Dentistry Uncensored with Howard Farran
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1042 Screening for Sleep Disordered Breathing with Mark Burhenne, DDS : Dentistry Uncensored with Howard Farran

1042 Screening for Sleep Disordered Breathing with Mark Burhenne, DDS : Dentistry Uncensored with Howard Farran

6/1/2018 9:50:45 AM   |   Comments: 0   |   Views: 182

1042 Screening for Sleep Disordered Breathing with Mark Burhenne, DDS : Dentistry Uncensored with Howard Farran

Dr. Mark Burhenne is a bestselling author and family dentist who has been in private practice 30 years. His focus is preventative and functional care with patients who come to him from all over the world. He received his degree from the Dugoni School of Dentistry in San Francisco and is a member of the American Academy of Dental Sleep Medicine and American Academy of Sleep Medicine. He is a TEDx speaker and his advice regularly appears on NPR, CNN, Prevention, Men's Health, and MindBodyGreen, and national television. He is the author of AsktheDentist.com, co-founded with his daughter in 2010. Dr. Burhenne believes that the mouth is the gateway to health in the rest of the body. His blog AsktheDentist.com is dedicated to helping people beyond the scope of his practice. He wrote the Amazon bestseller The 8 Hour Sleep Paradox: How We Are Sleeping Our Way to Fatigue, Disease and Unhappiness for his - and your patients - after experiencing the the disconnect between the medical profession and diagnosing and treating sleep disorders.  Personal Interests are mountain biking, skiing, photography, family, preventative medicine, natural health, nutrition, health education. He is most often referred to as Dr. B by his patients.



VIDEO - DUwHF #1042 - Mark Burhenne





AUDIO - DUwHF #1042 - Mark Burhenne



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1042 Screening for Sleep Disordered Breathing with Mark Burhenne, DDS : Dentistry Uncensored with Howard Farran

Howard: It's just a huge, huge honor for me today to be podcast interviewing Dr. Mark Burhenne at DDS. He's a bestselling author and family dentist who has been in private practice thirty years. His focus is preventative and functional care with patients who come to him from all over the world. He received his degrees from the Dugoni School of Dentistry in San Francisco and is a member of the American Academy of Dental Sleep Medicine and American Academy of Sleep Medicine. He is a TEDx speaker, and his advice regularly appears on NPR, CNN, Prevention, Men's Health and MindBodyGreen and national television. He is the author of AsktheDentist.com, cofounder with his daughter in 2010. Dr Burhenne believes that the mouth is the gateway to health of the rest of the body. His blog, AsktheDentist.com is dedicated to helping people beyond the scope of his practice. He wrote the Amazon bestseller, “The 8 Hour Sleep Paradox: how we are sleeping our way to fatigue, disease, unhappiness for his and your patients, and after experiencing the disconnect between the medical professional and diagnosing and treating sleep disorders. Personal interests are mountain biking, skiing, photography, family, preventive medicine, natural health, nutrition, health education. He is most often referred to as Dr. B by his patients. Dr B, seriously, I am so impressed by your AsktheDentist.com, that's why I asked you to come on the show. Even as a dentist, I can stay ten hours on that site, just reading articles. Job well done and you probably do more marketing for dentistry than any individual dentist I know.

Mark: Well that last sentence I really like. That's what we're trying to do. Thank you, and coming from you Howard, thank you. That's our intent.

Howard: Well a rising ship lifts all tides. I remember when Clear Choice came into Phoenix here and a lot of the oral surgeons and periodontists were all nervous that they were going to steal a lot of their business. All they did is a gazillion dollars to television advertising. I've had more patients ask me about dental implants since Clear Choice got here, and that's what they always say, a rising tide lifts all ships and man, you are a B to C educator.

Mark: Good. Well that's the definition of doctor, isn't it? It's the Latin root of the verb to teach.

Howard: Absolutely. So how did this journey start? What was going on in your mind in 2010, eight years ago, when you decided you were going to start AsktheDentist.com?

Mark: Right. It's a good question. I actually had another website before that, before I even had Catherine, my oldest daughter who's helped me found and create AsktheDentist.com and that was called thevirtual-dentist.com, and that was something I did on my own. That was back in the nineties. I've always been intrigued by the web; it's a great funnel. It's a great mouthpiece for getting information out and I like talking to my patients, but sometimes you want to go beyond that. You want to reach out to a lot more people. The web is the best thing for that. And of course now it's huge. The exposure, if you have a website that reaches out to millions of readers a month you can certainly make a difference. And again, doctor is an educator first and then a healer.

Howard: You and I both graduated in 1987 even though you look about ten years younger than me; you must have some good clean living out there in Silicon Valley. Do you prefer to go by Mark or Dr B? 

Mark: Mark. Mark's fine.

Howard: When I read your book, The 8 Hour Sleep Paradox, which you can get on Amazon, I don't think anyone even mentioned those words when I graduated in '87. I don't even think it was a concept. By the way, I don't know anybody in dentistry who wrote a book. The 8 Hour Sleep Paradox, all your reviews are five star and you have a hundred of them. My gosh, you must come from a very big family and have a very big family reunion to get one hundred.

Mark: We tried that. We've got a few reviews on there, but we had one bad review. The book binding was off; that's Amazon's fault. So thank you.

Howard: Did I go to the wrong dental school? In UMKC did they ever teach you about sleep apnea in Dugoni when you were back there? 

Mark: No.

Howard: When did this become a thing?

Mark: Well for me personally or? It's not a thing. 

Howard: When did it become in the public's mind? I mean, when did you hear about it first? I mean, we didn't hear about it in 87.

Mark: No we didn't. And it's not in the curriculum. When I go to dental schools now and ask them, essentially the reply's the same: the curriculum is full, there's no more room for anything else. For me, it was when we dropped off my oldest daughter at college, we were in the same room, hotel room, my three daughters and I literally woke up with them bumping elbows into my face, telling me that I was snoring and I was noisy. The short story is it turned out to be my wife, but I had no idea about sleep apnea. My parents had it, they didn't know, it runs in the family. It was a personal experience before it became known to me and I think that's how we learn these things. That's how we become good learners is if it affects us, then we absorb everything we possibly can. I had to learn it on my own. The dental curriculum is weak and now you're seeing it in continuing education and you've got the AADSM, which is a wonderful organization and I think that's where I learned most of my information on sleep apnea. That really changed my world and of course, treating my wife who was my first patient, she had an AHI score of thirty-four and a half and we got that down to zero and that was with an oral appliance. This was sitting under my nose the whole time: a Herbst appliance. First time I heard Herbst was in the orthodontic curriculum. That's what it was. It was a device to help class two patients, but now it helps open up the airway and bruxism. I was always very keen on bruxism. That always fascinated me and frustrated me at the same time because I never thought stress was the modality or the etiology for it, especially in kids. So when I heard that connection of trying to keep the airway open by bruxing, sleep bruxism, grinding at night that was a big tipping point for me.

Howard: So podcasters tend to be young. Guys like you and me, we read a bunch of books. By the way, is your book available on audio?

Mark: It is not, and we've had that request and I think we're going to do that. Would you like to be the reader for it?

Howard: Absolutely. I'll tell you what, seriously, I was listening to Jeff Bezos couple of years ago and I keep it out my book and he said that he wasted a billion dollars in ten years because he had an inventory problem with books because when you come out of the book, he doesn't know if he's [inaudible 07:16] a thousand, five thousand, a million and he has these warehouses and the more books he sold, the bigger his warehouses were. So he wanted this one size fit all print to order book machine, took him a decade, a billion and he said, damn it, by the time it was all right. That's why when you go to those bookstores, they're all the same size. It's because of that. And he said, by the time he got it all done, the whole market went to digital, Kindle and audiobook. And I put my book up there and gosh, Ryan made me sit down one day for five and a half hours and just sit there and read my own book and it's 90% of sales. Just like this podcast. People are going an hour commute and they're listening to audiobooks and.

Mark: That's the key word right there. We're sitting a lot in our cars or walking for exercise, we have a lot of downtime where we're moving and, that's the perfect time. I mean, I'm an audible book club member. When I drive, I'm listening to books and podcasts and that's the way we get information now. Written word in a book, a book like this, it's maybe an endangered species.

Howard: Yeah. I hear it all the time. I routinely have people say that they do all the cleanup of their house on Saturday morning and it takes about four hours and they'll wake up and find a four hour book or they'll listen to podcasts or commute or it's everything but I swear, whatever your sales are to date on your book, as soon as you come out on audio, it'll be times five, whatever you got now. But it's just a modem. Tell me this, so they're coming out of school again, they're young. Every time I tell people to send me an email, Howard@dentaltown.com, tell me who you are, where you're from, all that. 25% are still in school, the rest are all under 30. Maybe one guy a week is our age. But anyway, so she comes out of school and she's going to say, look, I don't know anything. Where would she begin? Where should she start a journey? You mentioned the American Academy of Dental sleep medicine. Should she read your book, start her out on her journey? What would her first three steps be? 

Mark: That's a great question because I think the sooner a young dentist gets up to speed on sleep, it will enhance their practice, it will kind of reinforce this whole root cause of where bruxism comes from and damage to the dentition, kind of a secondary way of getting periodontal disease. So I would read the book. I wasn't saying that a year ago, but now I get these dentists emailing me and they're going, thank you for writing that book; it was a great introduction. Even for me, a health care professional and that's not why I wrote it. I wrote it for the lay person, but I would start with the book. It’s a four and a half hour read and it gets you up to speed, and it will point you in different directions. The next thing, and you mentioned it already, would be the AADSM, the American Academy of Dental Sleep Medicine. For the membership costs of $350, I think it's $350 a year and then the cost of the yearly meeting, I would go to the first yearly meeting of the AADSM and I tell you, that will get you up to speed. They have introductory courses, they have it well segmented. Then you can take the more advanced courses. You can talk to all the professionals in this arena and then you're done. I mean, you're, on your way and it's a fascinating area of dentistry. And I'm not saying medicine. You heard me right. Of Dentistry. Of course it is a medical condition. So that would be my reply. Those two items alone. I mean, I can go on and on.

Howard: Their headquarters is, how do you pronounce that? L-I-S-L-E, Illinois. Lisle, Illinois, their headquarters? 

Mark: Yeah. I don't know. I've been there, it's outside of Chicago. It's nice.

Howard: So if you're wondering why there's so many set ups in Chicago because the American Dental Association is 211 East Chicago Avenue, so everything's down there in Chicago. So when they have their annual meetings, is it always the same place or same time or same bat station?

Mark: No, this year, this June, which is in a few weeks, it's going to be in Baltimore and then it's always in Seattle. I love the Seattle meetings. Actually they're all good. Baltimore's wonderful. That town is gentrified. The Boston meetings are great and then I think there's one in Minneapolis, I think. And then they have half meetings: Vegas, which covers the west coast. That's an easy trip; you can just go for the day. So it's easy, it's very approachable. If you don't know anything about sleep, it doesn't matter. And then you can get accredited through the organization and they'll get you up to speed quickly. This is a group of dentists and physicians working together to educate and to illuminate that this is something that dentists should be included in on. And again, recognition of sleep apnea or sleep disorder breathing occurs decades earlier when, when a dentist sees it in the mouth, than a physician sees it externally, like with a co-morbidity of sleep apnea, like high blood pressure or insulin resistance. So we're in the driver's seat here. Every dentist needs to get up to speed on this because it has dental implications and there is a fix for that. It's a root cause of so many things that go on in dentistry.

