Dentistry Uncensored with Howard Farran
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1003 Sleep Disordered Breathing in Children with Dr. Diana Batoon : Dentistry Uncensored with Howard Farran

1003 Sleep Disordered Breathing in Children with Dr. Diana Batoon : Dentistry Uncensored with Howard Farran

5/3/2018 8:51:40 AM   |   Comments: 0   |   Views: 230

1003 Sleep Disordered Breathing in Children with Dr. Diana Batoon : Dentistry Uncensored with Howard Farran

Dr. Diana Batoon is the founder and President of AZ Center for Breathing and Sleep Wellness and Bonita Dental in Scottsdale, AZ.  She is a 1996 graduate from Tufts University Dental School and is an active member of ADA, AGD, AADSM and AACFP.  Her combined passion and expertise calls for a change in the way we do dentistry today to help evaluate children and adults for potential sleep issues.  She is an international speaker and is actively involved with Spear Education and CEREC Doctors.

https://www.momentumdentistry.com/

https://www.bonitadental.com/

 

VIDEO - DUwHF #1003 - Diana Batoon




AUDIO - DUwHF #1003 - Diana Batoon


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1003 Sleep Disordered Breathing in Children with Dr. Diana Batoon : Dentistry Uncensored with Howard Farran


Howard: It is just a huge honor for me today to be podcast interviewing Diana Batoon, who we’ve had write articles on Dentaltown. I called her, she did not call me. I really loved your article on Dentaltown. Dr. Diana Batoon is the founder and President of Arizona Center for Breathing and Sleep Wellness and Bonita Dental in Scottsdale, Arizona. She is a 1996 graduate from Tufts University Dental School and is an active member of the ADA, AGD, AADSM and AACFP. Her combined passion and expertise calls for a change in the way we do dentistry today to help evaluate children and adults for potential sleep issues. She is an international speaker and is actively involved with Spear Education and CEREC Doctors. It's an honor that you came by the house today. I got to tell you, you graduated in ‘96. I graduated ‘87.

Howard: I never heard sleep apnea one time. I didn't hear it one time after a decade, but now you just keep hearing more and more and more and more. And so much of it, I would think that I would know a lot about it now. But, I am continually amazed. I was at a friend's house today and their little bitty, I don’t know, five-year-old little boy was laying on the couch and he was grinding his teeth. I've never even heard an adult do that. And, now you're kind of at the next frontier. When it first came out, everybody was saying, (I'm self-absorbed, since I'm an old fat bald guy), yet they're always trying to out the fat neck and all these things and they say, “Well, he's fat and his neck’s fat”, and I wasn't even thinking of the five-year-old, but that's where you come in.

Diana: Yeah, because I think that's what we're used to. We're used to seeing our grandfather sit on a lazy boy chair snoring loud and saying, “Hey, they have their snoring”. They might have sleep apnea. But in today's society, we see a lot of children that may not be breathing right and when they’re mouth-breathing during the day, they probably are mouth-breathing during the night-time and that can cause some serious issues and that can affect their REM sleep cycle at night. So, it's a concern, I think, that parents need to start looking at and then as dental providers, or people in the dental community, if we can help identify that, we're really going to set up that kid for growing and developing a whole lot better.

Howard: Well, you know, they say in business, I went to ASU, got my MBA at ASU, that was really fun, and they would always preach that, when you have all these different departments and they're all in the same computer system, it seems like the department never figures out their own problems. It's always another department’s, like it would be someone in marketing saying, “What are they doing in engineering?” Or, it will be someone in engineering saying, “What's wrong with the marketing department, or this?” And, I've been totally blown away this last year, where the anthropologists are talking amongst themselves saying, “Dude, we got hominid fossils going back millions of years, this whole malocclusion thing just popped up”. And, then I think of our poor country, America. Three hundred and twenty-four million people and we got ten thousand eight hundred orthodontic factories that we just churn all of our kids through, for something that didn't even exist a couple of hundred years ago. And that's got to hurt your brain.

Diana: Yeah. You know, I think in our Western Society there are a lot of factors, our diet, our environment, certainly allergies, all those things affect a child. And so, I think it’s important to note is that a lot of these kids, especially if they were bottle-fed, instead of breastfed, their ability to keep their tongue in the right position. You know, most people don't know that nasal breathing really is a key to healthy life. And if your tongue is positioned at the roof of your mouth, number one, it's going to help form the palate. Number two, it's going to keep in the right place, so that the child’s breathing through their nose. And number three, it will help with their speech. It's exercising the tongue muscles the way it should be intended to be used. And it's also going to provide enough room for all the permanent teeth.

Diana: So, sometimes kids will have a habit, like thumb sucking, biting on their shirts, some of the kids…

Howard: Biting on their shirts?

Diana: Yeah, chewing on their shirts, biting on pencils. They might have sensory issues, they might be very anxious. They can't sit still in school. So, those types of behavior issues may lend to why are they anxious? And so, the other question is, are we putting them on medication to keep them to function during the day, or are we not addressing the root cause? Why is their body so noisy? Why can they not sit still in a chair during school hours or why do they feel tired during the day? Why are they drowsy all the time? Probably because they've got some type of restless sleep pattern during the night-time and for that child to experience that night after night, it could be affecting their brain development, as far as memory, computating, adding, subtracting, reading, hand-eye coordination in sports. So, those types of things are really affected by poor sleep.

Howard: You know, it's really, everybody always says “America’s the greatest country in the world”. Everybody that always says that you could always be guaranteed of one thing. They've never been to another country ever. I mean, if they think this is the greatest country in the world, you obviously don't [inaudible 06:13], you probably don't even have a passport. My friends in China, in Cambodia and Vietnam and the Netherlands… I mean, in America, I mean even on Dentaltown, dentists in America are offended because (do a search for breastfeeding on Dentaltown), because some lady’s out there breastfeeding in the waiting room and the same idiot would probably go to a Rambo movie where you have some not natural man-made AK 47 and shoot a hundred people and that didn't bother him at all. And this breastfeeding thing and is a huge component of it and the mothers feel embarrassed to walk around. I mean, we're mammals. We give live birth to young and we feed them. And, if you have a problem with any three of those, you're an alien.

