knock on their door like "Hey, can you check something out? I found a [inaudible 00:31:39] infection in the mouth." You know, maybe we can go over their labs. I'll look at their labs first of all because I have access to their full medical records being in a electronic health records facility.

 

Howard:

So that's a sign that they're off their meds or they're not getting medical?

 

Daniel:

Or maybe it's the disease has become resistant to the meds because maybe they're not compliant with taking it everyday. So even just a few days every month where they missed a medication the virus can and will become resistant to it and so they'll have to have gentotyping and phenotyping to reassess what that -.

 

Howard:

Okay, I want to ask you another one and then we [inaudible 00:32:11]. By the way, thank you so much for that Daniel, because I've had that problem a couple of times this year. Here's another problem, I'm working on a HIV patient.

 

Daniel:

Right.

 

Howard:

We accidentally poke ourselves in any procedure. What's the protocol when I accidentally poke myself but I happen to be working on an HIV positive patient?

 

Daniel:

I mean it wouldn't be any different. Universal precautions are universal. That's the golden rule. So anything that wouldn't happen standard still applies to someone who is HIV positive. Now, when you get a poke with a patient and you can always have the patient tested if they don't know they're HIV positive. You have the patient tested and then if they come up negative, you make a choice, do you want to go on post exposure [inaudible 00:32:52] or not? Usually, doctors will recommend that you don't because it can make you very nauseous for a few days. It's probably not worth both the time and cost and whatnot to do that.

 

 

If you have a stake with the person who is HIV positive, they know that you know that, and so you want to start looking at other things. What was their [inaudible 00:33:13] like? How many copies of that virus is in a milliliter of blood? Usually, someone who is very compliant can likely or unlikely be undetectable where it's an extremely small risk that they can actually transmit HIV to anybody so you can then make another decision. I've been stuck with somebody who is undetectable and my doctors said it's your choice if you want to go ahead and just be safe but chances are very very unlikely. It's a fraction of a percent that you would even [inaudible 00:33:47]. So the chances are extremely minimal so standard precautions are still universally standard in being effective.

 

Howard:

HIV positive, any other issues that you think that the dentists should be aware of?

 

Daniel:

Yeah, when we consider oral surgery and one thing that a lot of people are taught to consider for oral surgery is you look at the patients T cell count because above 200 T cells in a blood sample indicates that they're not aid status. If you have below 200 you're considered aid status. It's this arbitrary number but it's actually not very indicative of their health status and their immunological defense. You want to pay more attention to their [inaudible 00:34:33] count to consider how well this patient is actually going to heal. You want to see if their white blood cells are up to [inaudible 00:34:39]. Is this patient going to be able to [inaudible 00:34:41]? Look at their [inaudible 00:34:42] count. So you really need to look at the whole blood value and not just the CD4 count because the CD4 count is much less significant.

 

Howard:

Tell me this, if you're a dentist and lets say you're in [inaudible 00:34:57] and you're in a small town of Oklahoma and you have an HIV patient, do you think for the patient's best care that that dentist should say, hey, is there someone in big ol' Oklahoma City like you who specializes in HIV positive care and you should be referring them there? Or do you think no that's crazy.

 

Daniel:

That's a good question.

 

Howard:

99 times out of 100 they're all okay and everyone should be treating them in the [inaudible 00:35:22] in America.

 

Daniel:

Right. There should be, unless we have severe [inaudible 00:35:25] count, like the patient's extremely sick, in which case you probably won't be seeing them anyway, they're probably going to be in the hospital, there's really no contrary indication of treating these people like you would anybody else.

 

 

Now, anybody can be effective at treating an HIV positive patient and they are resources from the federal government in actually educating both you and your whole team. It is called the Aids Education and Training Centers and what they are is it's a wing of the Ryan White program which is a program that provides federal dollars for keeping people on medication, keeping people healthy. They have centers of every region of the United States where you can just call them up and they'll provide free continuing education. They'll even take you, dentists and hygienists, and you can go spend two days in a ICU center or in a infectious diseases clinic and learn from start to finish everything you ever needed to know abut HIV and treating those patients. It connects you to a network of experts, infectious disease experts, oral medicine experts.