Howard: I've been on dentaltown several hours a day since, we actually launched it on St Patrick's Day, 1999 since I'm 100% Irish. But this is Dentistry Uncensored, so I don't want to talk about anything anyone agrees on. So I want to tell you the bad talk about this, that so much of the training is just trying to get you to buy a machine and there are so many people say, 'I went to a course and as soon as I bought the take-home machine,' it was all about the take home sleep machine. True or false, is that a real concern or do you not believe that?

Mark: Well that's an interesting point, I haven't heard that but I've seen it and you're right, a lot of these courses are overpriced and that's why I recommended the AADSM and then they do sell you or try and sell you, not only the machine but a yearly or monthly subscription. It's basically a pulse ox and an, I don't subscribe to that. In fact, in my training I was told that you don't have to have low saturation of oxygen to have sleep apnea. I know a lot of medical institutions use that as well. These are the home studies with a home test. So in my book I wrote about my frustration about not having an accurate way of knowing if my oral appliance is working or whether my patient does have sleep apnea and we now do have a test and it's a company that I was hired by as a medical advisor and it's called knithealth.com. Its knithealth.com.

Howard: That's your website?

Mark: It's a hundred [inaudible 14:22] dollar exam that anyone can take. They send you a device and it's a high res measurement of your breathing patterns. We're here now, we've got that, but stay away from those courses that try and sell you something that's antiquated and old. That went a long time ago. I know some physicians that do that. You need a PSG or something newer than that. The PSG is the attendance sleep study. Those are still hard to get, but it's getting easier. It's an incredible device, and it’s touchless; nothing gets wired to you. I can't tell you how many people come back from that sleep study, the attendance, sleep study where they glue electrodes to your face, your chest. Accelerometers, measuring airflow through the nose and I've had that test on many times and you're a little hesitant to roll over or sleep properly, but this test is just something you mount on the wall and you just jump into bed and that's it. And it's in your own home, in your own bed, your own pillow.

Howard: Wow. So you're saying you can do all of this without owning any take-home equipment.

Mark: Exactly, right. And as a dentist, you can use it. You just have the patient call knithealth, we'll have a program specifically tailored to dentistry, where the reports come back and that way we can, you know, look at our results with the titration or calibration of an oral appliance. That coming, but we'll wait till we get FDA approval, which we'll get. But there is no monthly subscription service and just a very accurate test that a patient can, can do, without too much resistance. A lot of patients don't even want to go into an attendant sleep study because the door doesn't lock, it's an unfamiliar place, and there are people next door sleeping and snoring and being tested. That's not a conducive environment to get a sleep study. It really isn't. And it's expensive. It's expensive. I mean, what's your deductible on your health care plan on medical? Most of us have, I mean being self-employed, $4,000 to $10,000, maybe $20,000. Well you're going to pay for that sleep study out of pocket $3,000 to $4,000.

Howard: Yeah, I went and had it done. And she said, I was her favorite patient because all the strands on the, being bald, she said that the most annoying thing for her is someone with a bunch of hair. So I was her favorite patient of the day. So another thing, a negative. They're saying, well, if I do this, am I going to have to learn medical billing? And is that hard? Do you do this medical billing? Is that a hurdle to jump?

Mark: At first it was maybe for the first few, but you learn to basically bill twice. The first time they're going to ignore it and it is a medical code. There are no dental codes for anything to do with TMJ and sleep and that kind of thing, as you know. It's simple. There are courses on medical billing and then they had these programs, software programs where they do all the medical billing for you, but they take a big chunk. So I would learn how to do it.

Howard: What is the chunk on that?

Mark: It's high. I don't know, but it's high. I've talked to some sleep dentist and they're like, oh my God, they're taking a big chunk and you don't need to do that. You can learn how to do this. This is as simple as billing just about anything else. You just have to learn how to do it, it’s one medical form. You can learn how to do this in a matter of hours and your auxiliary can do it and then it's out of sight, out of mind. You're just going to treat the patient and it gets billed. I collect upfront because you never know if the insurance is going to pay. Of course you're going to educate the patient. If the patient has the sleep study or recent sleep study at least five years or younger or more recent, and the prescription from the physician, which is being readily done now, physicians are on board now with the oral appliance. They've been educated. They used to think it was a TMJ device that would make things worse, but now we know, the studies are there that this can work and have a higher compliance rate in someone that has mild to moderate sleep apnea than a CPAP or EPAP. And the physicians love that; they're okay with this. They need to write a prescription for it. Those two things are needed before you bill the medical. Now Medicare is something different. I don't bill Medicare: that's a tougher, that's a different animal. But billing someone's medical plan, I would say 80 - 90% of it, we get an 80 - 100% coverage on a $3,000 to $3,500 oral appliance.

Howard: Now are you working with just one lab to make these appliances or do you use several different labs?

Mark: I use one lab, I used several in the beginning, and I've now found my favorite lab. Actually it was a Canadian lab, Strong Dental, 'Strong' as in 'strong', but they sold the American rights, Randy Strong, who modified the Herbst, it's called the Suad, S-U-A-D,  it's very strong, very robust. All the early appliances that I made weren't as robust as this one was and also this has a lot of adjustability, and I also liked that it doesn't have a lot of internal volume. It doesn't fill up the mouth. You need room for the tongue, you've got to let the tongue spread out, move forward and relax. Now Somnodent, sorry, Somnomed, Somnomed bought the rights to making the Strong or the Suad in the US So I use one lab. 

Howard: S-O-M-N-O-M-E-D?

Mark: Yes.

Howard: Is that the number one player in making these appliances, do they do the most units? Are they the four hundred pound gorilla?

Mark: Well, I wouldn't call them the number one player, but they're up there. They're definitely making a lot of appliances and I think that's why they bought the right to make this Suad because it's such a good device.

Howard: Yeah. And there's [inaudible 20:34] a device. I like to get specific because that's what they always asked me.

Mark: Right. I have it right here, I think. This is a model of it. I don't know if you can see that. It's basically a chromium cobalt kind of partial denture framework.

Howard: Raise it just a little higher.

Mark: And then they.

Howard: There you go, perfect.

Mark: It's got rubber bands, it's got the Herbst struts on it. The struts come in different sizes. You advance the device by adding little Delran spacers, you can use it with or without rubber bands. You can adjust vertical by adding acrylic or not. It's a thermal plastic material that of course will, as it warms up grips more but less tightly. I've had great success with this device and I've tried a lot of other ones. The Somnomed Fusion is pretty good. It has a lower lab fee, but there are certain things I don't like about it. So that's currently my favorite device. I'm always looking for a new one though.

Howard: What is that device called?

Mark: That's called the Suad.

Howard: Okay, that's the Suad.

Mark: Suad Elite.

Howard: Suad Elite? What is the lab bill roughly on something like that?

Mark: Good question. It's about $650, I think. $650.

Howard: And then what are you charging for this service?

Mark: $3,500.

Howard: And so that's definitely in the profit zone.

Mark: It makes you look like the hero. I had two follow-ups today and they're smiling, they're happy, they'll give you hugs, you've changed someone's life.

Howard: That is truly neat. So I'm trying to make a cookbook for them. So basically, your latest, you've got the book for them, The Eight Hour Sleep Paradox, how we're sleeping our way to fatigue, disease and unhappiness on Amazon. Ryan, can you push that out on social media? So on dentaltown, social media started with email groups and you'd open and you'd subscribe to dentistry@compuserve or dentistry and you'd open up your email, just crazy.

Mark: Bulletins?

Howard: Well that's what the scientists did, the Internet did on a computerized bulletin board services. That's what Dentaltown is. Dentaltown has fifty categories and the fiftieth one is TMJ Sleep, and we'll post it on that, we'll start a thread on that. So that's good. Then you're talking about, you've got the book, and then join the, AADSM and they have a meeting in Baltimore, June one. Are you going to that, this June one?

Mark: I am not, unfortunately I won't be able to go, but I will be going to the next one and I think that is going to be in Minneapolis, I think, or Boston.

Howard: And then you take a group, how many people are members, do you think of the AADSM, American Academy of Dental Sleep Medicine?

Mark: Oh, that's a good question. I'm sure it's thousands. I can't say more good things about it. It's done so much for me personally, health wise even. It's totally professional.

Howard: But the point I was going to make is: you want to go to Baltimore, June. Yankee is in Boston and it's in February. Boston is one of the greatest cities in the world, but not in February. And you go there and they say, 'well, you know, attendance isn't very good.' And you're like, 'well, yeah. Did you go outside? Do you think anybody wants to go to Boston?' And then you go to Chicago, Midwinter meeting. Chicago in mid-winter, just from the cab to running into the Hyatt and your bones are shivering. I think it's so funny how all these smaller groups all go to great destinations at the right time of year. It's like London. Do you really want to go to London in February and then see what the North Sea is all about? No, but London between May and October is one of the greatest cities. London might be the greatest city in the world for five months of the year and then the other eight months of the year you were wondering what you did in your previous lifetime to deserve this treatment. So you're saying they don't have to need a machine that knithealth, K-N-I-T, I wonder where that name comes from? Knit, like knitting. I grew up with five sisters. 

Mark: I wondered about that. I've been working with him for almost two years now and I never really asked but I sometimes wonder about it then I forgot to ask. Maybe it's knitting things together. There are a lot of things you have to pull together to have or to achieve overall good health. So I don't know, it's a good question. It did start out as a baby monitor, a very overqualified baby monitor.

Howard: So you started out with babies. I think it's funny because when I started getting into sleep years ago, you learn something, you never see anything the same. It wasn't that long after that and I was at a friend's house who had a five year old and I watch this five year old on the couch, he was grinding his teeth, he's kicking his leg and we all remember grandpa sitting in the rocking chair, snoring loud and being all weird, but my God, that kids only five. And then you started looking into it, and there's people saying that if he breathes like that through his whole development that he wouldn't have been maximum developed in brain and size and fitness. I just looked at him and think how many vaccinations he got, how many pediatrician visits. He's already been to the dentist every six months and he's five years old and nobody's picked up this kid can't breathe.

Mark: That's very well said. That's a great little story that everyone should keep in mind, and so I treat a lot of children. Again, I cannot diagnose sleep disorder breathing, but I can screen for it and I worked with the ENT's that are knowledgeable in this area. You can't just refer out to any ENT. Some of them will just turn around and say, forget it; the kid's fine. Even though they're mouth breathing, tonsils and adenoids are swollen. They're acting out, they're not sleeping well, and they’re bed wetting. It's amazing. But you're right. Again, as a dentist, you see kids at what age, one, typically, sometimes by age two or three, and you can make a big impact on their lives, especially if you catch a sleep disorder, breathing issue, mouth breathing because it leads to poor development over time. Crowded teeth and then they get the wrong type of Ortho and then they have sleep apnea for the rest of their life. So let's fix it before it starts. And that's a great opportunity for us dentists.

Howard: But what you're doing, it's not the American healthcare system. The American healthcare system, you see your doctor, you got a five minute appointment. 'Well, I'm having trouble sleeping.' 'Okay, here's Ambien. I got your blood work back. You got high triglycerides, here's a statin.' You go in there for ten minutes and he tries to write you five prescriptions and that's the US healthcare system. And we spend twice as much per person. I was born in '62, 1962 was the last time that the life expectancy went down two years in a row and the last two years. And now this is 2018, 2016 and 2017 it went down. You would have thought fifty- five years ago by now it'd be going up, up, up, and it's gone down the last two years. And then the stat that just blows my mind is that Americans are 5% of the world's population, which is nearly eight billion people, and in 2017 we took half the prescription pills.

Mark: That's shocking.

Howard: But if you really want to cure sleep apnea you need to just make a pill. Have you thought about that? Just making a pill?

Mark: Well, yeah, of course. I mean that's how we're wired to think and we're no better than physicians. I mean western dental care is reactive. In other words, if there's a hole, we can fix it. If there's a missing tooth, we can fix it. Medicine is the same way; medicine is great at patching you. Let's say you break an arm or you bash your head in. We can fix all that, right? But no one's looking for root cause and prevention. I don't know what you were told in dental school, but we were told that we were better than physicians in a way because we were more preventative orientated. And I don't see that in dentistry. In many ways we're just like modern Western medicine, is that we are reactive; we fix things. We don't talk about a dysbiosis in the mouth and how the oral microbiome is causing cavities and diet. We're just talking about acids dissolving calcium and we can go in there and fix it. We've got plastic, we've got metal, we've got gold, and we’ve got cubic Zirconia, whatever, porcelain. And that's got to change. We need to be more comprehensive healthcare practitioners. So physicians don't get paid to look for root causes. They've got their fifteen minutes and you can write meds and prescriptions in those fifteen minutes. That works and you can bill for it. So it's a flawed system.

Howard: Now, you don't take Medicaid, Medicare, PPO's or Delta, you don't take any of that do you? 

Mark: No, I don't take any of it.

Howard: Dr B. Does the B stand for Unicorn? Because a lot of them were really burned out and what's neat about looking around the world, I always tell people that you don't need an original idea with the SMP500, with the Russell 2000, we're two hundred countries. No matter what problem you have, why would you need an idea? There's two hundred countries, somebody's got a better outcome than you and it looks like to me, America and it's PPO looks like England when I got out of school thirty years ago when everybody worked for the NHS. And every year in [inaudible 30:42] your costs would go up and they would lower the reimbursement. And finally those two lines had to merge and now five thousand of the UK dentists flipped him off and said, I can't treat my own child like this, so I'm not going to treat people like that. Because it's very confusing when they come out of school, when they see people buy a Honda, the median average price of a new car in America is $33,500 a year and the average American will buy thirteen cars between the ages of sixteen and seventy-six. And they've got an $800 iPhone, they've got a $33,000 Honda or Toyota, and I'm supposed to do this filling for $100. Were you always off the grid with that or did you finally, like the NHS doctors, say enough's enough and walk away?

Mark: Yeah, it was the latter. But it happened early in my career because I was limited, my hands were tied and I agree with you and I hear a lot of complaints about the cost of dentistry. I think we're undercharging and I think we need to charge more and provide more of a service. I think our clinics, I think dentists need to practice together, my physicians do in group practices. And to lower the overhead and I think we need to provide more, and more of a hospital-like environment where, when we look at periodontal disease, we're looking at it in terms of a root cause kind of way of thinking and we're giving nutritional advice, we're measuring the type of bacteria and the flora or the biome in the mouth, and we're making decisions based on more data. Right now, we see gum disease, we see deep pockets, somebody go in there with our lasers and our scalers and there's really no way of knowing except over time, that we're doing the right thing, but it's not very evidence based. There's another term that gets thrown around very loosely, but I think we need to bump up our game here and go more clinical, more high end and then insurance has to follow us, hopefully, with that. They won't, they'll fight us on that, but right now we're just basically filling holes and scraping teeth. I'm exaggerating a bit but that's why sleep is so important. That's why you have to incorporate that into your practice. Also nutritional advice. I know that smoking cessation is a required thing now. It's a standard of care thing, but I don't know how many dentists do that. So it's something that we need to work on. Does it start in CE or does it start in the dental curriculum? I don't know, but we're talking about it now, which is great. And then there are millions of hundreds of thousands of dentists listening. So that's a start.

Howard: What I can't understand is that the person who holds all fifty-two cards of this deck are the dentists and they just fold to the insurance, the Medicaid, the Medicare, the lawyers. If the world's two million dentists all disappeared tomorrow, eight billion people will say, oh my God, where's my dentist? And dentistry is very different. Only 5% of Americans will see a chiropractor this year. But every single human on earth at one time in their life is going to need to see a dentist. So I want you to put your dad hat on. You're giving the graduation talk at Dugoni and they're coming out of school. They've got $400,000 in debt, they're twenty-five years old. What would you want to tell yourself if you were at that commencement hearing? Give advice to the kids in dental school since that's 25% of the people you're talking to right now.

Mark: Boy, that's a good, compound, loaded question. First of all, I feel I would say I feel bad for them. I mean, I came out with a lot of debt but not that much debt. I mean, that's a big chunk of debt. I would say, first of all, stay away from the big corporate dental concerns, you know, Western Dental, Smile Care, Smile Centers. The minute you step foot in there, you're going to be practicing dentistry, not the way you were taught in dental school and you're going to start feeling bad about yourself and you're not going to necessarily learn that much. I did that for about ten months and I learned a lot, but I learned what I didn't want to do and I think that was part of my decision not to take all these insurance plans. So that's the first thing, just don't get tempted or pulled in by a salary job that will start maybe beginning to pay off some of your debt. I would find a dentist that you admire, someone who's doing a good job where patients, they're getting good reviews, they're not necessarily dealing with insurance or they're managing it properly and they're treating their patients well. It may even be your dentist, your childhood dentist, maybe it's that. I get a lot of that from my patients. I've seen them grow up, they become ENT's and dentists and that's very gratifying of course, but they know your style of dentistry and that's something, maybe that's the reason they became a dentist because they thought that all dentists were that way. So I would, like in the old medieval times, there was an apprenticeship and, I forget what the analog to that is, the person who does the training and lock in on that person, and do an associateship, and with an option to buy, and work with that person for ten years or five years, however long it takes. But that's the only way to learn something properly, is to emulate and learn from someone who's done it. Don't take advice from people that their actions aren't speaking louder than their words, in other words, only take advice from people that you like what they've done and you admire what they've done. So I would go that route, again stay away from those big corporate clinics, where you can't put your name on the door. If you can't put your name on the door, walk away.

Howard: I always look at my dental office and say, okay, if I die tomorrow, how would this treat my grandchildren when I was six feet under ground? You know what I mean? What, what is the corporate culture of this place? So she's coming out of school and I'll tell you, whenever you get to a place and they're telling you, well if they have over five millimeter pockets, you've got to have these [inaudible 37:17] chips and when they say things like, well, 60% of your new patients are supposed to have periodontal disease. It's like what? I thought only people that had periodontal disease had periodontal disease, I didn't know there was a quota. So as soon as you start treating other people in ways you wouldn't treat yourself for money, you're going to feel bad, you're going to feel dirty, you're going to do depressed. And when you do things you don't like to do for money, it leads to disease and depression. I mean even the constitution says you have the right to pursuit of happiness. No one ever talks about that. They always talk about this amendment or that amendment. You've got the right to pursue happiness. If working in these clinics was a great idea, then they would all be happy and people would stay there for five, ten, twenty years, and is that what you see? Do you see a bunch of people going in there and staying ten, twenty years?

Mark: No, they branch out or they work for insurance companies. They sell out. Medscape today, I don't know if you saw the Medscape feed, physicians have the highest rate of suicide now, of professionals and I think it's just what you said.

Howard: Wow, can you find that on Medscape? About the highest rate of suicides?

Mark: Yeah, they've got their fifteen minutes to write a prescription and they know deep down that that's not going to fix things. It's a short term, it's going to make things worse, even. I mean the side effects and they're a part of a system that I don't think they were aware of before they went to medical school or they don't want to be a part of. I know a lot of physicians personally, I've done TEDx talks with them, I've talked books that we've written and everything and they're kind of in the same position we are. Oh, who's that? Is that your granddaughter?

Howard: Yeah, she just came home from school. Yeah.

Mark: Oh cool.

Howard: That's the thing, your granddaughter. You should be doing dentistry like you'd want to do it on your granddaughter. And once some big corporate things says, well, no you can't sit down with your granddaughter and tell her about lowering cholesterol with exercise and diet, or talking and you got to see a quote and you only get ten minutes to see a patient. Once you cross that line, it's not going to be good.

Mark: Right. Well, I came out of dental school and the first time I had to put an alloy into a kid's mouth, I kind of thought, oh God, I don't know if I can do this. And so I went exclusively to composites, even though back then they weren't perfect, but it all worked out. They lasted, they worked, and they were fine. There's no reason we should be putting a neurotoxin into the young people of America. That's just ridiculous.

Howard: I want to add another thing. I know how they think. I'm in a lot of dental schools each year. Here's what they come out with: Rome wasn't built overnight. They come out of school, they say, okay, I've got a limited budget and time, they've got to work, they've got to sleep, and they’ve got to eat. And I'm going to talk about the ugly. They have $400,000 of debt; they have to make money. Should she learn Invisalign? Should she learn how to place implants? Should she learn sleep medicine? Should she go to these institutes and learn TMD and occlusion, like Panky and Cois and Spear? She's got so many choices. Where do you think sleep medicine fits in all these decisions? And if you were twenty-five and you had $400,000 student loans, where would you begin? In what order would you learn it in?

Mark: Oh boy, that's a really good question, Howard. Well, the easy answer is all of it, but that's expensive and it takes a lot of time. I would work with sleep and Invisalign. Implants, I think that's something you can work on a little later. I would learn how to restore implants, that's not difficult to do and work with a good surgeon and then transition slowly, maybe after you get your practice going. As an associate, it's hard to do all this, because you don't own the practice. So I would work on sleep and Invisalign. Because it's easy, you're not buying a lot of equipment. When you buy a lot of equipment, for implant placement, and by the way that could all change. I think titanium is probably on its way out and that's going to be a big equipment change. I mean if we go to ceramic implants.

Howard: Okay. So what you're alluding to is, the largest implant company in the world, Straumann, as far as units bought, that's the high dollar. They bought the value system, Neodent, but they just bought Sir Calcium and then, and then Danaher, which is the largest dental company world, $17 billion. They had their high end Nobel Biocare and their value implants Drag. But everybody's coming out with a ceramic because there is no consensus in the marketplace because ceramics aren't even 1% of the market yet. But there's a lot of people that say well implants at five years, 20% have Peri-implantitis and in nine years the research shows 40 - 60%. So you're saying, you're one of the believers that the titanium metal is doing something and is part of the problem with Peri implantitis?

Mark: Yeah, I do. I think I'm seeing an immune response. Definitely. I don't see it that often, but I see it 20% of the time, maybe 25% of the time and know I don't like it. I don't like seeing pus coming from the focus.

Howard: Do you see any connection with race? Because if you came out thirty years ago, remember thirty years ago when they had PFM, they had the value PFM is a precious metal, porcelain depressed metal, that was the premium and then the value was porcelain the base and if they look like you and me, the skin would acid leach like costume jewelry, there'd be like green tattooing around the finger under the costume jewelry and there would be a tattoo around the gum. But I didn't see that in my American Indians, my Mexicans, and my African Americans. It just seemed to be northern European. Do you see that same association with titanium, that it's a northern European thing or do you think that Asians, Africans, and Latinos are having this too?