Howard: Scandinavia, China… Asia has the least problem with it. I mean, you could literally breastfeed anywhere in Asia and then people just say, “Yeah, it's a mammal. She gave birth to a live young and she's feeding it”. And so, in America, because a lot of that, the first time the kid starts and doesn't seem to be going well, they whip it off and give it a thirst buster. So, now the kid’s not developing forces, he should be fighting on that thing for at least a year or two. And then when it goes to the food, they're feeding it mush. When, I'm sure, for the last 2 million years you've probably found some mastered on bone and said, “Here, chew on that for an hour”. And if you don't find anything on it, you'll be dead. So yeah, so the diet and the society consequence. I mean, Saudi Arabia just legalized women to drive and America thinks, “Well that's shocking”. It's like, “America, you still haven't even allowed women to feed their own live young outside of a closet”. I mean, it's crazy. Just very, very crazy. So, um, when you, when you got out in 1996, were they even talking about any of this back then?

Diana: No.

Howard: How many years ago is that, twenty-two?

Diana: Gosh, yeah, over twenty years.

Howard: So where did all this come out of?

Diana: Well, I think part of it is adult sleep apnea is such a billion-dollar industry and that receives a lot of attention. But at that point, as an adult, you're managing the sleep apnea. It's when we look at children, we have the power and the capability to correct and prevent that risk for that child ever getting to have sleep apnea as an adult. So, I think that's why people are starting to pay attention to it because it does make sense. If you look at adults with sleep apnea, they had breathing or airway issues as a child and I think when we can kind of help those children now, we're going to set them up for better success. We're going to set them up for, reduce risks of crowded teeth, we're going to help them breathe right during the day. We're going to help them function better at school.

Diana: It's something I think that needs to be looked at seriously. But as dental providers, because we have the ability to see them twice a year, they come in for a checkup. When kids go to the doctor, they're going them when they're sick and they're treating them for that ear infection. But how about that kid that gets that multiple ear infection, gets multiple recurrent strep? What's the reason why they're getting those conditions so often? Do they mouth-breathe predominantly is probably a question I would ask the provider. But, I think this is something that we can address and really make a profound difference because the kids are our future, right? We need to help them to be more successful some way. And, I think as dental providers, or even as a hygienist, if you catch them on and you see that they can't keep their tongue still and they keep on thrusting their tongue forward while you're trying to clean their teeth, there's something that needs to be looked at, like a tongue tie, you know?

Howard: Now, that's funny that you said tongue drag because I'm going back to this. When I got here in 1987, thirty years ago, the first thing I notice is that it didn't have water fluoridation. And so, I blocked off every Friday for over year and met with Jack Dillenberg, who was a dean of a dental school, and we set up theirs [inaudible 10:24] and I thought, I don't want to sit here and drill, fill, and bill, Monday through Friday for sixty years and not make a pile in the dent. It seemed like the obvious low hanging fruit is water fluoridation. And I am embarrassed on behalf of orthodontists that the only people talking about this is anthropologists, so, it's like you're afraid this is going to hurt your gazillion dollar business.

Howard: And, so back to the breastfeeding. I'm glad that all my daughters-in-law, when they gave birth to live young, that actually some lady walked in there and gave them an hour deal on breastfeeding. But now because of that, there's a huge surge of people saying, “I think your baby is tongue tied”. And so, the ones they send to me, I'm sending him to a pediatric dentist. It's like, all of a sudden, I'm not an expert on some six-month-old, whether it can nurse or not. And so, what do you think of that? Did you buy yourself a laser?

Diana: I did and for a long time I had a diode and I just recently got a gas laser. And it's a world of difference and we were talking, between from fifteen to twenty minutes with a diode, to five seconds with the gas laser.

Howard: So, is the gas carbon dioxide?

Diana: Yes.

Howard: Which one?

Diana: LightScalpel.

Howard: And who makes LightScalpel?

Diana: I think it’s the company, LightScalpel? Lux? Is it called Lux?

Howard: So, you got a LightScalpel carbon dioxide laser?

Diana: Yes, gas laser.

Howard: Everybody thinks I have a gas laser. But that gas is natural. So, you got a carbon dioxide, gas laser and used to have a diode. You said the day that would take?

Diana: Fifteen to twenty minutes and for a child, they can't sit still in your chair for fifteen, twenty minutes while you're holding their tongue. This five-second procedure really makes a big difference.

Howard: And what are you actually sizing?

Diana: What do you mean?

Howard: Is it under their tongue?

Diana: So, it depends. I go through a protocol to check range of motion. Usually, a parent will come in and tell me they've got some speech issues or they're working with speech therapist or they're predominantly mouth-breathing. And so, I'll usually check that. So, you know, what we learned in dental school, tongue tie is we’re looking for the heart shape tongue when they raised it to the roof of their mouth. There are a lot of kids out there that have a short frenum or they have a tongue restraint, like if you touch it, it feels like a guitar string, right? If they can't reach it to the roof of their palate more than 50%, most likely they're not nasal breathing at night. So, that's something that needs to be addressed. The question is, when you see that, do they have a retrognathic mandible? What does their profile look like? Do they have a road lower lip? Like what are some of the things as dentists, we know and that we're comfortable with looking at, could this be a cause? Do they have crowded lower teeth or how about the adults that had braces, they may have a relapse right there on the lower anterior teeth. So those types of things we really look at.

Howard: So, do you recommend that laser?

Diana: I do.

Howard: Would you still buy it again today?

Diana: I would.

Howard: Do you want to know how much it was?

Diana: It's around thirty to thirty-five thousand.

Howard: So, did you just buy it or did you do payments for five years?

Diana: Well, you know there are different programs. I did mine like a financing.

Howard: Do you remember what the payment was, per month?

Diana: It might've been like around six hundred.

Howard: And the reason I ask kids is because, a lot of times you'll look at a number on a balance sheet, like balancing what the asset, the equal sign balance with the liability over equity [inaudible 14:17]. And you'll say, this machine's thirty thousand. And well that doesn't mean anything. If you finance that and it was $600 a month, so you already have an asset. So, you have an asset that does a dollar a day and someone says, “I'll put this asset in there. It doesn't matter if it's ten, twenty, thirty thousand, but the payment was six hundred a month”. The question is, could you do six – you’d have to do $600 a month of billable procedures to break even – so, what procedures are you doing? I mean, did you do more than the payments, were they cash flow positive?

Diana: Yes. So, what we did was, we did like a laser day. So, I usually book it in the morning and we’ll have four or five patients. It's code for Lingual Frenectomy, it’s D-79-60. Some of that could be built through medical. So, that's something that you should look into as well.

Howard: D-79-60?

Diana: Yeah. Frenectomy or Frenulum Frenectomy, yeah. But a lot of dental insurances will cover that procedure code. It might be subject to their deductible, but what's great about that is you'll start to notice if somebody, if a child maybe had a reverse swallow or could not nasal breathe because they couldn't reach their tongue up to refer their mouth, you'll start to see some of that improve. Maybe they working with a speech therapist and they couldn't do certain functions. You'll see that improve right away. I've had a speech therapist call me and go, “Hey, I've been trying to get her to do that exercise for months. What did you do?” I go, “I did a frenectomy”. Because in that field, they don't have access to a laser, right? But I do recommend the gas laser overdrive because it dissipates less heat too.

Howard: Now, your practice is in Scottsdale?

Diana: Yes.

Howard: And that's where all the rich people live and I'm down here where all the poor people live in Phoenix. Just want to clear that out.

Diana: There's rich people with debt.

Howard: So, fake it till you make it?

Diana: Yeah, exactly.

Howard: First of all, what type of practice do you, I mean, is it a family practice?

Diana: It’s a general practice, but I treat a lot of children. We’re a Sleep and TMD Practice.

Howard: So, what percent of your practice would you say is sleep and TMD?

Diana: Right now, it's probably about 35%, it's getting higher.

Howard: It’s a huge edge.

Diana: Yes, it is.

Howard: Because it is an edge. Kudos to you, I mean to have a – it’s very competitive in Scottsdale – and to have a family practice, which focuses on kids with sleep and TMD.

Diana: Here's the thing. Moms talk.

Howard: Five to one over men, right?

Diana: That’s true.

Howard: I don’t want to interrupt you but there’s things that you have to realize, like late 80% of the people on YouTube are men, 80% on Tumblr are women. Whether you're talking about any of the apes or monkeys, every time a boy monkey ape says something, the girl said five words or sounds. So, they're talkers and they're very social. A boy would rather stare at YouTube and watch something for fifteen minutes, he doesn’t want to get on Facebook and interact, say “Hey, you know”, and he doesn't want to interact. He wants one-way conversation and I bet you so many times, I mean I had four boys, you had three boys, right? How many times did your boys come home and you wanted to talk to you about their day and they just wanted to go to their room and shut the door. I mean, what percent?

Diana: Very high percent.

Howard: So, you’re saying that moms are talkers and focusing on kids was a big practice builder.

Diana: Right, and I think because they're nurturers, if they had a good experience or they were struggling with something like that. Say they went to their doctor, they went to a chiropractor, they would here, here and here and nothing was working for them, and they come to me and we look at their airway and we improve their sleep and all those other things get better. They are definitely going to share that with their neighbors, with their family, on social media, at school, and I think that's what started it. Parents started talking. The other thing too is, it might seem too radical for some families, you know, “Why didn't my orthodontist tell me about that? How come I didn't hear about this from my dentist before?” And that's the thing, we didn't know about it back then and I think there are, there's room for dentists to be educated about pediatric airway now more than ever. It's just we have to be open to that idea. Just like when oral cancer…

Howard: I get what you really saying is, he probably practiced in Phoenix, didn’t he? That’s what they all say in Scottsdale. Trust me.

Diana: No, but I think it's really important to kind of look at that. Just give a benefit of the doubt. We didn't know about what we know now. They're all connected. That idea of integrated dentistry is really at the forefront of our profession now.

Howard: Well, it's funny you say that because, today the big buzzword is the oral systemic link. So, the dentists all think that’s a big buzzword. But my friends who do kidneys, that's her big buzzword. For years, they just stared at a kidney and now they're realizing all these other things are going on too. So, every specialist I know, that's their big thing now. I spent my whole life in a colon and now I realize it's connected to the [inaudible 19:39] bone, and the funny bone, and the head, and the teeth, and you know what I mean? So that's everybody's Eurekan healthcare now.

Diana: But, as dentists, I think we’re so focused on there's a cavity. Let me drill and fill it. Okay, we're done. But, I think if you see other signs, grinding, why is this five-year-old, look at the teeth, what's happening? You know, are they stressed? No. Kids that are five or not stressed, they're not sleeping well. So, that's like their body's way to deal with, I need airway. So, they're moving their jaw around left and right.

Howard: And this one kid, taught me how to answer that one, it's crazy and I shouldn't say it, but he's so small. He looks like use a dwarf and I'm looking and then the mom sitting there saying, “Well he's shorter than his cousins, who are three and four” And I'm looking at this kid on that deal and you know, I read the papers for it. Do you think not breathing at all can make you not optimally develop?

Diana: Exactly.

Howard: Do you believe that?

Diana: It affects the growth hormone? Yes, I absolutely believe that. I mean, my background in undergrad was microbiology. There's so many hormones that come into play that work with our system and our organs. When you don't have enough growth hormone secreted at night, every night, over a period of time, it's going to affect something. So, I'm a strong proponent for believing that yeah, your growth hormone may be affected.

Howard: So, you're saying you should just have Lance Armstrong pedal his bike over to your house every night? Give it a shot.

Diana: No, I think we should look at why is that child shorter than he should be. His dad’s pretty tall, his mom’s pretty tall. Genetically, should be a little bit taller at that age. So, I do feel like there's a strong link.

Howard: So, what's the other two thirds of your practice? If one third of it is children and sleep?

Diana: It’s regular dentistry. I’m a really big advocate for CEREC. I love CAD/CAM dentistry. I restore my own implant crowns, screw retained, custom abutments. I think that kind of technology, I think as a dentist, especially if you're a young dentist starting out, I wish that I had done all those education forums earlier. I mean, back in my day I did pack live and …

Howard: Pack Live with Warnberg?