 

 

I work with Stephen Abel who is the biggest name in dentistry when it comes to paradontol disease and whatnot. He's been treating HIV positive patient since the start of the epidemic.

 

Howard:

Well, you have got to hook me up with him. Send me an email, howard@dentaltown.com CCM. What was his name?

 

Daniel:

Yeah. Stephen Abel. He is the dean of paradontics at University of Buffalo.

 

Howard:

Steve?

 

Daniel:

Stephen Abel.

 

Howard:

Stephen?

 

Daniel:

Yeah. Abel. A-B-E-L.

 

Howard:

Abel. Stephen Abel.

 

Daniel:

So any dentist clinician can contact the AETC, the Aids Education Training Center, receiving continuing education, receive that network where they can even refer patients to them so they can go find the doctors that they need to see to get comprehensive care.

 

Howard:

Okay, I want to switch to a totally different subject. So we will just start from scratch again.

 

Daniel:

Okay.

 

Howard:

So when I got out of school and I started doing implants and everything and think they're going to last forever. If you put in [inaudible 00:37:23] it's just going to work. All the dental manufactures were making implants. They were doing all the studies on mainly [inaudible 00:37:31] and people who lost their teeth from [inaudible 00:37:35]. They're telling everybody that there is about a 4% failure rate. You should expect like a 95/96% [inaudible 00:37:43]. Turns out, we're not just placing implants in the [inaudible 00:37:46] where the bone is wood. We're putting them in softer, poster, [inaudible 00:37:51]. It's like [inaudible 00:37:52] wood. The whole [inaudible 00:37:54] is like Styrofoam.  Most of these people lost all of their teeth from [inaudible 00:37:58] and now they're saying Peri-implantitis is so huge. Most reasonable people are saying about 20% of implants placed are going to fail and most are going to fail from Peri-implantitis.

 

 

So a lot of these dentists are looking at this illness like I see them losing bone I see the Peri-implantitis but you know what it's still rock solid and it's holding in a three inner bridge, what are you thinking when you see Peri-implantitis? Are you scaling around it or you Ultrasonic it? How are you treating Peri-implantitis?

 

Andrew:

Well, maybe, I'll address it first. You know one of the biggest things as hygienists is obviously home care. So the adamant of the [inaudible 00:38:38] brush has been way different as far as instead of just flossing, right? That's what we used to always say, flossing use a plastic instrument to get these things to clean up around the Peri-implantitis.

 

 

I actually just learned this year, Howard, that you're not supposed to use plastic instruments to clean anymore to clean a round implants. There's actually special instruments that's supposed to be made.

 

 

When I was in school, we were also taught that we can't see an Ultrasonic around implants. But now they have Ultrasonic tips that you can use to clean around implants. I'm not as versed as maybe the other two are about it but as a hygienist whose been out for a little bit, it's very interesting just to see that in the seven years that I've been out now from pretty much don't touch those implants with anything ever to go ahead and use an Ultrasonic with a special tip. It's come a long way in those seven years.

 

Howard:

So what's the special tip, something that doesn't, what is it made of?

 

Andrew:

I actually don't know what it's made of. I want to say some sort of titanium tip, as well.

 

Howard:

Because implants and titanium [inaudible 00:39:36].

 

Andrew:

So it won't scratch it. Yeah. Similar metals or something.

 

Howard:

Do you like any mouth wash? Any periochips? Any other thing that you like?

 

Andrew:

I don't care so much for the periochips and things like that. We do a lot of chlrohexidine. I just heard of a new mouth wash. I want to say it's called like Oral Rinse. I think the only thing I've heard negative about the chlrohexidine is or the [inaudible 00:40:05] or whatever is that when the fibers are trying to regenerate way down in the pockets that there is a little bit of inhibition there. I don't know all of the studies behind it but Daniel is our studies guy. He knows all the stats about everything. But [inaudible 00:40:24] is pretty much still my go to with oral irrigation.

 

Howard:

What do you guys work together? Do you guys have a group website or a group blog?

 

Daniel: