Dr Ahron Jodaikin is an expert in the fields of tooth structure, dental materials and tooth restoration interfaces. His pioneer research at the molecular level, has been recognized and achieved awards, including the Elida Gibbs Research Award, the Colgate Palmolive Prize, and the Weizmann Institute Reshof Memorial prize. Dr Jodaikin received his dental BDS and MSc degrees from the University of the Witwatersrand, South Africa , and thereafter his basic science PhD from the Weizmann Institute of Science, Israel. He has lectured at various universities and institutes at undergraduate and post graduate levels and maintains a dental practice while advancing his research which is focused on preventative dentistry and oral health. In fact, his clinical awareness of the lack of effective prevention between teeth gave rise to the Phocal concept which he patented and developed. His publications numbering more than 25 have been published in peer review journals, and he has developed patents including those of the Phocal series designed to prevent interproximal caries.
VIDEO - DUwHF #975 - Ahron Jodaikin
AUDIO - DUwHF #975 - Ahron Jodaikin
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Howard: It's just a huge honor for me today to be podcast interviewing Ahron Jodaikin, all the way from Jerusalem, Israel. He is an expert in the fields of tooth structure, dental materials and tooth restoration interfaces. His pioneering research at the molecular level has been recognized and achieved awards including the Elida-Gibbs Research Award, the Colgate-Palmolive prize, and the Weizmann Institute Reshof Memorial Prize. Dr. Jodaikin received his dental degree, BDS, and MS, Master’s in Science degree, from the University of Witwatersrand South Africa, and thereafter his basic science PhD from the Weizmann Institute of Science in Israel. He has lectured at various universities and institutes at undergraduate and postgraduate levels and maintains a dental practice while advancing his research which is focused on preventative dentistry and oral health. In fact, his clinical awareness of the lack of effective prevention between teeth gave rise to the Phocal concept, which he patented and developed. His publications, numbering more than twenty-five, have been published in peer review journals and he has developed patents, including those of the Phocal series, designed to prevent interproximal caries. My gosh, Ahron, you might be the smartest man I've ever podcast interviewed before. I hope I'm smart enough to ask the right questions, but let's just start is start with: what is the focal concept?
Ahron: The original idea started from my clinical experience, just doing interproximal restorations, two things bothered me. First of all, it's time-consuming. The second thing is that you have to remove, for access, incredible amounts of healthy tooth tissue and it involves a lot of pain and unnecessary suffering. So, my original idea was to develop something that would at least do good in terms of preventing interproximal decay. Fluoride was the big hope, but it failed in terms of interproximal decay, primarily because the fluoride is not targeted. There's a concept called the Isocap; this theory, and I think it's true, was developed by an American from Ann Arbor whose name is [sounds like: O'Brien]. You probably might have heard his name. He developed the idea - and I think it's very solid - that when you have two pieces of glass with a little bit of water between them, they create a negative pressure and it's very hard to access that area. So, just like the drop of water between two pieces of [sounds like: slide glasses], the same applies between two teeth and you develop what's called an Isocap. It's an isolated negative pressure area and the fluoride, for example, the rinse, or even toothpaste, doesn't get there so easily. So, my idea of the Phocal was we had to break that Isocap and put the fluoride right there between the teeth and have it there long enough to fluoridate the area to prevent and maybe reverse incipient decay. That's basically the Phocal idea. It's basically a little disk that fits between the teeth. It slowly dissolves releasing fluoride and other substances there as well to encourage or enhance re-mineralization.
Howard: I love on your website: 'Phocal Fluoride Disk. What in the phôc is Phocal? The name is oh-so-clever, the way it changes up the F-sound, pinpoints the precision of its delivery mechanism, adds in a little calcium and acid/base interplay there. Plus, the little disks sorta kinda look like contact lenses. Phocal - the latest in fluoride therapy ...' So, how are these to be used?
Ahron: The key to it is to diagnose the cases where it's going to be effective and the best situation is when you can reach it in the initial stages or you can predict that there's a very high chance of decay starting in that particular area. It's based on the stats showing the incidence and the prevalence of decay between teeth - we can speak about that later - but basically once a dentist has decided, or even the oral hygienist has decided this is a site that needs to be treated, the disk is removed from the packaging and it's simply pushed and placed between the teeth. Often, especially in posterior teeth, you have to separate the teeth, so you need to apply a wedge. What you can do to prevent unnecessary pain, you can put the wedge, especially a wooden wedge, in a little bit of liquid topical anesthetic material, and then you wedge it in slowly and the space increases and then it's much easier to position. Normally, it's very, very difficult to position in the interproximal area in posterior teeth, but with a wedge it can be done.
Howard: So, a very confusing thing around the world last year was when media companies were saying that there is zero evidence on flossing and everybody was saying, "Oh, well, I didn't floss to begin with and now the New York Times is telling me that there is no research to even prove that it works. So, hell, now I'm never going to floss." What are your thoughts on flossing?
Ahron: First of all, I don't think the studies were 100% accurate. First of all, flossing has to be effectively done. Just simply slipping the floss between the teeth, that's not going to do it, because a lot of decay is below the contact area of the teeth. So, you have to floss correctly for it to be effective. I believe that if someone does brush and floss - floss and brush is better - I think the chances of decay are much lower, but it has to be done properly. I don't know if the average person does floss effectively. That's mainly a failing of the dental profession and maybe in the commercial world, but that's my take of it.