Diana: Yeah, do you remember that? I'm dating and love that guy.

Howard: [inaudible 22:12] when it was just Larry Rosenthal and Bill Dickerson and David Warnberg.

Diana: So, I think as dentists, if you kind of keep at the forefront of the technology with [inaudible 22:20] up there, like we use oral id detection for oral cancer. ViziLite was one we used in the past too. So, there are different types of things that can separate you from other dental practices and so people love it when you're a one-stop shop, so to speak, right? When they can get all their services for themselves and their family and you could take care of them right then and there, I think if you offer them that, that is what's going to separate you from another dental practice.

Howard: When I got out of school thirty years ago, it was all amalgams and gold crowns and the cosmetic dentistry was a PFM. And then we went through the materials revolution. Like Den-Mat, these early companies [inaudible 23:06] and 3M, which then enabled the next cosmetic revolution. And then we're in the backyard of Intel and then the one is, the digital revolution. And what's funny by CEREC, which started in France and then they gave it up and then went to America. The problem was they had to wait until the process got bigger and bigger. I mean, when they knew everything they want to do, they were working with an intel two-eighty-six and the three-eighty-six. I had a CEREC One.

Diana: So, did I.

Howard: And tall handsome man in the scuffs, Sameer Puri, who's the world-renowned expert on that. I don't even know if he was in grammar school when I started. The problem wasn't CEREC, it was the processing speed and the processing speed really didn't get great enough, until like CEREC three, you know what I mean? So, that's that whole digital revolution film to digital [inaudible 24:06 actuaries or ice age?] Then I'd say, was the implant and sleep and so I was wondering, do you place implants?

Diana: I don't place them, I restore them.

Howard: But, tell the kid right there. So, you’re in our backyard. You live in Mesa, which has a dental school that graduates how many a year?

Howard: I think it's one seventy.

Diana: Wow.

Howard: Or Midwestern I think, is one seventy.

Diana: Midwestern is larger.

Howard: Try to find [inaudible 24:30] western because when I go lecture in those schools, those kids tell me, “I'm going to come out of school $350,000 net. Unless you’re Mormon, and then it's like I'm already married, have a kid and it's four hundred thousand and that. So, they're looking at the CEREC machine, which is a big chunk of change. So, what would you tell a kid if he said, “I'm worried about debt. I got four hundred thousand in debt and you're telling me to buy a machine that cost, how much?”

Diana: Yeah, one fifty.

Howard: So, what would you tell them?

Diana: I would tell them to meet with your accountant, have a business plan and see if it makes sense to do it now or wait till later, but that's where I think sleep and TMD is something that doesn't have a lot of high overhead. It's just like a lab bill, into investigate some of those services that as a young dentist you could start doing. Technology's expensive, but it's an investment. It's an investment and allowing you to do your work flow better, to do what you do daily, better. So, if you are that type of dentist that you can do Cera crowns, you like that kind of technology, I would say go for it because that's why I bought a laser. I figured out what I needed to do, what the payment was, so that I can incorporate it with the practice.

Howard: Midwestern class size in Glendale, Arizona is one hundred and forty-one and AT still, is seventy-six.

Diana: It’s a lot of dentists.

Howard: Ryan, can you add those two number together, that would be two hundred and seventeen. I believe you're in the most competitive area.

Diana: Oh yeah, I am.

Howard: So, what would you tell a kid that was coming from Midwestern, you’d go, two hundred and seventeen kids say, “You know, I'm going to go to North Scottsdale. That's the greatest place to go”.

Diana: I would tell them to think twice, to think three times, to think four times about it, because I think there are other areas in Arizona that they could benefit from.

Howard: And where do you think those are?

Diana: You know, there's some pockets I think where the growth is. I mean, it looks like Chandler's a growing area. Am I right? I think Gilbert’s saturated already.

Howard: How rock bottom would you have to go to live in Chandler? Wouldn’t you just move under a bridge and live in a box first.

Howard: You know, the big boogeyman in dentistry that everybody hates is Pew Research, which I love Pew Research because dentistry is not even a fraction of what they do. Most of its environmental stuff in the ocean. Fish, size of the tuna, you know, I love Pew, but Pew does the research for every state because they're a big proponent of dental therapists, just like physicians.

Diana: That's a big topic now.

Howard: Oh, its huge. Well, it's actually two issues. I want to talk about one first. One is dental therapists. That's a whole other issue, but what I like is that they've done the research, they've done the demographics of every single state. Like you go to Pew Research, go to Arizona, and you can see every county from dentists for thousand, cities with none. And so, you're in AT still, I mean when I got out of school thirty years ago, you know how hard it was to do demographics. If I just told someone, “What is the number of dentists per patient and in San Diego”. God, you’d have to go sit in the city library for a week. You'd be opening up the yellow pages.

Diana: Now, there are no yellow pages, they online.

Howard: And, now you have Pew Research cranks this stuff out. I mean, I knew kids and what's really interesting with student loans is the highest default rate is with the lowest amount of [inaudible 28:18] and by the time you're over $100,000 in student loan debt, the default rate’s almost none. And so, who's the only person watching demographics? The people over four hundred to five hundred, so they're in so damn much debt. They're like, okay, I already got an F in student loan debt, I better get an A in demographics and they're usually the ones in school who got married, had kids. For whatever reason, they already blew half a million dollars before they got out.

Howard: So, they'll find these cities with no dentists, with six thousand people in the county, set their own fees, take no Medicaid, no [inaudible 28:57], no nothing, charging fees higher than you are in hootie tootie Scottsdale, with no insurance cash at the door. And the first year, they'll do a million and take home four hundred thousand.

Diana: And that would be my advice is, they'd really have to research the demographic data. Yeah, so I think that that's really important too, especially if you're thinking about opening your own practice. Unless, you were going in with somebody who was phasing out, that would be a different story, the patient base is already there. But yeah, I wish I had that resource when I got out.

Howard: And you know how you make the older dentists phase out faster?

Diana: How?

Howard: You start crushing glass with a roller and making meatloaf and bringing in [inaudible 29:35], “I made you lunch today. Last night, I stayed up and made you this meatloaf, potatoes”.