Mark: Well with the crowns and, I guess you're talking about metal poisoning, which is kind of a strong term. I think it's more readily viewable on skin that's pigmented lightly, oral mucosa that is pigmented lightly and I think I've seen it. You just have to look a little harder or provocate the tissue and you'll see the bleeding. So I see that little purple corona, I call it a purple corona. I mean there are many different terms for it and I stopped using Base and Nobel metals, if I use metal, only High Nobel. But with implants, I don't have enough information on that, but I see it. It's prevalent and I'm tired of seeing it.

Howard: Well the other thing, let's not kid ourselves, those implants aren't pure titanium because that's not ideal. So there are other elements in there and it might be just one of those little trace elements in the alloy to make it do what it needs to do. It might not even be the titanium because there is no such thing as a pure titanium implant.

Mark: Exactly. And then there are coatings and all that, but it could be the titanium as well. And have you ever thought of this, Howard, that the reason the bone integrates with the titanium is that it's an immune response? In other words, it's grabbing the implant because it's afraid of it or it's reacting to it. It's not necessarily a good reaction. It's a negative reaction, but for us, because it integrates, we can put a tooth on it. I don't know. That's just metaphysical kind of stuff. And root canals kind of have the same reputation. A poorly sealed root canal is basically a kind of a sepsis machine, right? I don't know. We need to redefine what we consider to be a success with an implant. And right now if there's no mobility, that's a success. Well what about the effects to the oral microbiome and tissue, and what about systemic effects? Are there systemic effects down to your big toe and to your heart, and to your liver tissue and is the kidney responding to that? Is it having to work on fixing that reaction? The big problem has always been, and dentistry knows this, is inflammation. We die of that. Chronic inflammation is a real big bad boy and we need to deal with that. That's what perio disease is. That's what a cavity is. And we talk about it, but it's all kind of lip service I think. And I think implants do create a systemic effect. It does activate the immune system. I mean, the studies are out there. I've read them. I mean, I'm not an expert on that level in microbiology and biochemistry and all that, but I've seen it.

Howard: I am so into research that I've never told Ryan this in twenty-two years, but you had an identical twin brother and I gave him up for adoption at birth for the control. And then I figured you guys could meet up when you're sixty and see what was DNA. Ryan just sent it to me on Medscape. Physicians experience highest suicide rate of any profession. Holy moley. Holy moley.

Mark: Holey moley, it's managed care. It’s managed care.

Howard: I want to say another thing that a lot of people don't think about, especially the young ones listening to us under thirty about sleep medicine and Invisalign, and that is when you're doing molar endo and you're placing implants and you're pulling wisdom teeth, you need some really exact vision, eye-hand motor skills, whatever, and then something happens to them. They can have an injury, they can have a car wreck, they can have a stroke, this and that and this and that, but doing hygiene checks, Invisalign checks and sleep medicine checks, don't you think that's a lot less technical motor skills? Eye-hand surgery than molar endo and removing wisdom teeth? And there are a lot of dentists that I know personally that when after they had the carpal tunnel syndrome, after they had the ski accident, skied into a tree, after they had the car wreck, said thank God I had Ortho skills, sleep apnea skills, hygiene check skills, because some of them forever lost. And it might have been just be psychological confidence where something happens to them and they just don't feel like they can go back and do that because it is more of animal spirits, eye-hand surgery to do molar endo and pull wisdoms and even implants then do Invisalign, sleep medicine, bleaching, bonding, veneers, and hygiene. Do you agree with that?

Mark: Absolutely I agree with that. And I think even for older dentists that aren't handicapped, if they want to continue to practice, sell a portion of the practice, or sell the practice,  work in your own practice on your patients and do a little sleep dental work, do some Invisalign, you could do a little consulting. As you get old and you've seen a lot of patients and results and all that, you're experienced, don't go away.

Howard: Come on, we graduated the same year, in eighty-seven. What is your definition of old now? I'm just curious where your number is?

Mark:       Well, I just turned fifty-nine, but I see a lot of dentists in my area working into their seventies, but their clinical skills. We wear a lot of hats in dentistry and after a while you slow down and you don't have the dexterity or the eye sight or even the core strength to bend over and lean over the patient and get in and so loupes have helped there. But let the young guys come in, let them buy your practice, help them, kind of foster them, nurture them, and you can still do some of things you really enjoy like sleep dentistry or Invisalign. Although Invisalign, how do you. Let me ask you a question, Howard, what do you think of these Smile Direct Clubs? How are they going to get away with that? They're not seeing the perio, they're not seeing the contraindications or the issues. I mean, how is that happening?

Howard: It blows my mind. So if you just got to the United States because a lot of dental students, they just got the United States freshman year. They come from all over Asia, Africa, everywhere. In my fifty-five years, the Washington DC Federal Government has always been pretty much useless with about 11% approval rating for decade after decade after decade. The game changer always comes from a renegade Attorney General straight out of school, wanting to make a name for himself and takes on big tobacco, takes on something. So what I am predicting is that, like even the Facebook, security deal and Cambridge and all that stuff; there's no way the Congress or the Senate will do anything. Did you see Mark Zuckerberg trying to explain that to a bunch of, it looked like he was at a senior citizen care center. The questions they were asking. I'm surprised he didn't bust up laughing. There are fifty states and there's always one renegade Attorney General. They did it with Microsoft, remember Microsoft, some guy went after them, the next thing you know he had twenty-two states sign on behind him. So, what's going happen is they're going to trip up and fall down on one patient somewhere on a Smiles Direct Club where some girl in a mall scanned the tooth, she's probably got a long face, jacked it all up and then they're going to have a Tyrannosaurus Rex because he wants to build a career for himself. They come out of law school and before they go and develop their big, expensive private practice, they want to go to the other side first and they want to cut their teeth on the government side. And so a lot of people think those government, they're all young and lame and all that. No, there's a lot of really ambitious young attorneys at these Attorney General's Office in fifty states. So that's my prediction, because that's all I see; you see patterns. I want to go back to where we started. We started this thing. I can't believe we've already done our hour. I want to go back to AsktheDentist.com because when I read AsktheDentist.com, you know it's funny for me. I was born and raised in Wichita, Kansas and I went to college, Creighton in Omaha and went to dental school at University of Missouri, Kansas City. And everybody in the Midwest knows that all the smart decisions, they start in California and they slowly roll over, everybody in Kansas [inaudible 52:27], they say, well, if you want to know what it's going to be like in ten years, just go to Disneyland and talk to someone in California. When I talk to dentists and I read AsktheDentist.com, you guys are in the middle of Silicon Valley. And when I read all your AsktheDentist.com, I like natural mouthwash, you don't like Amalgam, and you’re already backing out of titanium. My dad always said you guys were first because you were all hippies. Berkeley; it's a culture of innovation, Steve Jobs. Why do you think that people like you are already thinking about: I'm ready to go from titanium and ceramic when you know nobody in the Midwest is thinking about it and it'll be ten years. Why is California always ten years ahead of the United States? And if you're young and you think they're all a bunch of crazy bowl of granola, I used to always hear in Kansas: California are full granola; they're just a bunch of nuts and flakes. Well go back through history every ten years. Everything you guys did that was nutty and flaky, eventually ended up in Kansas. Why do you think that is?

Mark: Well, that's a good question. I never thought of it that way. I live and work in an environment where everyone is innovating. I mean my patients are BC's, they are engineers, they work at Apple, they work at Google and so I'm just used to that. And then when you have an original thought or you are counter or contrary to the byline, what the profession thinks, then you're not criticized. So I think it's the environment I'm in, I don't know. I was against mouthwash, killing things in the mouth. That just didn't make sense. Putting fluoride into water, that stuff didn't make sense to me early on, but because maybe where I work and live and because of the people, my peers who I'm around, maybe that's where it came from. Maybe I'm comfortable expressing myself and being contrary. Although I'm not always that way, I don't know. My dad was that way, maybe it's a family thing.

Howard: I really don't know if I should say this on my show, but it is Dentistry Uncensored so I'm going to say it. How many times have you heard people say the biggest problem with Google and YouTube and Facebook and all those companies is that there's no way to talk to a human. That you can't get anybody on the phone?

Mark: Yeah.

Howard: You always hear that?

Mark: Well, absolutely.

Howard: Yeah.

Mark: Drives me nuts.

Howard: Every time Dentaltown has ever had [inaudible 55:18] we've got a community, we've got an app and our programmer's like, 'Well we don't know. We don't know anybody at Apple, we just have to submit it and they send it back. We don't know.' And I always say to them, 'Well, just tell me where the headquarters is?' And they'll say it's in Cooperton, so I'll just google Cooperton dentists and I'll just get on the phone and say, 'yeah, this is Dr Howard Farran, is Dr. Mark Burhenne there?' And he’ll get on the phone, I'll say, "hey buddy, I got this problem with this company, this app, do you have any patient that you could give me their cell phone number or I could send you an email with the problem you could forward on?' Every single time your homies in the town, I don't care what the company is, I don't care. You know the President, all the top people in the Fortune500 they all have a dentist and those are the most likely people to go and get their teeth cleaned every six months. What's so funny is because if you just know where the company's headquartered, just get the zip code, and then put zip code, the dentist, start calling the office. What did they used to call that? We are six degrees of separation, that you are six relationships away from the Pope or any leader. So, Dentaltown, we've been saved so many times over the years. Now is that a hipaa compliant deal?

Mark: Well it's always about community.

Howard: It's always what?

Mark: It's always about community. Community works well, it always has. The electronic communities I'm not very fond of, but if we stick together and learn from each other, that always works. It's never failed.

Howard: Now dentists are always looking for articles to populate their Facebook page, all that kind of stuff like that. So is it cool if they post your article? Just links to your articles?

Mark: It's already happening. People do it all the time. All over the world. I'm happy.

Howard: That's great because I've already ripped off all your stuff. So I'm glad to get permission.

Mark: Okay, good.

Howard: It's always better to ask for forgiveness than it is to ask for permission. So is there anything else you wanted to talk about that I wasn't smart enough to ask?

Mark: Gosh, you asked some good questions actually. I'm just concerned for the profession and I just hope that we keep it all together. And again, I mentioned before, I think we've got to up our game. I think we've got to go more root cause and be a little bit more scientific, medical. We need bigger, better facilities and we've got to figure out a way to get reimbursed for it. We've got to stop just filling the holes.

Howard And the bottom line. A lot of times a kid will ask me, they'll say on Dentaltown they posted a case, and they're saying, 'God, Mark, would you re-treat the root canal or would you pull it and do an implant?' And I would say, 'Well, the first damn thing you should say to yourself, what would you do if it was your tooth? Follow your tooth.' You can present the options to the patient, but obviously most people are going to say. My physician says, 'well you can do this or this.' I'm going to say, 'well, what would you do if you were me?' And once you're treating the patient exactly how you treat yourself, are you good to invert that and say exactly the opposite of how you treat one of your children. So once you do that, it's easy. So if you catch yourself in a job doing things that you don't like to do for money, leave, be true to yourself because at the end of the day, the two hundred and eleven thousand dentists and the one million MD's hold all the cards. It's funny, it's the one of the greatest political scientists’ quotes in the world. They said, when you study history, they said all the people always go along with the government until they don't. You beat them up, you push them down, you push them around, and one day they tear down the Berlin Wall and say, we're done. Nobody predicted the Arab uprising. Everybody always goes along with what you're doing to them until they've had enough and then they don't do anymore. So just everyone be true to yourself. Same thing I asked from my four boys, the only thing I want them to be as happy and healthy. Mark, it was just an honor that you would come on and give me an hour of your life to talk to my homies today.