Howard: So, when did you start selling these?
Ahron: These came on the market, we first produced them in Switzerland and then it was introduced and then afterwards the commercial people changed to an American firm that's producing it. So, about a year ago, or a little bit maybe less, it hit the market and in the terms of the financial or the commercial area, I'm not so familiar about that. I was primarily involved with the science and developing the content, but from a commercial and a financial point of view, I'm not so clued up.
Howard: Are you the sole owner or did you sell your technology?
Ahron: No, there's shares. I have some royalties and a few little shares here and there, but that's basically my whole, in terms of the company, but I'm not involved in the directorship or anything, I'm just involved in the science.
Howard: On Dentaltown we started an online continuing education program. We've put up 411 courses and they're coming up on a million views. This might be something where, if you created an hour-long course, an online CE course, maybe if they saw videos, pictures, all that, you might explain your concept easier. Would you be willing or interested in making an online CE course showing clinical cases?
Ahron: Yes, I could do that.
Howard: I am email@example.com. The guy that does the online CE is Howard Goldstein. So, since I was already firstname.lastname@example.org, he's hogo - h-o-g-o - he goes by hogo, since we already had a howard, but if you email hogo - email@example.com, I personally would love to see an online CE course on that. I want to go off into completely left field. It contains 0.1135 milligrams of sodium fluoride per disk. What's really weird in the United States, I don't know if it's the same in Israel, but about a quarter of Americans think fluoridated water is a communist plot, a conspiracy, it makes teeth soft so that they break down, so they need expensive dentistry. What are your thoughts? And now I've noticed some of the younger Millennial dentists are actually buying into this and are against water fluoridation. Does Jerusalem or Israel have community water fluoridation? And what is your thoughts on water fluoridation and its effectiveness of preventing tooth decay?
Ahron: First of all, Israel does have it, but there was a stage where there was a different governmental control and then someone that was an anti-fluoridationist took it off, it came back on. It's sort of swung back and forth based on the political show, especially in terms of Jerusalem. I'm pro-fluoride, but I don't believe that it should be used to the extent that it is used. It has to be used effectively. In other words, it should be targeted. You can't just apply fluoride everywhere and hope that it reaches its destined site. You have to put it where it needs to be placed and you have to put it in the right concentration and not to overuse it and, on the other hand, not to fail to take advantage of its benefits. That's basically my ...
Howard: But are you, for water fluoridation in Jerusalem or do you think it's ...?
Ahron: I'm for it.
Howard: You're for it?
Howard: And have you seen good research that when they were taking it out of the water in Jerusalem, did pediatric decay go up, when they put it back in did it go down? Were there any great measurements or insights of data?
Ahron: I don't think there was good enough data. First of all, it was only for two years that it was taken off. So, I'm not sure if you would pick up such a change so easily unless you did an incredibly extensive study, which wasn't done, my according to my knowledge.
Howard: And what toothpaste you recommend? I mean, I would just think that you would just know a lot about fluoride, sodium fluoride. Because there are hygienists in America that follow dry brushing and they say that to remove plaque, you need a really nice, soft-bristled toothbrush with very straight bristles and that if you brush for two minutes dry, that you effectively remove the plaque just the same and that the toothpaste is not really relevant.
Ahron: From the research point of view, I think toothpaste decreased decay by about 20%. It has its limitations because it didn't, for example, in the States many years ago, they were so encouraged by the effectiveness of fluoride, that they actually started closing dental schools - I remember Northwestern was closed because of that - because they predicted that there would be an incredible change in dentistry because of fluoride, but that didn't come about because I think fluoride has its limitations. You can't expect it to work everywhere if it's not getting there first of all, and you also have to be careful not to overuse it. Untargeted fluoride, like I said, I think that's a pity because you don't need to do that type of thing.
Howard: They closed down seven dental schools. I don't remember all the names, but it was Northwestern, Georgetown, Fairleigh Dickinson, Emory and - it was thirty years ago, I don't remember the other three, but it was actually seven of them closed down.
Ahron: Right. Northwestern was a very good university. That was a pity in the way from a research point of view.
Howard: What else do they need to know about Phocal therapy, Phocal interproximal therapy?
Ahron: I think the most important thing, there are two things: dentists are in the habit of just filling and drilling, and you get into that mindset and then it's very hard to get out of it, so I don't think it's going to be used so easily because dentists - and I know for myself - because of habit and I think also, although we speak about fluoride so much in prevention, most dentists, once they're in the working chair, they don't get there. I think - this is my take of it, I don't know it might be wrong - the human brain is divided into two parts from the two hemispheres and the one deals with a speech and logic and that's where I think we speak about prevention and we encourage it and we think it's right, and then the opposite side deals with spatial factors and that's where the dentist, when he's sitting in the chair, is dealing mainly with spatial parameters and I think that sets his mind in a stage where he doesn't think of prevention. So, something's going to have to change if we're going to move into prevention, especially regarding dentists that are involved in filling all the time. That's the first thing. The second thing is that dentists are going to have to understand the research data for - I'll give a few examples in terms of the prevalence and incidence of decay and the statistics - they're going to have to understand where the decay occurs. For example, we took data from the NIH, beautiful study by [sounds like: Win], but it's thirty years old and there's never been a study that is close to this study, and we translated the statistical data - I have it here. You can see it here, the percentages of decay between teeth. So, it ranges, for example, in some cases close to 40% in molars and, for example, in the bottom teeth, the average American is around about 2%. So, the first thing is the dentist is going to have to change his mind set and understand where's the prevalence and the incidence of decay. That's the first thing. The second thing ...
Howard: Well, on that, the upper teeth and lower teeth, is it the same percentage going around?
Ahron: Very similar, except for the anterior teeth.
Howard: Okay, let's go through those numbers. Between second and first molar, what's the percent?
Ahron: It's around about 40% on both.
Howard: 40% what? End up having an interproximal lesion?
Ahron: 40% of Americans will have either a lesion or there would have been an extraction or there would be a restoration in those positions.
Howard: By what age?
Ahron: This is the average. It gets higher with age.
Howard: But is it for their entire lifetime or just ...?
Ahron: This was a study that took a range of ages, and that's the average in terms of age and population, different groups, racial groups or whatever.
Howard: Did you have a number between the wisdom tooth and the second molar?
Ahron: No, they don't have data on that.
Howard: So, no data there. So, between the second molar and the first molar is 40%. What about first molar and second bi?
Ahron: The molar has around about 40% and the bicuspid is around about 30% on both sides.
Howard: And then that's same for first bicuspid?
Ahron: Then it goes down. First bicuspid and second one is around about 17% on both sides.
Howard: And then what about between first bicuspid and canine?
Ahron: That's also 17% and on the uppers it's slightly lower. It's 13% for some reason. I'm not sure why, but that's ...
Howard: And then between the canine and the lateral?
Ahron: The canine and lateral on the lower is around about 4% and on the upper teeth it's around about 12%.
Howard: Interesting. I still can't figure out why they named the canine teeth after a dog! Did you ever figure that out in your research?
Ahron: No, I didn't. Did you think about it?
Howard: No, but you know what? That would be a great post. I think you should start a thread. I know you guys are shy and humble. I mean, Millennials, they just post away on Facebook, but I know dentists between 55 and 75 - like, take [sounds like: Bob Ibsen], I couldn't get him to post on Dentaltown because he says, "Oh, that's bragging", or "I don't want to draw any attention to myself", but you should start a thread on Dentaltown and say, "Hey, I just got done on a podcast with Howard and he told me to post this chart and tell you what I've done." Plus, you're a dentist. I mean, it's not like you're an MBA and a salesman trying to sell something slick. I mean how many years have you been chairside clinical dentistry?
Ahron: Around about thirty-five, forty years.
Howard: Yeah. So, I mean, so ...
Ahron: I'm inclined to forget these types of things, like you probably. How long have you been?
Howard: Thirty years. My dental office, which is three miles up the street from my house, had its thirty-year anniversary September 11th, last year, 2017. I graduated in 1987, University of Missouri, Kansas City. You just have instant credibility. I mean, you're a dentist for thirty-five, forty years. You should start a thread on Dentaltown and post that they're looking at everything spatial and the first thing you're wanting them to do is, when they're looking at these teeth, to start thinking about the chance of them getting an interproximal lesion and that tooth ending up having to be extracted or a restoration. What were you going to say after that?
Ahron: Besides the incidence and prevalence, the other factor is there's a study of an English group, which basically [sounds like: Win's] data shows the same thing. If you have a restoration on the left side, on the same symmetrical side, the opposite side, there's an 80% chance the same thing's going to happen over there, so there you have a classic case. If you just placed an MOD or an MO or a DO on the opposite side, there's an 80% chance, if there isn't restoration there already, that you're going to have decay. So, that's an ideal spot.
Howard: Amazing concept, but they taught us that thirty years ago, that if you're not quite sure if this tooth has an interproximal lesion, look on the other side of the tooth. And just start doing this, kids, when you're looking at a patient, when you're looking at someone my age, fifty-five years old, start noticing on the pano, the FMX, and looking in the mouth, that the right side pretty much mimics the left side, and I'll tell you, so many times, they'll have ... and where it comes into effect, maybe they have a bridge replacing a first molar on the left side and now they have a toothache on that first molar on the other side, and your first thought is, "Well, I'm going to do a root canal and a crown." Well, then you need to start talking to the patient, "Why is this missing?" "Well, they did a root canal build-up and crown and it only lasted a couple years, and then they had to extract it and they did a bridge or an implant or a crown." That probably means this tooth has got some vertical fracture in it that you might not see. But, for diagnosing and treatment planning, looking at your contralateral side is the best damn second opinion you're ever going to get. I mean, your right hand looks like your left and your right foot looks like your left foot, and by the time you're fifty-five, the right half of your mouth is going to look like the left half of your mouth. And you say you have a study you can reference on that and I would love to read that and post that on Dentaltown, or you can post it when you start your Phocal there. You can post that JPEG that you held up. Do you have that on a JPEG? That 'Incidence of Decay'?
Howard: You could post that: 'The Incidence of Decay'.
Ahron: I can give it to you as well.
Howard: Yeah, email it to me. Email me that - firstname.lastname@example.org - and send me the study because that is so profound, and I know we've never talked about that on this show before, and you're right, the contralateral side as an 80% chance of looking like the other side, that's what you're saying.
Ahron: Right. That's based on research, and as a clinician you get the feeling that's true.
Howard: Absolutely. You have a lot of interesting case studies and one is Dr. Berg, a pediatric case study, Dr. Parham and Dr. Jackson. I wish you could get them to go on Dentaltown and start posting these cases. So, let's start with Dr. Berg in pediatrics. One of the biggest controversial things right now in the United States ... you know, there's tons of controversy always when you start talking about occlusion, TMJ, neuromuscular headaches, all that stuff, but there's pretty much never been any controversy in pediatric dentistry in my thirty years until now with the advent of silver diamine fluoride. There are pediatric dentists who say, if this kid needs to be put under - the kid's two or three years old and you need to put them under - that's a very high risk procedure and it seems like every three or four months in America has some little kid is put under by a Board certified anesthesiologist to be worked on by a specialist pediatric dentist and the kid doesn't wake up. So, some people are saying, "Just start painting the teeth were silver diamine fluoride." And then other ones are saying, "No, they need to be treated." What are your thoughts on silver diamine fluoride and what are your thoughts on using the Phocal therapy on pediatric decay?
Ahron: I can tell you what's happening from the financial people - that I do know because it's something to do with science. They are looking into using it within the focal concept. In other words, the disk would contain the same material as what they're painting on in order to be more effective interproximally. Obviously, because it's a preventative regime, there's no health hazards, then I'm very much for it. It's been used in Japan for a long time, so it seems to be reasonably safe regime.
Howard: For the silver diamine fluoride or for the ...?
Ahron: Yeah, sure, that's what we're talking about, silver diamine fluoride.
Howard: So, are you using it in your office?
Ahron: No, I don't have any and I'm not using it at this time, but I'm certainly thinking of it.
Howard: The case was Dr. Joel Berg, DDS MS, Professor at the University of Washington. Is he still there or is he no longer there?
Ahron: From my knowledge, I think he's still there, but I'm not sure.
Howard: So, October 26, 2017, it says "The University of Washington's Dental School Dean has resigned, and the University is looking for ways to reduce their $36,000,000 Dental School deficit. Faced with a growing Dental School deficit that now totals $36,000,000, the Dean of the University of Washington School of Dentistry has resigned. Joel Berg resigned Monday because - which was Monday, October 26, 1972 - because he believes it will be best for the School of Dentistry to have fresh leadership to resolve its urgent financial challenges", wrote provost Jerry Baldasty in an email to the staffers. Baldasty's having an all-school meeting with dental school faculty and students. So, yeah, that was a lot of turmoil. I've known Joel for thirty years. I actually got lucky one time. We were both lecturing at some convention and then we both had to fly somewhere to catch a layover, for me to fly to Phoenix, him to fly to Washington. And I sat next to him for three hours and I felt sorry for him because he pulled out his laptop - I knew he wanted to get a lot of work done and I just interviewed him like this for the whole three hours. My goal is to suck everything out of that amazing man's mind for three hours, and I could tell he was getting frustrated, but I just couldn't say no. I just had to ask him everything. He's a world-renowned pediatric dentist and he's doing a case for yours. Are you friends with him?
Ahron: I've never met him and I'm not familiar with him in terms of the Phocal concept.
Howard: Well, Joel, if you're out there listening, I want you to come on the show and talk about silver diamine fluoride, the Phocal concept and what the hell happened, the $36,000,000 school deficit, how did that happen? And sorry you had to resign over that. I bet that was not a very fun time of your life. Is the market using a lot of these Phocal disks in pediatric kids or are they more adolescent and adults? Who's mostly the clinical cases?
Ahron: I'm not familiar with the financial and the commercial side of things. But it certainly is appropriate for children. The only person from the States that I worked with in terms of the science was Frank Lippert, Indiana University, where they did an independent study to check the effectiveness of Phocal. It's an in vitro study using teeth in human saliva, and it was shown to be very effective.
Howard: His name was Frank what?
Howard: How do you spell that?
Howard: Frank Lippert at Indiana ...
Ahron: Indiana University, yes. That was an independent study. The other studies we did were sort of in-house, so that hasn't been published, but this study was published.
Howard: He teaches cariology, operative dentistry and dental public health at Indiana. Current position: Associate Research Professor. Interesting. So, now was he a colleague of yours? How did you get Frank to do the research on this?
Ahron: I think it was an American consultant that put us in contact with him, with their group. [sounds like: Bill Cooley], I think was his name. He put us in contact with them and, together with him, we designed the study and they conducted the study independently and published the results. They put my name on the paper as well, because I helped them design the study and made the Phocals, I guess, but it was done together.
Howard: Now, tell us about your journey? When you got out of dental school, when did you start having a love with research? Were you always research-driven? Did you always have the mind of a scientist? Are you a mad scientist? How do you go from being a clinical dentist to inventing something like this?
Ahron: At Dental School where I studied in South Africa, there was an elective where, in the final year, you could choose which department you wanted to go and spend a certain amount of time in. I went to the Dental Research Institute at the University of the Witwatersrand. That's the University where I graduated and there was a Prof. Cleaton-Jones there and I admired him. He was a very special person on a personal level and as a scientist he was also excellent, and I enjoyed the two months that we spent together. We did a study and I was taught and I very much appreciated his input and that drove a love for dentistry. He offered me a job at the Institute and at that time I remember thinking - I was about to graduate, "There's no chance that I'm going to go there. I'm graduating and I'm going to be a dentist." But about six months after practicing I thought, "I don't want to spend my whole life just doing dentistry. I'd like to go back." So, I took the job at the Dental Research Institute, and he encouraged me to carry on in dentistry. So, I spent at that time, 20% of my time in clinical practice and the rest in research, and eventually I taught dental materials at that university in a different department. At that stage, I was very involved in research and I moved to Israel and did a PhD in Biophysics using enamel as the material that was studied. That's where I did the PhD and basically the idea was to understand protein/enamel relationships and to understand dental tissue better in terms of being able to appreciate dental materials at a more sophisticated level. That's basically the background to it. But I always maintained a dental practice and I practiced.
Howard: So, you were born in South Africa? Where were you born?
Ahron: In Johannesburg.
Howard: Who's the famous dentist we had on the show? I love him so much. Howie ...? Is it Howie Gluckman? Do you know him?
Ahron: I know of him. He does implants. He's a periodontist, from what I understand. I don't know him personally, I know of him.
Howard: So, tell us about your journey. Yeah, Howard Gluckman, but he goes by Howie. My mom's the only one that calls me Howie, no-one else calls me Howie. They usually call me Howard or a bunch of profanity, but Howard Gluckman. South Africa has a very robust dental community, very robust dental schools. Howard Gluckman and there's just a ton of really ... some of the world's most amazing dentists are in South Africa. Tell us about your journey. What made you leave Howard Gluckman and the town of Johannesburg and end up in Jerusalem? Tell us about your journey.
Ahron: Prof. Cleaton-Jones once told me that I should do an elective at the Weizmann Institute because he knew of that Institute, so I spent an elective for two months there and I liked it very much and I was invited to do a PhD there, and that's why I landed up doing a PhD there.
Howard: But you never went home, which makes me think that usually, they say in The Economist that the only time you leave your country, they say only 1% of the seven and a half billion humans on earth are living outside the country they were born, it's only 1%. And they say they almost always leave for only four reasons. It was economic opportunity, love or they were being abused at home - they're refugees - or they're running from the law. So, which one was it? Was it economic opportunity? Did you meet a woman? Were you running from the law? Were they beating you up in South Africa?
Ahron: I think the answer would be opportunities.
Howard: Opportunities. But you stayed, you didn't go back, so you must have found love in Jerusalem.
Ahron: You can include love, maybe.
Howard: You what?
Ahron: There you can include love. So, I guess it's a combination of opportunities and love.
Howard: So, you went there for opportunity and then you fell in love.
Ahron: I fell in love with the land. When I arrived here I was already married. My wife is also an ex-South African.
Howard: So, you found love in South Africa and then you went there for opportunity, but you stayed.
Ahron: And love.
Howard: By the way, I have to thank you so much because my mother turns eighty this summer. I don't know if I'm allowed to say that for HIPPA, since she is my patient, am I giving away personal information? But, I've sent my mom to Paris, London, Rome. I mean, she's the most Catholic woman on earth and I even sent her to Rome, but nothing thrilled her more than when I sent her and her girlfriends all to Jerusalem on some ten-day tourist bus deal. I mean, my gosh, that was the highlight of her life. She just thinks that was the greatest trip and I should send her back. In fact, we should go with her, Ryan. But I always tell her, I said I would only go if I can make it business, if I was lecturing there, if you could just put me in a bar and have two dentists sit there so I can tell the Internal Revenue Service that it was a dental lecture, then everything would be paid for with pre-tax money, but on a vacation it's paid with 38% post tax money. But seriously, she just thinks that was the greatest time in her entire life. I wonder if tourism, is that one of the top three sectors of Israel's economy? I mean, is it a big, huge factor of the economy?
Ahron: It is a big factor. I'm not sure what percentage or where it rates. I guess Israel's know for start-up companies. That's probably the biggest thing. Tourism is a big thing, because there are a lot of places, and, having lived here, what's amazing is there are other places that are not well-known by tourists that are also fascinating. So, if you come, I can introduce you to a excellent tour guide who, if you have time, can take it to very, very interesting places.
Howard: Email that to me and this will become a very expensive podcast for me. You know why?
Ryan: Why's that?
Howard: Because last time I had a guest - who was really jealous?
Ryan: Sister Ann?
Howard: Sister Ann of [sounds like: Yahweh] and my other sister and I should probably just send the three of them. I would go with them, but I couldn't because they would be running around the city from like 6 a.m. to 10 p.m. seven days a week, and if I said, well, "Well, let's just sit in the bar and have some beers and watch some sports", they would think I had completely lost my mind. I couldn't think of anything more exhausting than running around with my mom and two sisters for ten days. I'd probably find the only cliff on Jerusalem and jump off it. Would you say that there are too many dentists in Israel, there's the right amount or there's not enough? I mean, some countries, like you go to Malaysia, forever they had one dental school, and then they opened up about six private dental schools and it's really changed the economics of being a dentist. So, what do we have? Ryan just found: Israel has seventy-five hundred practicing dentists and close to three hundred new dentists joining the profession each year. Israel has one of the highest proportions of dentists to the general population in the world. Around 85% of all dentists in Israel work in private clinics or group practice. So, there are seventy-five hundred, so you said eight million. You could probably do this in your head, but since I have a walnut brain, eight million divided by seventy-five hundred ... wow! So, you guys have a dentist for every one thousand and sixty-six people. America has a dentist for every eighteen hundred and fifty people. And if you're listening to me now, remember that in the United States, half the people live in a hundred and forty seven metros, the other half live in nineteen thousand and eight towns, and when you start going in downtown famous areas like Scottsdale and L.A. and Manhattan, you're down to about a dentist for every five hundred people and the average ... so, if your location's just neutral in America, you'd want to be one dentist for eighteen fifty and I can show you rural places all day long where there's not even a dentist and there's six to ten thousand people living and every dentist that goes there, the first year will collect about a million two and take home $400,000 in cash. Demographics matter. I would have to say to you, Ahron, that Israel is a very competitive market for a dentist, with only one thousand and sixty-six people per dentist. We've already talked for 42 minutes. What other questions did you want to talk about that I wasn't smart enough to ask you about?