Howard: The dental therapist side. Okay, this happened to me a lot, you know, I raised four boys. You don't want to go the emergency room, so you go to Walgreens because they fell down, they broke something, whatever. And you go in there and they don't have an MD and it's not a registered nurse. It's halfway in the middle. It's a PA, it's a PA. And they're saying, so dentistry needs that. What are your thoughts on that?

Diana: You know, I've listened to both sides of that and as a clinician I can see where the concern is. But, on the other end of the spectrum that there's a need and how many people would go out there and serve those people and jump to do that is really scarce too. So, I think that there's a happy medium where we can meet in the middle, but if there's a need in Arizona, it can afford to have those therapists as long as it's regulated in the right proper way. I don't see a problem with it, but I don't know where they are as far as setting those regulations and certain procedures. How are we going to regulate that? I know they've done them in other states and some have been successful with it and some have not. What's your opinion on that?

Howard: Well, my townies in other states, you know, it's kind of the same really all over, like, you go back to Bob Barker days in the seventies and everybody thought hygienists was going to ruin the profession. And, soon as they got them and they realize they never wanted to do a cleaning again, let her do them. So, my buddies and the stage dental therapists, I go, “oh my God, I'm hiring these and I've never doing my fillings again”. So now they got the hygienists doing the cleaning, the dental therapists doing their fillings and they're just concentrating on everything else. So, they all love him. Now what did Pew want? They thought, well, we get a hold of these dental therapists, they'll go into the far reaches of the woods.

Diana: And they didn't.

Howard: And they didn’t and that’s because the deans, all except for ours, AT. Still, Jack Dillenberg pioneered it. He's the only one who did it. Everybody in this state threw him under a bus and said he was a hippie. He was a New York hippie. It's like, “Dude, hippies are from Berkeley, you need to get the coast right”. You know what I mean? But he said the problem with all the dental schools, they pick all these people with the highest grades in Calculus and Physics and Math and where do they go? Wherever they came from. And he said, if you want people to go to rural then just accept kids from the rural. But all the dental schools won't because the little farm town girl might have only had a three two. So, they'll take the four-point-0 check who grew up in downtown Scottsdale. I'll say one final answer and its case closed. All the white deans of all the white dental schools couldn't believe nobody would go the Indian reservations.

Howard: And Jack said, “I got an idea”. Why did you just accept a bunch of kids from the Indian reservation? Well, the kids from the Indian reservation might not have got into the dental schools. But guess what? The Navajo Indian reservation is loving that every year that Jack was dean. I mean, we have what, eighteen, I mean how many, how many reservations in the United States? Like two hundred and twenty, or something like that. And Jack was out there saying, and they're still doing it because they want to make the top rank, you know, UAP as a higher freshmen class, grade point average than USC, and that elitist means little kids get no dental care in rural areas, poor areas, Indian reservations. And Jack was the one that everybody said he was full of crap, that all of his kids would just come into Phoenix. Well, if you're from the Navajo Indian reservation, where do you think you want to live?

Diana: Right there in their Navajo reservation.

Howard: My God, I mean Jack, he was such a pioneer and it was really tough to watch him get thrown under a bus and beat up so many times so bad. But, it's true. So, if Pew wants to spend any money, they should be giving debt forgiveness to kids who go to these places. But, that kid going to that place isn't going to be happy because where's he going to be happy? Wherever his live birth mammal mother gave birth to him.

Diana: So, there's a dilemma here. There’s problem there, how those people going to get served. I don’t know.

Howard: And, what's really sad is, half of America lives in one hundred and forty-seven metros and the other half live in nineteen thousand and eight towns. Well that means, those half pays half the tax bill, but all the universities are in the cities and they only then get city folks. There’s like, the rural pays for half the bill and they don't even get a third of the assets really. I mean, if they're going to build a museum, is it going to be in rural? Yeah, so everybody in rural pays half the bills and then all those universities just accept the people you know, in the urban.

Diana: Well, you know there’s a growing problem with having dentists commissioned to work in the Indian reservations. It’s all [inaudible 35:05].

Howard: Yeah, but that’s even another problem. I've gone up there a lot, to the city. Do you think a Navajo who doesn't speak a word of English once this white cracker to work on them?

Diana: No.

Howard: No. I mean, it’s the same thing with women. Do you think a woman wants to go to a male gynecologist, like me?

Diana: Probably not.

Howard: Yeah. I mean people are tribal and I couldn't imagine being in like, say I was in Iran and I need a root canal. And they said, “Well, everyone's Persian, they speak Farsi, but there's one Persian and he's clear on the other side of town, but he speaks fluent English”. Well, where would I want to go? To that guy. So, I don't think the Navajo don't want to have dentists that don't speak their language. But anyway, we're on so many different subjects. So, when you say you restore implants at sixty months, 20% have peri-implantitis. Are you doing any laser therapy? Are you using laser on any peri-implantitis?

Diana: I do. I work closely with our periodontist, especially with the group that place the implant for us.

Howard: What group’s that?

Diana: AZPerio.

Howard: With Ralph?

Diana: With Ralph and Steve and Dirk. Yeah and Holly.

Howard: I love Ralph. You know, he has over six thousand posts on Dentaltown.

Diana: Really? Kudos to Ralph. But yeah, I think that when you have a good…

Howard: And he owes me. You know why?

Diana: Why?

Howard: Do you know who his wife is?

Diana: Yes.

Howard: He stole her from me. She was my hygienist. She worked for me. Ralph stole my hygienist and married her.

Diana: They have a family now.

Howard: Can I sue him?

Diana: No.

Howard: Okay.

Diana: Yeah, he’s got a kid now.

Howard: So, when you get peri-implantitis, you send it to Ralph, you don’t use your laser?

Diana: A lot of our implant patients, if they have more than one implant, we try to keep them on a strict hygiene re-care. So, whether they come in, instead of every six, we might see them every four, especially as they get older. There are certain things that I think you have to train your patients on the dental work that they have invested in and how to take care of it. Because for the longest time, I remember, people thought when they had a crown, the tooth’s covered, I don't have to floss there. And I tell them, you have to floss even more that you have a crown, your body recognizes it as foreign.