Mark: Any time.

Howard: Thank you so much.

Mark: Call me again anytime.

Howard: All right buddy. Thank you so much for all that you do for dentistry. Thank you for educating so many consumers. Ryan, thanks so much.

 


Howard: It's just a huge, huge honor for me today to be podcast interviewing Dr. Mark Burhenne at DDS. He's a bestselling author and family dentist who has been in private practice thirty years. His focus is preventative and functional care with patients who come to him from all over the world. He received his degrees from the Dugoni School of Dentistry in San Francisco and is a member of the American Academy of Dental Sleep Medicine and American Academy of Sleep Medicine. He is a TEDx speaker, and his advice regularly appears on NPR, CNN, Prevention, Men's Health and MindBodyGreen and national television. He is the author of AsktheDentist.com, cofounder with his daughter in 2010. Dr Burhenne believes that the mouth is the gateway to health of the rest of the body. His blog, AsktheDentist.com is dedicated to helping people beyond the scope of his practice. He wrote the Amazon bestseller, “The 8 Hour Sleep Paradox: how we are sleeping our way to fatigue, disease, unhappiness for his and your patients, and after experiencing the disconnect between the medical professional and diagnosing and treating sleep disorders. Personal interests are mountain biking, skiing, photography, family, preventive medicine, natural health, nutrition, health education. He is most often referred to as Dr. B by his patients. Dr B, seriously, I am so impressed by your AsktheDentist.com, that's why I asked you to come on the show. Even as a dentist, I can stay ten hours on that site, just reading articles. Job well done and you probably do more marketing for dentistry than any individual dentist I know.

Mark: Well that last sentence I really like. That's what we're trying to do. Thank you, and coming from you Howard, thank you. That's our intent.

Howard: Well a rising ship lifts all tides. I remember when Clear Choice came into Phoenix here and a lot of the oral surgeons and periodontists were all nervous that they were going to steal a lot of their business. All they did is a gazillion dollars to television advertising. I've had more patients ask me about dental implants since Clear Choice got here, and that's what they always say, a rising tide lifts all ships and man, you are a B to C educator.

Mark: Good. Well that's the definition of doctor, isn't it? It's the Latin root of the verb to teach.

Howard: Absolutely. So how did this journey start? What was going on in your mind in 2010, eight years ago, when you decided you were going to start AsktheDentist.com?

Mark: Right. It's a good question. I actually had another website before that, before I even had Catherine, my oldest daughter who's helped me found and create AsktheDentist.com and that was called thevirtual-dentist.com, and that was something I did on my own. That was back in the nineties. I've always been intrigued by the web; it's a great funnel. It's a great mouthpiece for getting information out and I like talking to my patients, but sometimes you want to go beyond that. You want to reach out to a lot more people. The web is the best thing for that. And of course now it's huge. The exposure, if you have a website that reaches out to millions of readers a month you can certainly make a difference. And again, doctor is an educator first and then a healer.

Howard: You and I both graduated in 1987 even though you look about ten years younger than me; you must have some good clean living out there in Silicon Valley. Do you prefer to go by Mark or Dr B? 

Mark: Mark. Mark's fine.

Howard: When I read your book, The 8 Hour Sleep Paradox, which you can get on Amazon, I don't think anyone even mentioned those words when I graduated in '87. I don't even think it was a concept. By the way, I don't know anybody in dentistry who wrote a book. The 8 Hour Sleep Paradox, all your reviews are five star and you have a hundred of them. My gosh, you must come from a very big family and have a very big family reunion to get one hundred.

Mark: We tried that. We've got a few reviews on there, but we had one bad review. The book binding was off; that's Amazon's fault. So thank you.

Howard: Did I go to the wrong dental school? In UMKC did they ever teach you about sleep apnea in Dugoni when you were back there? 

Mark: No.

Howard: When did this become a thing?

Mark: Well for me personally or? It's not a thing. 

Howard: When did it become in the public's mind? I mean, when did you hear about it first? I mean, we didn't hear about it in 87.

Mark: No we didn't. And it's not in the curriculum. When I go to dental schools now and ask them, essentially the reply's the same: the curriculum is full, there's no more room for anything else. For me, it was when we dropped off my oldest daughter at college, we were in the same room, hotel room, my three daughters and I literally woke up with them bumping elbows into my face, telling me that I was snoring and I was noisy. The short story is it turned out to be my wife, but I had no idea about sleep apnea. My parents had it, they didn't know, it runs in the family. It was a personal experience before it became known to me and I think that's how we learn these things. That's how we become good learners is if it affects us, then we absorb everything we possibly can. I had to learn it on my own. The dental curriculum is weak and now you're seeing it in continuing education and you've got the AADSM, which is a wonderful organization and I think that's where I learned most of my information on sleep apnea. That really changed my world and of course, treating my wife who was my first patient, she had an AHI score of thirty-four and a half and we got that down to zero and that was with an oral appliance. This was sitting under my nose the whole time: a Herbst appliance. First time I heard Herbst was in the orthodontic curriculum. That's what it was. It was a device to help class two patients, but now it helps open up the airway and bruxism. I was always very keen on bruxism. That always fascinated me and frustrated me at the same time because I never thought stress was the modality or the etiology for it, especially in kids. So when I heard that connection of trying to keep the airway open by bruxing, sleep bruxism, grinding at night that was a big tipping point for me.

Howard: So podcasters tend to be young. Guys like you and me, we read a bunch of books. By the way, is your book available on audio?

Mark: It is not, and we've had that request and I think we're going to do that. Would you like to be the reader for it?

Howard: Absolutely. I'll tell you what, seriously, I was listening to Jeff Bezos couple of years ago and I keep it out my book and he said that he wasted a billion dollars in ten years because he had an inventory problem with books because when you come out of the book, he doesn't know if he's [inaudible 07:16] a thousand, five thousand, a million and he has these warehouses and the more books he sold, the bigger his warehouses were. So he wanted this one size fit all print to order book machine, took him a decade, a billion and he said, damn it, by the time it was all right. That's why when you go to those bookstores, they're all the same size. It's because of that. And he said, by the time he got it all done, the whole market went to digital, Kindle and audiobook. And I put my book up there and gosh, Ryan made me sit down one day for five and a half hours and just sit there and read my own book and it's 90% of sales. Just like this podcast. People are going an hour commute and they're listening to audiobooks and.

Mark: That's the key word right there. We're sitting a lot in our cars or walking for exercise, we have a lot of downtime where we're moving and, that's the perfect time. I mean, I'm an audible book club member. When I drive, I'm listening to books and podcasts and that's the way we get information now. Written word in a book, a book like this, it's maybe an endangered species.

Howard: Yeah. I hear it all the time. I routinely have people say that they do all the cleanup of their house on Saturday morning and it takes about four hours and they'll wake up and find a four hour book or they'll listen to podcasts or commute or it's everything but I swear, whatever your sales are to date on your book, as soon as you come out on audio, it'll be times five, whatever you got now. But it's just a modem. Tell me this, so they're coming out of school again, they're young. Every time I tell people to send me an email, Howard@dentaltown.com, tell me who you are, where you're from, all that. 25% are still in school, the rest are all under 30. Maybe one guy a week is our age. But anyway, so she comes out of school and she's going to say, look, I don't know anything. Where would she begin? Where should she start a journey? You mentioned the American Academy of Dental sleep medicine. Should she read your book, start her out on her journey? What would her first three steps be? 

Mark: That's a great question because I think the sooner a young dentist gets up to speed on sleep, it will enhance their practice, it will kind of reinforce this whole root cause of where bruxism comes from and damage to the dentition, kind of a secondary way of getting periodontal disease. So I would read the book. I wasn't saying that a year ago, but now I get these dentists emailing me and they're going, thank you for writing that book; it was a great introduction. Even for me, a health care professional and that's not why I wrote it. I wrote it for the lay person, but I would start with the book. It’s a four and a half hour read and it gets you up to speed, and it will point you in different directions. The next thing, and you mentioned it already, would be the AADSM, the American Academy of Dental Sleep Medicine. For the membership costs of $350, I think it's $350 a year and then the cost of the yearly meeting, I would go to the first yearly meeting of the AADSM and I tell you, that will get you up to speed. They have introductory courses, they have it well segmented. Then you can take the more advanced courses. You can talk to all the professionals in this arena and then you're done. I mean, you're, on your way and it's a fascinating area of dentistry. And I'm not saying medicine. You heard me right. Of Dentistry. Of course it is a medical condition. So that would be my reply. Those two items alone. I mean, I can go on and on.

Howard: Their headquarters is, how do you pronounce that? L-I-S-L-E, Illinois. Lisle, Illinois, their headquarters? 

Mark: Yeah. I don't know. I've been there, it's outside of Chicago. It's nice.

Howard: So if you're wondering why there's so many set ups in Chicago because the American Dental Association is 211 East Chicago Avenue, so everything's down there in Chicago. So when they have their annual meetings, is it always the same place or same time or same bat station?

Mark: No, this year, this June, which is in a few weeks, it's going to be in Baltimore and then it's always in Seattle. I love the Seattle meetings. Actually they're all good. Baltimore's wonderful. That town is gentrified. The Boston meetings are great and then I think there's one in Minneapolis, I think. And then they have half meetings: Vegas, which covers the west coast. That's an easy trip; you can just go for the day. So it's easy, it's very approachable. If you don't know anything about sleep, it doesn't matter. And then you can get accredited through the organization and they'll get you up to speed quickly. This is a group of dentists and physicians working together to educate and to illuminate that this is something that dentists should be included in on. And again, recognition of sleep apnea or sleep disorder breathing occurs decades earlier when, when a dentist sees it in the mouth, than a physician sees it externally, like with a co-morbidity of sleep apnea, like high blood pressure or insulin resistance. So we're in the driver's seat here. Every dentist needs to get up to speed on this because it has dental implications and there is a fix for that. It's a root cause of so many things that go on in dentistry.

Howard: I've been on dentaltown several hours a day since, we actually launched it on St Patrick's Day, 1999 since I'm 100% Irish. But this is Dentistry Uncensored, so I don't want to talk about anything anyone agrees on. So I want to tell you the bad talk about this, that so much of the training is just trying to get you to buy a machine and there are so many people say, 'I went to a course and as soon as I bought the take-home machine,' it was all about the take home sleep machine. True or false, is that a real concern or do you not believe that?

Mark: Well that's an interesting point, I haven't heard that but I've seen it and you're right, a lot of these courses are overpriced and that's why I recommended the AADSM and then they do sell you or try and sell you, not only the machine but a yearly or monthly subscription. It's basically a pulse ox and an, I don't subscribe to that. In fact, in my training I was told that you don't have to have low saturation of oxygen to have sleep apnea. I know a lot of medical institutions use that as well. These are the home studies with a home test. So in my book I wrote about my frustration about not having an accurate way of knowing if my oral appliance is working or whether my patient does have sleep apnea and we now do have a test and it's a company that I was hired by as a medical advisor and it's called knithealth.com. Its knithealth.com.

Howard: That's your website?