Ahron: I think we've covered most of the important things. I wrote a few notes down and I think we've covered most of it. The only thing that I thought you might ask me was, how do you know Phocal works?
Howard: That was my next question. That was my very next question. You took the words right out of my mouth. Ryan!
Ahron: First of all, fluoride is known to be effective. That's the first thing. The first study we did is, once we develop the Phocal, I placed it on extracted orthodontic teeth and measured the infrareds changes on these. What we did is we scraped the enamel off and subjected it to infrared studies and there you can see changes that the [sounds like: hydroxyapatites] had changed to [sounds like: fluorapatite]. So, that was the first clue we knew that what we were making was working. After that we did a little bit of a pilot study together with Prof. Davis at the University of London, where they used 3D micro radiographic studies, and there we show that there are changes as well. So, those were the stepping stones to say we knew we were onto a good thing, and then after that - the reason these weren't published is because they were in-house - after that, we allowed the Indiana University to use the Phocals and there the results were much more positive and much more effective than I had expected. That's basically the proofs. Besides the clinical studies, which is not really science, they sort of more empirical. We have a few dentists here and there showing results from radiographs, so there could be other factors involved. It could be that you're missing stuff. You need many, many more subjects to be able to publish something sensible, but from my personal view, I think the Phocals are effective and I think the key to it is the effectiveness is higher if you catch it earlier. I'm going to be a little bit controversial now, because what happens is at the initial stages you have porous piece of enamel and you can get good fluoridation and you can change the situation, but if it's too late, if you're only seeing it radiographically, you're seeing a very old, for example, microscopically it's much more advanced than we ever would imagine. So, you're treating something that shouldn't really be subjected to fluoride, because it already needs restoration. The key to it is to find it at the earlier stage. Another problem is that what's happening is when decay starts, the surface develops a strong remineralization zone and that unfortunately acts as a barrier to further fluoridation, so you're compromised. So, the controversial thing that I'm thinking of is to actually file interproximally to remove that layer and then subject them to fluoridation like Phocal. Now, I don't know what people are going to say about that, but that's pretty radical. What do you think?
Howard: I agree. They taught us decades ago, thirty years ago, that the cavity you see on the bitewing x-ray is only about 40 to 60% of the size of the lesion, and you're right, that is a demineralized dead zone and the active decay zone is not showing up on the radiograph yet.
Ahron: It's also under. There's a shield. The remineralization that takes place naturally, occurs on the surface and then the decay carries on internally, so sometimes even clinically, you can see an interproximal restoration, that on the surface it looks okay, and then if you probe a little bit deeper, there is decay underneath. On the other hand, you can get situations which they call 'the fluoride [sounds like: bomb]', where you've fluoridated so well that the enamel is completely fluoridated, but the decay in the dentine carries on. My idea with that is if you do such things, we could treat interproximal decay with fluoridation and not have to go into the interproximal zone and just treat the dentine from the occlusal area. These are radical views and they need to be tested.
Howard: So, do you use caries indicator, because they always talk about the difference between 'affected dentin' versus 'infected dentine'. Infected dentine is the outer layer that has softened and contaminated with bacteria, it is irreversibly denatured and not remineralized; versus affected dentine, has a demineralized phase but not yet invaded by bacteria, it can be remineralized. Some people think that these caries indicator stuff like, say Seek by Ultradent, Dan Fischer, that it's staining affected dentin and you're removing too much dentine. Do use a caries indicator yourself?
Ahron: I used to use it more. I don't use it so often anymore.
Howard: Because of that? Because you thought it was staining affected dentin and you're removing a bunch of demineralized dentine that was not yet infected by bacteria, which could be remineralized? Is that why?
Ahron: Howard, truth be told, I think it's more laziness and a lack of information. That's the truth. There was a stage that I was into it and I used it much more then. I hardly use it anymore. I have it, but I don't use it and I'm not sure if it's clinically worthwhile. Does it change the prognosis of the treatment? I'm not sure.