Howard: So, let me ask you this, your undergraduate degree was in?

Diana: Microbiology.

Howard: Microbiology. The New York Times pissed off every dentist in North America when they ran the article that there was no research on floss. And then, the dentist had a rude awakening when they went to PubMed and found out there were five thousand two hundred PubMed’s on why you should fluoridate the water, but there were none on why you should floss. There was none. And now it seems like a lot of the most exciting breakthrough research is that when I look at you, I see ten million cells that you got from your mom and dad, but in your thirty-foot digestive organ from your mouth to your rectum is a hundred trillion cells. And NYU, their Dental School just got a $2.2 million grant tying gut microbiome to periodontal disease. And almost everything I turn around they're like, wow.

Howard: I was reading one the other day, this caused type, was highly linked to type two diabetes. This was linked to periodontal disease. And then when you start reading the most common transplant on earth, is not a kidney or lung, but it's a fecal matter transplant and I mean, that is some amazing stuff.

Diana: I didn’t read that.

Howard: It is amazing. You can have twin mice and one has a disease and one doesn't and fecal matter transplant and this one cure’s the disease and the FDA has already approved it for one disease in America.

Diana: Okay.

Howard: And you got a heavy background in that. So, I've always thought because do you agree or disagree with this, if they have a mouthful of cavities, they don't have gum disease? If they have a mouthful of gum disease, they don't have ten cavities.

Diana: Yeah. I think that the gut biome is really linked to all this.

Howard: That [inaudible 39:41] tube is all one piece.

Diana: Yeah. Now, I've been reading more and more about that and there's a book too, I think, by Steven Lin, The Dental Diet.

Howard: Right, we have it on the shelf. I got it right in that room over there. In fact, Ryan, go get that book. Steven Lin, The Dental Diet. [inaudible 39:56] My Australian buddy, Steve Lin. He'll love you for that. Did you read the book?

Diana: Not yet.

Howard: Do you have the book?

Diana: No, you’re going to give it to me?

Howard: I’m going to autograph, I'm going to forge Steve Lin’s name.

Diana: Okay. No, there's some truth to that. I mean all of that makes sense. I mean, isn't that coming full circle?

Howard: Some of it where you think, oh, well, you know, they're eating crackers. Here's, The Dental Diet by Dr Steven Lin who lives in Australia, where my brother gave up on America and moved to Australia and he loves it. But you know what, whenever you say, “Oh, that candy or that sugar brush supply [inaudible 40:33], it might be that the cracker, and the candy, and the sugar is going into the gut, and different bacteria that live off sugar are very different than ones that live off say, greens or pork (or in my case, Cheetos and Mountain Dew), so know it's very amazing. What do want Steve Lin to say to you?

Diana: Steve Lin, I want him to say…

Howard: “Dear Diana, you are the best dentist on earth. I wish I could be half as good as you. Love Steve or Steven Lin, and Howard too”.

Howard: Did you read my book? Yes, I did. Yes.

Diana: I'm very excited that you and I are thinking on the same wavelength here.

Howard: You say you restore implants at sixty months 20% peri-implantitis, at nine to fourteen months, it's 40-60% and what I see in the future, is two things. A lot of people believe that it's the titanium and they're not seeing it with the zirconium implants. But, the people treating peri-implantitis or mostly doing like Lanap lasers. Is Ralph using Lanap or is he treating peri-implantitis with lasers?

Diana: I don’t know. I know that he does treat, but I don’t know what he’s using.

Howard: Do you talk to him much?

Diana: I just talked to him last week.

Howard: Tell him to come on the show and answer that question.

Diana: Okay.

Howard: But get them to come on the show and answer that question. Tell him you made the pilgrimage all the way to the poor part of town.

Diana: This is not a poor part of town, by the way.

Howard: Just tell him to go down to where Mother Teresa of Calcutta treated the poor and then I'm like two blocks south.

Diana: No, I think that that really needs to be addressed because more and more people are getting implants now. Overdoing three unit bridges or they're doing All-On-Fours instead of the traditional denture. So, I think we really need to hone in on how to take care of those restorations.

Howard: So, when I called you, you said wrong number and hung up and I had to call you back three more times. You wrote an amazing article in Dentaltown, Sleep, Breathing and Children by Dr Diana Batoon. Do you remember writing that?

Diana: Yes, I do.

Howard: And tell them why they should go on Dentaltown. And one of the [inaudible 43:27] magazine and tell them what month and year was that.

Diana: This was February of 2018. But I think it's really important for everybody to read this. Not only because Dentaltown's online, but it's a great way for you to find information of something that is important to look at your pediatric patients and we're talking about eighteen and younger, taking a look at these kids in a different way. And you know, with the new verbiage or the statement from the ADA, their position on sleep apnea, they're holding dentists to be looking at evaluating children for sleep issues. We can't diagnose sleep apnea, but we can help evaluate for that.

Howard: We're getting close though?

Diana: Yeah, we are. I mean there's a lot of reasons, as a dentist, how you can help identify that, but it's a starting point. I think if we start to screen for these children, the same way we're screening for oral cancer, we're going to be way ahead of the game. We're going to be saving lives. We're going to be making a lot of change, you know, and the growth and development of children. So, yeah.

Howard: Okay. So, it seems like you can't listen to someone talk about sleep apnea that isn't also talking about medical insurance billing. It is that, is that extra noise and confusion? Is that a big part? Do bill much with medical or not really?

Diana: Okay. So, if there's a medical condition, that's the hard part about medical billing for children, they have to be really sick or have had multiple cranial surgeries, maybe a cleft palate, cleft lip. There are different services out there that can help you determine if you'll have a good chance of being able to bill for some of this. The problem is medical billing is a different beast than dental billing and you might not get reimbursed for anywhere for four to six months. It could be longer. And as dentists, we're not used to that. We’re used to doing a procedure, we get reimbursed within a reasonable amount of time, two to four weeks, right? It's a different beast and it's more work for your staff. So, that means you have to invest in software maybe, that can help all medical billing for sleep apnea requires soap notes, requires documentation, proper x-rays maybe. Nowadays, a comb beam might be helpful if it's warranted. But, there are different types of documentation that really the dentist has to provide. And if you're missing one of those pieces, your claim will get kicked back, denied and longer to get reimbursed.