Mark: It's a hundred [inaudible 14:22] dollar exam that anyone can take. They send you a device and it's a high res measurement of your breathing patterns. We're here now, we've got that, but stay away from those courses that try and sell you something that's antiquated and old. That went a long time ago. I know some physicians that do that. You need a PSG or something newer than that. The PSG is the attendance sleep study. Those are still hard to get, but it's getting easier. It's an incredible device, and it’s touchless; nothing gets wired to you. I can't tell you how many people come back from that sleep study, the attendance, sleep study where they glue electrodes to your face, your chest. Accelerometers, measuring airflow through the nose and I've had that test on many times and you're a little hesitant to roll over or sleep properly, but this test is just something you mount on the wall and you just jump into bed and that's it. And it's in your own home, in your own bed, your own pillow.

Howard: Wow. So you're saying you can do all of this without owning any take-home equipment.

Mark: Exactly, right. And as a dentist, you can use it. You just have the patient call knithealth, we'll have a program specifically tailored to dentistry, where the reports come back and that way we can, you know, look at our results with the titration or calibration of an oral appliance. That coming, but we'll wait till we get FDA approval, which we'll get. But there is no monthly subscription service and just a very accurate test that a patient can, can do, without too much resistance. A lot of patients don't even want to go into an attendant sleep study because the door doesn't lock, it's an unfamiliar place, and there are people next door sleeping and snoring and being tested. That's not a conducive environment to get a sleep study. It really isn't. And it's expensive. It's expensive. I mean, what's your deductible on your health care plan on medical? Most of us have, I mean being self-employed, $4,000 to $10,000, maybe $20,000. Well you're going to pay for that sleep study out of pocket $3,000 to $4,000.

Howard: Yeah, I went and had it done. And she said, I was her favorite patient because all the strands on the, being bald, she said that the most annoying thing for her is someone with a bunch of hair. So I was her favorite patient of the day. So another thing, a negative. They're saying, well, if I do this, am I going to have to learn medical billing? And is that hard? Do you do this medical billing? Is that a hurdle to jump?

Mark: At first it was maybe for the first few, but you learn to basically bill twice. The first time they're going to ignore it and it is a medical code. There are no dental codes for anything to do with TMJ and sleep and that kind of thing, as you know. It's simple. There are courses on medical billing and then they had these programs, software programs where they do all the medical billing for you, but they take a big chunk. So I would learn how to do it.

Howard: What is the chunk on that?

Mark: It's high. I don't know, but it's high. I've talked to some sleep dentist and they're like, oh my God, they're taking a big chunk and you don't need to do that. You can learn how to do this. This is as simple as billing just about anything else. You just have to learn how to do it, it’s one medical form. You can learn how to do this in a matter of hours and your auxiliary can do it and then it's out of sight, out of mind. You're just going to treat the patient and it gets billed. I collect upfront because you never know if the insurance is going to pay. Of course you're going to educate the patient. If the patient has the sleep study or recent sleep study at least five years or younger or more recent, and the prescription from the physician, which is being readily done now, physicians are on board now with the oral appliance. They've been educated. They used to think it was a TMJ device that would make things worse, but now we know, the studies are there that this can work and have a higher compliance rate in someone that has mild to moderate sleep apnea than a CPAP or EPAP. And the physicians love that; they're okay with this. They need to write a prescription for it. Those two things are needed before you bill the medical. Now Medicare is something different. I don't bill Medicare: that's a tougher, that's a different animal. But billing someone's medical plan, I would say 80 - 90% of it, we get an 80 - 100% coverage on a $3,000 to $3,500 oral appliance.

Howard: Now are you working with just one lab to make these appliances or do you use several different labs?

Mark: I use one lab, I used several in the beginning, and I've now found my favorite lab. Actually it was a Canadian lab, Strong Dental, 'Strong' as in 'strong', but they sold the American rights, Randy Strong, who modified the Herbst, it's called the Suad, S-U-A-D,  it's very strong, very robust. All the early appliances that I made weren't as robust as this one was and also this has a lot of adjustability, and I also liked that it doesn't have a lot of internal volume. It doesn't fill up the mouth. You need room for the tongue, you've got to let the tongue spread out, move forward and relax. Now Somnodent, sorry, Somnomed, Somnomed bought the rights to making the Strong or the Suad in the US So I use one lab. 

Howard: S-O-M-N-O-M-E-D?

Mark: Yes.

Howard: Is that the number one player in making these appliances, do they do the most units? Are they the four hundred pound gorilla?

Mark: Well, I wouldn't call them the number one player, but they're up there. They're definitely making a lot of appliances and I think that's why they bought the right to make this Suad because it's such a good device.

Howard: Yeah. And there's [inaudible 20:34] a device. I like to get specific because that's what they always asked me.

Mark: Right. I have it right here, I think. This is a model of it. I don't know if you can see that. It's basically a chromium cobalt kind of partial denture framework.

Howard: Raise it just a little higher.

Mark: And then they.

Howard: There you go, perfect.

Mark: It's got rubber bands, it's got the Herbst struts on it. The struts come in different sizes. You advance the device by adding little Delran spacers, you can use it with or without rubber bands. You can adjust vertical by adding acrylic or not. It's a thermal plastic material that of course will, as it warms up grips more but less tightly. I've had great success with this device and I've tried a lot of other ones. The Somnomed Fusion is pretty good. It has a lower lab fee, but there are certain things I don't like about it. So that's currently my favorite device. I'm always looking for a new one though.

Howard: What is that device called?

Mark: That's called the Suad.

Howard: Okay, that's the Suad.

Mark: Suad Elite.

Howard: Suad Elite? What is the lab bill roughly on something like that?

Mark: Good question. It's about $650, I think. $650.

Howard: And then what are you charging for this service?

Mark: $3,500.

Howard: And so that's definitely in the profit zone.

Mark: It makes you look like the hero. I had two follow-ups today and they're smiling, they're happy, they'll give you hugs, you've changed someone's life.

Howard: That is truly neat. So I'm trying to make a cookbook for them. So basically, your latest, you've got the book for them, The Eight Hour Sleep Paradox, how we're sleeping our way to fatigue, disease and unhappiness on Amazon. Ryan, can you push that out on social media? So on dentaltown, social media started with email groups and you'd open and you'd subscribe to dentistry@compuserve or dentistry and you'd open up your email, just crazy.

Mark: Bulletins?

Howard: Well that's what the scientists did, the Internet did on a computerized bulletin board services. That's what Dentaltown is. Dentaltown has fifty categories and the fiftieth one is TMJ Sleep, and we'll post it on that, we'll start a thread on that. So that's good. Then you're talking about, you've got the book, and then join the, AADSM and they have a meeting in Baltimore, June one. Are you going to that, this June one?

Mark: I am not, unfortunately I won't be able to go, but I will be going to the next one and I think that is going to be in Minneapolis, I think, or Boston.

Howard: And then you take a group, how many people are members, do you think of the AADSM, American Academy of Dental Sleep Medicine?

Mark: Oh, that's a good question. I'm sure it's thousands. I can't say more good things about it. It's done so much for me personally, health wise even. It's totally professional.

Howard: But the point I was going to make is: you want to go to Baltimore, June. Yankee is in Boston and it's in February. Boston is one of the greatest cities in the world, but not in February. And you go there and they say, 'well, you know, attendance isn't very good.' And you're like, 'well, yeah. Did you go outside? Do you think anybody wants to go to Boston?' And then you go to Chicago, Midwinter meeting. Chicago in mid-winter, just from the cab to running into the Hyatt and your bones are shivering. I think it's so funny how all these smaller groups all go to great destinations at the right time of year. It's like London. Do you really want to go to London in February and then see what the North Sea is all about? No, but London between May and October is one of the greatest cities. London might be the greatest city in the world for five months of the year and then the other eight months of the year you were wondering what you did in your previous lifetime to deserve this treatment. So you're saying they don't have to need a machine that knithealth, K-N-I-T, I wonder where that name comes from? Knit, like knitting. I grew up with five sisters. 

Mark: I wondered about that. I've been working with him for almost two years now and I never really asked but I sometimes wonder about it then I forgot to ask. Maybe it's knitting things together. There are a lot of things you have to pull together to have or to achieve overall good health. So I don't know, it's a good question. It did start out as a baby monitor, a very overqualified baby monitor.

Howard: So you started out with babies. I think it's funny because when I started getting into sleep years ago, you learn something, you never see anything the same. It wasn't that long after that and I was at a friend's house who had a five year old and I watch this five year old on the couch, he was grinding his teeth, he's kicking his leg and we all remember grandpa sitting in the rocking chair, snoring loud and being all weird, but my God, that kids only five. And then you started looking into it, and there's people saying that if he breathes like that through his whole development that he wouldn't have been maximum developed in brain and size and fitness. I just looked at him and think how many vaccinations he got, how many pediatrician visits. He's already been to the dentist every six months and he's five years old and nobody's picked up this kid can't breathe.

Mark: That's very well said. That's a great little story that everyone should keep in mind, and so I treat a lot of children. Again, I cannot diagnose sleep disorder breathing, but I can screen for it and I worked with the ENT's that are knowledgeable in this area. You can't just refer out to any ENT. Some of them will just turn around and say, forget it; the kid's fine. Even though they're mouth breathing, tonsils and adenoids are swollen. They're acting out, they're not sleeping well, and they’re bed wetting. It's amazing. But you're right. Again, as a dentist, you see kids at what age, one, typically, sometimes by age two or three, and you can make a big impact on their lives, especially if you catch a sleep disorder, breathing issue, mouth breathing because it leads to poor development over time. Crowded teeth and then they get the wrong type of Ortho and then they have sleep apnea for the rest of their life. So let's fix it before it starts. And that's a great opportunity for us dentists.

Howard: But what you're doing, it's not the American healthcare system. The American healthcare system, you see your doctor, you got a five minute appointment. 'Well, I'm having trouble sleeping.' 'Okay, here's Ambien. I got your blood work back. You got high triglycerides, here's a statin.' You go in there for ten minutes and he tries to write you five prescriptions and that's the US healthcare system. And we spend twice as much per person. I was born in '62, 1962 was the last time that the life expectancy went down two years in a row and the last two years. And now this is 2018, 2016 and 2017 it went down. You would have thought fifty- five years ago by now it'd be going up, up, up, and it's gone down the last two years. And then the stat that just blows my mind is that Americans are 5% of the world's population, which is nearly eight billion people, and in 2017 we took half the prescription pills.

Mark: That's shocking.

Howard: But if you really want to cure sleep apnea you need to just make a pill. Have you thought about that? Just making a pill?

Mark: Well, yeah, of course. I mean that's how we're wired to think and we're no better than physicians. I mean western dental care is reactive. In other words, if there's a hole, we can fix it. If there's a missing tooth, we can fix it. Medicine is the same way; medicine is great at patching you. Let's say you break an arm or you bash your head in. We can fix all that, right? But no one's looking for root cause and prevention. I don't know what you were told in dental school, but we were told that we were better than physicians in a way because we were more preventative orientated. And I don't see that in dentistry. In many ways we're just like modern Western medicine, is that we are reactive; we fix things. We don't talk about a dysbiosis in the mouth and how the oral microbiome is causing cavities and diet. We're just talking about acids dissolving calcium and we can go in there and fix it. We've got plastic, we've got metal, we've got gold, and we’ve got cubic Zirconia, whatever, porcelain. And that's got to change. We need to be more comprehensive healthcare practitioners. So physicians don't get paid to look for root causes. They've got their fifteen minutes and you can write meds and prescriptions in those fifteen minutes. That works and you can bill for it. So it's a flawed system.

Howard: Now, you don't take Medicaid, Medicare, PPO's or Delta, you don't take any of that do you? 