Howard: Okay. The other two huge controversies in decay is you still have people wondering if it's contagious. I don't know why people wonder if it's contagious. I mean, if you walked out in your backyard and you saw a giraffe, didn't that giraffe have to come from a mom and dad giraffe? I mean, it had to come from somewhere. It just didn't all of a sudden show up in your backyard. So, how does some human all of a sudden have streptococcus mutans in his mouth? I think, what I've noticed for thirty years, because ... let's go back to that pediatric case. Every time some young two or three year old child is taken to the hospital and put under and doesn't recover from the anesthesia, the press makes the dentist be the bad guy, but, like in my own backyard, when that happened the last time, everyone in the State knows that that pediatric dentist is one of the best and he had a Board certified anesthesiologist and they did everything right. And what the media doesn't talk about is that that little kid couldn't be treated by any of the general dentists. They referred it there. They couldn't do it. And then that pediatric dentist couldn't do it, so he needed to put on anesthesia. But what I'm asking is, why does a two year old or a three year old need multiple pulpotomies and [unclear] crowns? What I've seen is it's in families - the whole family has bombed out mouths or they don't. And I'm thinking that two year old kid is being kissed by her mother and father who have bombed out teeth, that need teeth extracted, they've got periodontal disease, they're totally infected, and then that kid, who does occasionally drink sugar and does things wrong a lot, they just don't seem to have the decay problem. I mean, why is it? And then the other side of that, which I think is going to change everything in ten years, I've always noticed that you either have a lot of gum disease and perio with very little to no decay or you have a bombed-out decay and you don't have perio. I don't really see mouths that have fifteen cavities with rampant gum disease, which makes me think there's something in the gut microbiome that's affecting this. Because when you look in the mirror, you see one trillion human animal cells that you got from your mom and dad, but from the thirty foot tube from your mouth to your rectum is ten trillion organisms, viruses, fungi, yeast, that didn't come from mom and dad, and I think there's something going on in the gut microbiome that has effects at the ends of that tube - our end is the mouth, the proctologist's end is the other end - but I think there's something going on in the microbiome because you just see ... I've seen patients for thirty years that tell me, "I've never flossed my teeth. I hardly ever brush", and they don't have any decay problems. And then I have hygienists that are patients of mine. I have one who cries at almost every appointment - she's my age - she gets her teeth cleaned every three months, she does everything right and she still is losing teeth from periodontal disease. There's more to it than we know. So, my two questions are: do you think dental decay is contagious and you shouldn't kiss someone with a bunch of cavities; and number two, do you think the gut microbiome is affecting gum disease and dental decay in the mouth?
Ahron: Very interesting questions. First of all, there's a genetic factor as well that we have to take into consideration. The second thing is, I have noticed in my personal practice that there is a high incidence of perio where the husband and the wife both have it? I wouldn't say it's 100%, but it's certainly sticks out. In terms of the decay, what I've also noticed with larger families, the older kids have better teeth than the younger the kids. When we have a lot of, say, six children, siblings, usually the older kids have better teeth than the younger ones. So, that's a question in terms of, I doubt whether the parents are kissing the younger kids more than the older ones, or did so. I guess it's a combination of genetics and what you're saying. I think for sure there is something to do with the microflora and it wouldn't be contagious.
Howard: Well, as far as you see this in married couples, to me that's been so obvious for thirty years, but think of the human body. If we turned the human body over and you were seeing that every three months for chlamydia and just every three months he still had chlamydia, wouldn't you say, "Hey, dude, I think you're sleeping with someone with chlamydia", and then you get his wife in there, you treat them both and it's gone. I cannot believe how many dental offices have seen the wife every three months for ten years and they've never seen her husband one time. How can I treat your periodontal disease if every night you're going to bed and you're kissing Grandpa and he's got six millimeter bleeding pockets and gum disease? Why does it make sense below the belt and it doesn't make any sense above the belt? It's almost like we have two medical philosophies for a human, one is below the belt and one is above the belt. To me it's insanely obvious.
Ahron: I agree with you. 100%. [Unclear], I don't see it so much. The husband and wife, in terms of the amount of caries, from my limited clinical experience, I don't see such a correlation, but perio, for sure, I see a strong correlation.
Howard: But do you see a correlation that if they have a lot of perio, they don't have a lot of decay; and if they have a lot of decay, they don't have a lot of perio?
Ahron: Yes, and it makes sense.
Howard: All my friends tell me that too, which makes me think, you know, like go to the jungle, maybe if you have a lot of cheetahs, you don't have a lot of deer and maybe you have a ... I mean, to me there's something going on and I think just thinking about the very end of that thirty-foot tube and you think that's where all the answers are. I think when you start studying gut microbiome, just your colon probably has ... I mean, you're a trillion cells, your gut microbiome is ten trillion, so your gut microbiome, ten trillion. The largest zoo in America is the San Diego Zoo with forty-two hundred species. That ten trillion gut microbiome has over ten thousand species. So, you'd have to have two and a half San Diego Zoo's worth of species. So, to me, I think when they eventually figure out that gut microbiome, I really think that's going to change how we treat and view gum disease and dental decay.
Ahron: I agree with you, but there are other factors. There's the amount of [sounds like: calcium] in the saliva as well, where a person with a lot of calcium that forms a lot of tartar or calculus will have a bigger tendency towards perio and less restorations because of the calcium, which is remineralizing.
Howard: Is this true or false? If someone has a lot of decay and I touch the saliva and pull my finger out, it's ropey, the saliva sticks and I can pull out two or three inches of ropey saliva from my finger to the saliva, but if it's periodontal disease, that's not the fact. Do you agree that saliva is thick and ropey and stringy if they have full decay but not periodontal disease?
Ahron: Yes. That's a known thing. I think the more viscous, the less ...