Howard: So, what percent of your practice is medical billing, would you say negligent?

Diana: Yeah, I think it's small. It's getting more and more because a lot of dental insurances don't cover TMD. If it's sleep apnea and you have a diagnosis, we usually build that through medical because it's a medical condition.

Howard: So, I also noticed you lecture for Ortho-Tain. Does that name come from Ortho entertainment, ortho-tainment. Now, what is the ‘Tain’ in Ortho-Tain?

Diana: Sure. Well, Ortho-Tain is a parent company for a system called The Healthy Start. And The Healthy Start system is functional appliance system that is comprised of different types of appliances depending on the age of the child, the arch width, whether they're like a pseudo class three, because you can correct that, if they're a pseudo class three. And if you catch it earlier on, you'll help correct that condition and hopefully put them into a class one malocclusion. The other thing that it does, is it helps guide permanent teeth into an ideal overbite and overjet. So, some of their functional appliances can actually help prevent and stop grinding that children are doing at night or correct the thumb sucking, and other habits, oral habits that they may have, finger sucking or things, types of things.

Howard: And how did you find these? Were they in Winnetka, Illinois?

Diana: Yeah, Illinois near Chicago. And the founder actually is Dr Earl Bergerson, who is a certified orthodontist, so board-certified orthodontist. So, his appliances are actually very well thought out. There's research behind it. I went to Tufts and their Pediatric and Ortho Department, they used a lot of their functional appliances.

Howard: What the guy's name?

Diana: Earl Bergersen.

Howard: So, Earl, I'm sure he goes by a bigger role.

Diana: Dr B, they call him Dr B.

Howard: So, basically then he's done an innovation, you feel it's different?

Diana: Yeah, because number one, their appliances are ISO certified and FDA cleared. That's really a big deal for me in my practice. I don't want my patients choking on material, right? So, it's not a choking hazard if they have to go through those certifications and it's gone through a lot of research. They have, in their appliances, and I'm sorry I didn't bring one today, but they have pads to close like an anterior open bite. There are different things that are developed into those appliances and they help to train the tongue to be up in the right position so that we're nasal breathing. It corrects a tongue thrust for a child so that they’re not thrusting their tongue forward, causing an anterior open bite. So, a lot of times you might see an older child that had phase one and phase two Ortho and then they end up with an anterior open bite. It’s because nobody corrected their mouth breathing and maybe they had a tongue tie.

Howard: So, you have two different websites. You have momentumdentistry.com.

Diana: Yes.

Howard: And you have Bonitadental.com. Why do you have two websites? What's the difference?

Diana: Well, part of me being an educator as I speak, and so my momentum dentistry that [inaudible 50:00] is my speaking website and that's where I talk about technology, CEREC, talk about sleep apnea, and adults, and children. And also, I'm developing a lecture series for the young dentist ten years and under.

Howard: And you're developing a lecture series because you were in the ADA young speakers.

Diana: New and emerging speakers. So hopefully, that'll be coming around the corner and I'll help develop that to help younger dentists.

Howard: That course is going to be online on your website?

Diana: I’m hoping to do it online with you guys. And then we're developing a series, I worked with Lois Spann [inaudible 50:42], so we'll start working on developing a series of lectures for you.

Howard: And why did, why did you pick Lois?

Diana: Because she knows her stuff.

Howard: She does. I love Lois.

Diana: She's very genuine. Hey Lois! She's a very great mentor. She's all about paying it forward and helping people and I think that's how I feel too. I think there are some people in the dental industry that really like to help our colleagues because I don't want people to go through the hardships that I had and if I could tell them something that'll help them, we need to do that in our profession. Remember, you said we're tribal.

Howard: Yeah, every animal is. I mean, I love watching on YouTube where you'll see like a pride of lions and some girls pride gets trashed so she tries to join the other pride. They killed her. It's like people are tribal, whether it’s a lion, tiger, whatever. It’s crazy. Why did you go with Momentum Dentistry instead of Angular Momentum?

Diana: Well, because dentistry is ever-changing, right? And you kind of have to move with the flow. You can't get stuck in thinking old ways. You have to be open. Like back when I started my practice, I didn't have to advertise on social media, it was just my patient told her neighbor. And now I think all dental practices, you have to have some type of social media presence to survive.

Howard: So now, this is dentistry uncensored. I saved the ugly till the very end. I've always been sensitive to sexism because I grew up with five sisters and we were within a hundred yards of the Kansas River and I could fish and swim in the river, but my sisters couldn't go within ten feet of the edge. They were paranoid if they got off the yard, but I could leave for a day. I remember when I graduated high school in 1980, Margaret Thatcher became the first woman Prime Minister of the United Kingdom. And even the priests were saying, “What the hell would they do that for?” And, it's like every male adult in Kansas thought that England’s flushed themselves down the toilet. And then all through college, I watched her to become one of the greatest prime ministers. And when I was a little boy and I fell in love with dentistry because my next-door neighbor, Kitty Anderson said “Dentist? I never saw a girl dentist in my life”.

Howard: So, now fast forward thirty years, every dental school is half women. Half a Britain would rather have women, Margaret Thatcher back than the one they got now. But I still see a lot of sexism. I still see a woman dentist and she’s married to a man and they both have a long exhausting day. And the dad grabs a beer and watches ESPN in the lazy boy while he's snoring and the mom's like, “I still got to do all the cooking, cleaning. I had to do all that”. Where you’re sitting now, twice I've had a woman ball so hard she could barely talk because after building a practice as great as yours, her husband making $75,000 a year, he gets transferred to where he's going to make eighty. But, he gets a bigger title and he's like, “Come on, Honey, let's go”, and he's like, “I'm going”. So, she looks at her little boys and says, “Do I blow up the family because this freakin Neanderthal Cro Magnon Peking Man, is that tribal male dominant dumb”. What's it like being a supermom? Because you're a woman dentist who owns her own business, and you're married, and you got three kids and I can't talk about that because I have a baby maker.