Mark: No, I don't take any of it.

Howard: Dr B. Does the B stand for Unicorn? Because a lot of them were really burned out and what's neat about looking around the world, I always tell people that you don't need an original idea with the SMP500, with the Russell 2000, we're two hundred countries. No matter what problem you have, why would you need an idea? There's two hundred countries, somebody's got a better outcome than you and it looks like to me, America and it's PPO looks like England when I got out of school thirty years ago when everybody worked for the NHS. And every year in [inaudible 30:42] your costs would go up and they would lower the reimbursement. And finally those two lines had to merge and now five thousand of the UK dentists flipped him off and said, I can't treat my own child like this, so I'm not going to treat people like that. Because it's very confusing when they come out of school, when they see people buy a Honda, the median average price of a new car in America is $33,500 a year and the average American will buy thirteen cars between the ages of sixteen and seventy-six. And they've got an $800 iPhone, they've got a $33,000 Honda or Toyota, and I'm supposed to do this filling for $100. Were you always off the grid with that or did you finally, like the NHS doctors, say enough's enough and walk away?

Mark: Yeah, it was the latter. But it happened early in my career because I was limited, my hands were tied and I agree with you and I hear a lot of complaints about the cost of dentistry. I think we're undercharging and I think we need to charge more and provide more of a service. I think our clinics, I think dentists need to practice together, my physicians do in group practices. And to lower the overhead and I think we need to provide more, and more of a hospital-like environment where, when we look at periodontal disease, we're looking at it in terms of a root cause kind of way of thinking and we're giving nutritional advice, we're measuring the type of bacteria and the flora or the biome in the mouth, and we're making decisions based on more data. Right now, we see gum disease, we see deep pockets, somebody go in there with our lasers and our scalers and there's really no way of knowing except over time, that we're doing the right thing, but it's not very evidence based. There's another term that gets thrown around very loosely, but I think we need to bump up our game here and go more clinical, more high end and then insurance has to follow us, hopefully, with that. They won't, they'll fight us on that, but right now we're just basically filling holes and scraping teeth. I'm exaggerating a bit but that's why sleep is so important. That's why you have to incorporate that into your practice. Also nutritional advice. I know that smoking cessation is a required thing now. It's a standard of care thing, but I don't know how many dentists do that. So it's something that we need to work on. Does it start in CE or does it start in the dental curriculum? I don't know, but we're talking about it now, which is great. And then there are millions of hundreds of thousands of dentists listening. So that's a start.

Howard: What I can't understand is that the person who holds all fifty-two cards of this deck are the dentists and they just fold to the insurance, the Medicaid, the Medicare, the lawyers. If the world's two million dentists all disappeared tomorrow, eight billion people will say, oh my God, where's my dentist? And dentistry is very different. Only 5% of Americans will see a chiropractor this year. But every single human on earth at one time in their life is going to need to see a dentist. So I want you to put your dad hat on. You're giving the graduation talk at Dugoni and they're coming out of school. They've got $400,000 in debt, they're twenty-five years old. What would you want to tell yourself if you were at that commencement hearing? Give advice to the kids in dental school since that's 25% of the people you're talking to right now.

Mark: Boy, that's a good, compound, loaded question. First of all, I feel I would say I feel bad for them. I mean, I came out with a lot of debt but not that much debt. I mean, that's a big chunk of debt. I would say, first of all, stay away from the big corporate dental concerns, you know, Western Dental, Smile Care, Smile Centers. The minute you step foot in there, you're going to be practicing dentistry, not the way you were taught in dental school and you're going to start feeling bad about yourself and you're not going to necessarily learn that much. I did that for about ten months and I learned a lot, but I learned what I didn't want to do and I think that was part of my decision not to take all these insurance plans. So that's the first thing, just don't get tempted or pulled in by a salary job that will start maybe beginning to pay off some of your debt. I would find a dentist that you admire, someone who's doing a good job where patients, they're getting good reviews, they're not necessarily dealing with insurance or they're managing it properly and they're treating their patients well. It may even be your dentist, your childhood dentist, maybe it's that. I get a lot of that from my patients. I've seen them grow up, they become ENT's and dentists and that's very gratifying of course, but they know your style of dentistry and that's something, maybe that's the reason they became a dentist because they thought that all dentists were that way. So I would, like in the old medieval times, there was an apprenticeship and, I forget what the analog to that is, the person who does the training and lock in on that person, and do an associateship, and with an option to buy, and work with that person for ten years or five years, however long it takes. But that's the only way to learn something properly, is to emulate and learn from someone who's done it. Don't take advice from people that their actions aren't speaking louder than their words, in other words, only take advice from people that you like what they've done and you admire what they've done. So I would go that route, again stay away from those big corporate clinics, where you can't put your name on the door. If you can't put your name on the door, walk away.

Howard: I always look at my dental office and say, okay, if I die tomorrow, how would this treat my grandchildren when I was six feet under ground? You know what I mean? What, what is the corporate culture of this place? So she's coming out of school and I'll tell you, whenever you get to a place and they're telling you, well if they have over five millimeter pockets, you've got to have these [inaudible 37:17] chips and when they say things like, well, 60% of your new patients are supposed to have periodontal disease. It's like what? I thought only people that had periodontal disease had periodontal disease, I didn't know there was a quota. So as soon as you start treating other people in ways you wouldn't treat yourself for money, you're going to feel bad, you're going to feel dirty, you're going to do depressed. And when you do things you don't like to do for money, it leads to disease and depression. I mean even the constitution says you have the right to pursuit of happiness. No one ever talks about that. They always talk about this amendment or that amendment. You've got the right to pursue happiness. If working in these clinics was a great idea, then they would all be happy and people would stay there for five, ten, twenty years, and is that what you see? Do you see a bunch of people going in there and staying ten, twenty years?

Mark: No, they branch out or they work for insurance companies. They sell out. Medscape today, I don't know if you saw the Medscape feed, physicians have the highest rate of suicide now, of professionals and I think it's just what you said.

Howard: Wow, can you find that on Medscape? About the highest rate of suicides?

Mark: Yeah, they've got their fifteen minutes to write a prescription and they know deep down that that's not going to fix things. It's a short term, it's going to make things worse, even. I mean the side effects and they're a part of a system that I don't think they were aware of before they went to medical school or they don't want to be a part of. I know a lot of physicians personally, I've done TEDx talks with them, I've talked books that we've written and everything and they're kind of in the same position we are. Oh, who's that? Is that your granddaughter?

Howard: Yeah, she just came home from school. Yeah.

Mark: Oh cool.

Howard: That's the thing, your granddaughter. You should be doing dentistry like you'd want to do it on your granddaughter. And once some big corporate things says, well, no you can't sit down with your granddaughter and tell her about lowering cholesterol with exercise and diet, or talking and you got to see a quote and you only get ten minutes to see a patient. Once you cross that line, it's not going to be good.

Mark: Right. Well, I came out of dental school and the first time I had to put an alloy into a kid's mouth, I kind of thought, oh God, I don't know if I can do this. And so I went exclusively to composites, even though back then they weren't perfect, but it all worked out. They lasted, they worked, and they were fine. There's no reason we should be putting a neurotoxin into the young people of America. That's just ridiculous.

Howard: I want to add another thing. I know how they think. I'm in a lot of dental schools each year. Here's what they come out with: Rome wasn't built overnight. They come out of school, they say, okay, I've got a limited budget and time, they've got to work, they've got to sleep, and they’ve got to eat. And I'm going to talk about the ugly. They have $400,000 of debt; they have to make money. Should she learn Invisalign? Should she learn how to place implants? Should she learn sleep medicine? Should she go to these institutes and learn TMD and occlusion, like Panky and Cois and Spear? She's got so many choices. Where do you think sleep medicine fits in all these decisions? And if you were twenty-five and you had $400,000 student loans, where would you begin? In what order would you learn it in?

Mark: Oh boy, that's a really good question, Howard. Well, the easy answer is all of it, but that's expensive and it takes a lot of time. I would work with sleep and Invisalign. Implants, I think that's something you can work on a little later. I would learn how to restore implants, that's not difficult to do and work with a good surgeon and then transition slowly, maybe after you get your practice going. As an associate, it's hard to do all this, because you don't own the practice. So I would work on sleep and Invisalign. Because it's easy, you're not buying a lot of equipment. When you buy a lot of equipment, for implant placement, and by the way that could all change. I think titanium is probably on its way out and that's going to be a big equipment change. I mean if we go to ceramic implants.

Howard: Okay. So what you're alluding to is, the largest implant company in the world, Straumann, as far as units bought, that's the high dollar. They bought the value system, Neodent, but they just bought Sir Calcium and then, and then Danaher, which is the largest dental company world, $17 billion. They had their high end Nobel Biocare and their value implants Drag. But everybody's coming out with a ceramic because there is no consensus in the marketplace because ceramics aren't even 1% of the market yet. But there's a lot of people that say well implants at five years, 20% have Peri-implantitis and in nine years the research shows 40 - 60%. So you're saying, you're one of the believers that the titanium metal is doing something and is part of the problem with Peri implantitis?

Mark: Yeah, I do. I think I'm seeing an immune response. Definitely. I don't see it that often, but I see it 20% of the time, maybe 25% of the time and know I don't like it. I don't like seeing pus coming from the focus.

Howard: Do you see any connection with race? Because if you came out thirty years ago, remember thirty years ago when they had PFM, they had the value PFM is a precious metal, porcelain depressed metal, that was the premium and then the value was porcelain the base and if they look like you and me, the skin would acid leach like costume jewelry, there'd be like green tattooing around the finger under the costume jewelry and there would be a tattoo around the gum. But I didn't see that in my American Indians, my Mexicans, and my African Americans. It just seemed to be northern European. Do you see that same association with titanium, that it's a northern European thing or do you think that Asians, Africans, and Latinos are having this too?

Mark: Well with the crowns and, I guess you're talking about metal poisoning, which is kind of a strong term. I think it's more readily viewable on skin that's pigmented lightly, oral mucosa that is pigmented lightly and I think I've seen it. You just have to look a little harder or provocate the tissue and you'll see the bleeding. So I see that little purple corona, I call it a purple corona. I mean there are many different terms for it and I stopped using Base and Nobel metals, if I use metal, only High Nobel. But with implants, I don't have enough information on that, but I see it. It's prevalent and I'm tired of seeing it.

Howard: Well the other thing, let's not kid ourselves, those implants aren't pure titanium because that's not ideal. So there are other elements in there and it might be just one of those little trace elements in the alloy to make it do what it needs to do. It might not even be the titanium because there is no such thing as a pure titanium implant.

Mark: Exactly. And then there are coatings and all that, but it could be the titanium as well. And have you ever thought of this, Howard, that the reason the bone integrates with the titanium is that it's an immune response? In other words, it's grabbing the implant because it's afraid of it or it's reacting to it. It's not necessarily a good reaction. It's a negative reaction, but for us, because it integrates, we can put a tooth on it. I don't know. That's just metaphysical kind of stuff. And root canals kind of have the same reputation. A poorly sealed root canal is basically a kind of a sepsis machine, right? I don't know. We need to redefine what we consider to be a success with an implant. And right now if there's no mobility, that's a success. Well what about the effects to the oral microbiome and tissue, and what about systemic effects? Are there systemic effects down to your big toe and to your heart, and to your liver tissue and is the kidney responding to that? Is it having to work on fixing that reaction? The big problem has always been, and dentistry knows this, is inflammation. We die of that. Chronic inflammation is a real big bad boy and we need to deal with that. That's what perio disease is. That's what a cavity is. And we talk about it, but it's all kind of lip service I think. And I think implants do create a systemic effect. It does activate the immune system. I mean, the studies are out there. I've read them. I mean, I'm not an expert on that level in microbiology and biochemistry and all that, but I've seen it.