Howard: More viscous - that was the word I was looking for. That was the next word out of my mouth: more viscous. One of the biggest practice builders that I've had is, I'll get a new patient and they've moved in from, say Iowa or Kansas, in Phoenix, everybody's moving here from the northern cold parts, so they're tired of living in Canada, Minnesota, North and South Dakota, and they always come down here and so many people move in and they say, "Well, I always get my teeth cleaned every three months because I've got to stay on top of my periodontal disease and blah, blah, blah, blah", and I say, "Okay, so then how often does your husband get his teeth cleaned?" And she rolls her eyes and says, "My husband hasn't had his teeth cleaned in ten years!" And when you start comparing STDs to perio, her eyes get big and she gets them in there. It's a huge practice builder that says, "I can't treat you for periodontal disease or chlamydia, gonorrhea, syphilis or whatever every three months without treating your lover too." So, that immediately doubles your periodontal practice. Number two, when I see a girl showing - and you better put that on their health history because at least every five years I ask a girl when she's due and what she tells me she's not pregnant and you can tell she wants to just shoot me in the head - but when a girl is pregnant from the health history, or she's obvious, and you tell her, "Look, now you know that baby's not going to be born with syphilis, gonorrhea, chlamydia, HPV. Well, the mouth is the same thing. That baby's not going to be born with streptococcus mutans that causes decay, P. gingivalis that causes gum disease, HPV that causes oral cancer. They're not going to be born with cold sores and canker sores. They're not going to get any of these 'herd diseases' until people start kissing them and licking them and sharing utensils with them, and what I want you to do is promise me that nobody's gonna kiss that baby on the mouth. And it's called loading dose, say the number one killer on earth is cholera, we know you have to drink a hundred thousand cholera bacteria for enough to survive the acid and the pH of the stomach to actually set up an infection in the small intestine and cause the cholera and the diarrhea. It's the same thing with humans. I tell that pregnant mother, "I need everybody that's gonna hold, kiss, everybody that's going to be around that baby: your babysitter, your grandmas and grandpas. You can't hand your newborn baby to your grandmother who's got an upper denture, a lower partial and a bunch of gum disease and have her kiss that baby on the mouth. You need to start instructing everybody, 'Kiss the baby on the head, kiss it on the back of the hand!' What I do is, I used to kiss my grandbabies and grandkids on the bottom of the foot. Hell, it makes them laugh, giggle, scream, kick. I mean, you just don't kiss a baby on the mouth. And I need to get everybody who's going to be around that baby, I need to get them a new patient exam: cleaning, exam, x-rays. If they've got gum disease and bombed out teeth, let's fix it so they have less of a chance. Some people are walking around with hundreds of millions of streptococcus mutans and P. gingivalis in just a nickel's worth of saliva. Let's try to get that to go away. And the only country that I've seen - I've only seen two countries who really are on top of it, and that is Liechtenstein and Austria, and somewhat the Germans; and how I can prove that is Ivoclar, Williams Ivoclar, which is out of Lichtenstein, they sell streptococcus mutans testers, incubators, the whole nine yards, they don't even advertise it in any country around the world because the only people that have ever shown an interest to it is in Liechtenstein and Austria and a few Germans, and I have lectured in fifty countries and you ask a pediatric dentist, "Well, how's your practice?" They'll say, "It's good. I have three hygienists. I work two chairs and I go into the hospital once a week." You have that same conversation with the pediatric dentist in Lichtenstein, he'll say, "Well, you know, I'm doing really good. I have eighteen hundred patients and nine hundred of them still don't even test positive to streptococcus mutans." Life is a marathon. There's people that finish the marathon in three hours and one minute, and then there's me who's at the back of the line finishing in six and a half hours, looking for a donut stand, but I think the front of the race on preventing the transmission of these oral diseases that Homo sapiens is not born with is in Liechtenstein, it's in Austria, and everybody listening to this podcast could start really consulting the pregnant mother that says, "Hey, your baby doesn't need to be an inoculated with streptococcus mutans and periodontal disease any more than it needs to be inoculated with HPV." I think the best dentistry ever done is no dentistry at all. I don't want my grandchildren to have the finest gold restorations like Grandpa. Grandpa only has seven restorations. They're all gold cemented with zinc phosphate cement - those are the best. I don't want my grandchildren to, when they're fifty-five, to have seven gold inlays, onlays and crowns. So, the best doctors prevent disease. The worst doctors just drill, fill and bill and don't ever prevent disease. So, be a preventative dentist. Don't be a drill, fill and bill assembly line. Ahron Jodaikin, it was an honor that you accepted my invitation to come on the show. Remember, there's no commercials. You're such a scientist. Are you a mad scientist or just a normal scientist?
Ahron: I hope just a normal one! Thank you very much for your input. I enjoyed listening to your ideas.
Howard: It's 11:16 a.m. in Phoenix. What time is it in Jerusalem right now?
Ahron: It's now 8:16. That's what I have recorded on the internet.
Howard: 8:16 p.m. Well, thank you for staying up late at night to talk to my homies. You were amazing. I hope you have a great evening. Thank you so much for coming on the show today.
Ahron: Thank you. And if you ever come to Jerusalem, I'd be pleased to meet you.
Howard: Oh, we're coming. I'm going to bring my mom and my sisters. You don't want to meet my mom - she'll talk your ear off.