Diana: Thanks for asking because you have a lot of women viewers. It's not easy. You know, we're there nurturing a family, but behind a strong woman there's a strong man and I have to say a lot of how I'm able to do what I want to do is my husband's very supportive of that. My kids are very understanding about it.

Howard: Are your kids all boys?

Diana: Yeah.

Howard: Do you think it makes it easier to be a woman dentist if all your kids are boys or not really?

Diana: Not really. They don't like to do dishes. We're getting there, we're training them, they’ll be there. But, I think it's core values, you know, like if you set the expectation in the stage, like I can't do this all by myself. Your family has to chime in, they'll learn to help you. And then just to be able to be appreciative of that, to show them that you're thankful for doing that. We're a very faith-based family so when we go through hard times, we're going through it together. When we have good times, we are going through it together. But I think having like a vision, a focus of where you want to be. So, I've done a lot in dentistry already so that's why I want to educate more and speak more because I feel like I had a great time doing dentistry. I love my patients. I don't want to give that up, but yet I want to help more people in a different way. So, if it's in my profession, I think that's great, but keeping my family unit together is also part of that communication. Like when we don't agree with something, we have to talk about it. We have to sit down and talk about it. And my boys, [inaudible 56:22] don't necessarily want to talk it with women. We want to, I need to talk to you, this is what's bothering me now.

Howard: So, you believe that's true? You don't believe that sexist? You believe that's true?

Diana: I think it's finding the balance.

Howard: There is some data. I mean, 80% of people on YouTube are boys. Yes, 80 percent on Tumblr are girls. I mean, you do believe that women want to talk about it more and men want to go in the bat cave and shut the door?

Diana: So, then as a woman, I connect with other women who are business owners or who are dentists so that I have a place to vent, get my fill, feel supportive, right? Because maybe my husband isn't, or my kids, they don't want to listen to me then a little bit, but having that knit group, I think that's where study clubs come into play. Having other female dentists that you network with, like your meetings are a great venue for that. Your Dentaltown meeting, annual meeting, volunteer activities, those types of things, but also the online forum that you have. So, when people comment, we're all helping each other.

Howard: I have Dentaltown, you should start Women Dentaltown. I’m not even kidding you. I would take all of Dentaltown, cut and paste it, call is Women Dentaltown and give it to you. But I want to ask you, I want to ask you a bigger question because this is what they're struggling with AT Still. She's sitting here saying, “I got all these mixed emotions. I'm going to graduate at AT Still or Midwestern. I'm going to be a dentist and I'm going to have a practice just like you in Scottsdale. She’s got that dream. But then her biology saying, “Yeah, but I want to marry some stupid Neanderthal and drop a couple of frogs”. Here's the exact question. Is it easier to marry a Neanderthal Caveman, drop two kids, and just work for Heartland? So, I don't have to worry about any of the business. I just go in there and do my Monday through Friday, eight to five, at [inaudible 58:28] Heartland. Any DSO or would marrying a caveman and dropping two frogs be easier and a better idea if I own my own business because if she owned her because that's what keeps you up at night. What's the better strategy?

Diana: I think it depends on the personality of that woman dentist because I have a lot of friends who they're driven, they're ambitious like me and we all own our own practice and we manage. We take vacations with our family, we do our CE, we sometimes we bring our families to our CE, but then there's that other side of my friends who they don't want the business side of it. Then they'll work for somebody else, leave it at the door and they're fine with that. Or work only two days a week, three days a week. I think it depends on the personality of that women dentist, because there's room for two types of women dentists. But if you are in the wrong one, that's why I feel like women are struggling. They're taking Lexapro or different types of anxiety…

Howard: It’s crazy to say that all women would want the same thing. I get offended when people say that all Irish are alcoholics. I'm 100% Irish, only 38% of Irish are alcoholics. So, it’s very racist to say we’re all alcoholics, when it's only 38%. So, give her a litmus test. She's listening to you on the way home. How does she know at twenty-two whether she's cut out for my own business or lead that it? What questions could she be hearing right now from you?

Diana: Well, how much free time do you want? How much do you want to earn? What's your typical work schedule look like? How much do you want to invest in continuing education to boost your knowledge, those types of things, because those are all investments. Those are all time-dependent things. So, I failed a couple of things, so then I realized that I don't want to go down that route or I don't want to do this. So, sometimes we have to find out the hard way, right? The way that you succeed is you fail a little bit to figure out, oh, that didn't work for me, then I'm going to try something else. But I think having good mentors, like me talking to you, or talking with people who are in the same profession, who have succeeded at it, who have failed at certain things, they'll share their experiences with you. Having a mentor or coach to kind of help you think out your thoughts is really helpful.

Howard: And what if she wanted to contact you?

Diana: Any woman dentist can contact me at my email.

Howard: Are you going to give it out now?

Diana: Yeah, I'll give it out now. My email is Bonitodental@gmail.com.

Howard: And what is Bonita?

Diana: Well, it means pretty in Spanish.

Howard: Does it? Its bonitadental@gmail.com. And what about your website?

Diana: Our website is Bonitadental.com

Howard: That’s your dental practice?

Diana: Yes.

Howard: But if she wanted to contact you about personal stuff or having you lecture?

Diana: Yeah, momentumdentistry.com

Howard: Momentumdentistry.com? You got a contact there.

Diana: Yes. You could email me through that website.

Howard: So, that’s a Spanish name. Do you speak much Spanish?

Diana: I understand it really well. I understand a lot of languages

Howard: I’m across from the Guadalupe Indian reservation. There’s twenty-five thousand Spanish speaking people over there with no dentist and I don't speak a word of Spanish but I do know over the years, I can understand. Like, I know my name in Spanish, I know what Howard is in Spanish.

Diana: What is it?

Howard: They always say Gordo cracker. Did I get it right?

Diana: Not quite, but we’ll go with that.

Howard: Hey seriously, it was a huge honor for me to come over. Your teenage boys are gorgeous and adorable and so well-behaved. And, thank you so much for writing an article on Dentaltown. I really hope you contact Howard Goldstein and build us an online course because everything that you're a master in, didn't even exist ten years ago and I've been doing it thirty, so congratulations on being a pioneer.

Diana: Thank you.



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