Howard: I am so into research that I've never told Ryan this in twenty-two years, but you had an identical twin brother and I gave him up for adoption at birth for the control. And then I figured you guys could meet up when you're sixty and see what was DNA. Ryan just sent it to me on Medscape. Physicians experience highest suicide rate of any profession. Holy moley. Holy moley.

Mark: Holey moley, it's managed care. It’s managed care.

Howard: I want to say another thing that a lot of people don't think about, especially the young ones listening to us under thirty about sleep medicine and Invisalign, and that is when you're doing molar endo and you're placing implants and you're pulling wisdom teeth, you need some really exact vision, eye-hand motor skills, whatever, and then something happens to them. They can have an injury, they can have a car wreck, they can have a stroke, this and that and this and that, but doing hygiene checks, Invisalign checks and sleep medicine checks, don't you think that's a lot less technical motor skills? Eye-hand surgery than molar endo and removing wisdom teeth? And there are a lot of dentists that I know personally that when after they had the carpal tunnel syndrome, after they had the ski accident, skied into a tree, after they had the car wreck, said thank God I had Ortho skills, sleep apnea skills, hygiene check skills, because some of them forever lost. And it might have been just be psychological confidence where something happens to them and they just don't feel like they can go back and do that because it is more of animal spirits, eye-hand surgery to do molar endo and pull wisdoms and even implants then do Invisalign, sleep medicine, bleaching, bonding, veneers, and hygiene. Do you agree with that?

Mark: Absolutely I agree with that. And I think even for older dentists that aren't handicapped, if they want to continue to practice, sell a portion of the practice, or sell the practice,  work in your own practice on your patients and do a little sleep dental work, do some Invisalign, you could do a little consulting. As you get old and you've seen a lot of patients and results and all that, you're experienced, don't go away.

Howard: Come on, we graduated the same year, in eighty-seven. What is your definition of old now? I'm just curious where your number is?

Mark:       Well, I just turned fifty-nine, but I see a lot of dentists in my area working into their seventies, but their clinical skills. We wear a lot of hats in dentistry and after a while you slow down and you don't have the dexterity or the eye sight or even the core strength to bend over and lean over the patient and get in and so loupes have helped there. But let the young guys come in, let them buy your practice, help them, kind of foster them, nurture them, and you can still do some of things you really enjoy like sleep dentistry or Invisalign. Although Invisalign, how do you. Let me ask you a question, Howard, what do you think of these Smile Direct Clubs? How are they going to get away with that? They're not seeing the perio, they're not seeing the contraindications or the issues. I mean, how is that happening?

Howard: It blows my mind. So if you just got to the United States because a lot of dental students, they just got the United States freshman year. They come from all over Asia, Africa, everywhere. In my fifty-five years, the Washington DC Federal Government has always been pretty much useless with about 11% approval rating for decade after decade after decade. The game changer always comes from a renegade Attorney General straight out of school, wanting to make a name for himself and takes on big tobacco, takes on something. So what I am predicting is that, like even the Facebook, security deal and Cambridge and all that stuff; there's no way the Congress or the Senate will do anything. Did you see Mark Zuckerberg trying to explain that to a bunch of, it looked like he was at a senior citizen care center. The questions they were asking. I'm surprised he didn't bust up laughing. There are fifty states and there's always one renegade Attorney General. They did it with Microsoft, remember Microsoft, some guy went after them, the next thing you know he had twenty-two states sign on behind him. So, what's going happen is they're going to trip up and fall down on one patient somewhere on a Smiles Direct Club where some girl in a mall scanned the tooth, she's probably got a long face, jacked it all up and then they're going to have a Tyrannosaurus Rex because he wants to build a career for himself. They come out of law school and before they go and develop their big, expensive private practice, they want to go to the other side first and they want to cut their teeth on the government side. And so a lot of people think those government, they're all young and lame and all that. No, there's a lot of really ambitious young attorneys at these Attorney General's Office in fifty states. So that's my prediction, because that's all I see; you see patterns. I want to go back to where we started. We started this thing. I can't believe we've already done our hour. I want to go back to AsktheDentist.com because when I read AsktheDentist.com, you know it's funny for me. I was born and raised in Wichita, Kansas and I went to college, Creighton in Omaha and went to dental school at University of Missouri, Kansas City. And everybody in the Midwest knows that all the smart decisions, they start in California and they slowly roll over, everybody in Kansas [inaudible 52:27], they say, well, if you want to know what it's going to be like in ten years, just go to Disneyland and talk to someone in California. When I talk to dentists and I read AsktheDentist.com, you guys are in the middle of Silicon Valley. And when I read all your AsktheDentist.com, I like natural mouthwash, you don't like Amalgam, and you’re already backing out of titanium. My dad always said you guys were first because you were all hippies. Berkeley; it's a culture of innovation, Steve Jobs. Why do you think that people like you are already thinking about: I'm ready to go from titanium and ceramic when you know nobody in the Midwest is thinking about it and it'll be ten years. Why is California always ten years ahead of the United States? And if you're young and you think they're all a bunch of crazy bowl of granola, I used to always hear in Kansas: California are full granola; they're just a bunch of nuts and flakes. Well go back through history every ten years. Everything you guys did that was nutty and flaky, eventually ended up in Kansas. Why do you think that is?

Mark: Well, that's a good question. I never thought of it that way. I live and work in an environment where everyone is innovating. I mean my patients are BC's, they are engineers, they work at Apple, they work at Google and so I'm just used to that. And then when you have an original thought or you are counter or contrary to the byline, what the profession thinks, then you're not criticized. So I think it's the environment I'm in, I don't know. I was against mouthwash, killing things in the mouth. That just didn't make sense. Putting fluoride into water, that stuff didn't make sense to me early on, but because maybe where I work and live and because of the people, my peers who I'm around, maybe that's where it came from. Maybe I'm comfortable expressing myself and being contrary. Although I'm not always that way, I don't know. My dad was that way, maybe it's a family thing.

Howard: I really don't know if I should say this on my show, but it is Dentistry Uncensored so I'm going to say it. How many times have you heard people say the biggest problem with Google and YouTube and Facebook and all those companies is that there's no way to talk to a human. That you can't get anybody on the phone?

Mark: Yeah.

Howard: You always hear that?

Mark: Well, absolutely.

Howard: Yeah.

Mark: Drives me nuts.

Howard: Every time Dentaltown has ever had [inaudible 55:18] we've got a community, we've got an app and our programmer's like, 'Well we don't know. We don't know anybody at Apple, we just have to submit it and they send it back. We don't know.' And I always say to them, 'Well, just tell me where the headquarters is?' And they'll say it's in Cooperton, so I'll just google Cooperton dentists and I'll just get on the phone and say, 'yeah, this is Dr Howard Farran, is Dr. Mark Burhenne there?' And he’ll get on the phone, I'll say, "hey buddy, I got this problem with this company, this app, do you have any patient that you could give me their cell phone number or I could send you an email with the problem you could forward on?' Every single time your homies in the town, I don't care what the company is, I don't care. You know the President, all the top people in the Fortune500 they all have a dentist and those are the most likely people to go and get their teeth cleaned every six months. What's so funny is because if you just know where the company's headquartered, just get the zip code, and then put zip code, the dentist, start calling the office. What did they used to call that? We are six degrees of separation, that you are six relationships away from the Pope or any leader. So, Dentaltown, we've been saved so many times over the years. Now is that a hipaa compliant deal?

Mark: Well it's always about community.

Howard: It's always what?

Mark: It's always about community. Community works well, it always has. The electronic communities I'm not very fond of, but if we stick together and learn from each other, that always works. It's never failed.

Howard: Now dentists are always looking for articles to populate their Facebook page, all that kind of stuff like that. So is it cool if they post your article? Just links to your articles?

Mark: It's already happening. People do it all the time. All over the world. I'm happy.

Howard: That's great because I've already ripped off all your stuff. So I'm glad to get permission.

Mark: Okay, good.

Howard: It's always better to ask for forgiveness than it is to ask for permission. So is there anything else you wanted to talk about that I wasn't smart enough to ask?

Mark: Gosh, you asked some good questions actually. I'm just concerned for the profession and I just hope that we keep it all together. And again, I mentioned before, I think we've got to up our game. I think we've got to go more root cause and be a little bit more scientific, medical. We need bigger, better facilities and we've got to figure out a way to get reimbursed for it. We've got to stop just filling the holes.

Howard And the bottom line. A lot of times a kid will ask me, they'll say on Dentaltown they posted a case, and they're saying, 'God, Mark, would you re-treat the root canal or would you pull it and do an implant?' And I would say, 'Well, the first damn thing you should say to yourself, what would you do if it was your tooth? Follow your tooth.' You can present the options to the patient, but obviously most people are going to say. My physician says, 'well you can do this or this.' I'm going to say, 'well, what would you do if you were me?' And once you're treating the patient exactly how you treat yourself, are you good to invert that and say exactly the opposite of how you treat one of your children. So once you do that, it's easy. So if you catch yourself in a job doing things that you don't like to do for money, leave, be true to yourself because at the end of the day, the two hundred and eleven thousand dentists and the one million MD's hold all the cards. It's funny, it's the one of the greatest political scientists’ quotes in the world. They said, when you study history, they said all the people always go along with the government until they don't. You beat them up, you push them down, you push them around, and one day they tear down the Berlin Wall and say, we're done. Nobody predicted the Arab uprising. Everybody always goes along with what you're doing to them until they've had enough and then they don't do anymore. So just everyone be true to yourself. Same thing I asked from my four boys, the only thing I want them to be as happy and healthy. Mark, it was just an honor that you would come on and give me an hour of your life to talk to my homies today.

Mark: Any time.

Howard: Thank you so much.

Mark: Call me again anytime.

Howard: All right buddy. Thank you so much for all that you do for dentistry. Thank you for educating so many consumers. Ryan, thanks so much.

 


Howard: It's just a huge, huge honor for me today to be podcast interviewing Dr. Mark Burhenne at DDS. He's a bestselling author and family dentist who has been in private practice thirty years. His focus is preventative and functional care with patients who come to him from all over the world. He received his degrees from the Dugoni School of Dentistry in San Francisco and is a member of the American Academy of Dental Sleep Medicine and American Academy of Sleep Medicine. He is a TEDx speaker, and his advice regularly appears on NPR, CNN, Prevention, Men's Health and MindBodyGreen and national television. He is the author of AsktheDentist.com, cofounder with his daughter in 2010. Dr Burhenne believes that the mouth is the gateway to health of the rest of the body. His blog, AsktheDentist.com is dedicated to helping people beyond the scope of his practice. He wrote the Amazon bestseller, “The 8 Hour Sleep Paradox: how we are sleeping our way to fatigue, disease, unhappiness for his and your patients, and after experiencing the disconnect between the medical professional and diagnosing and treating sleep disorders. Personal interests are mountain biking, skiing, photography, family, preventive medicine, natural health, nutrition, health education. He is most often referred to as Dr. B by his patients. Dr B, seriously, I am so impressed by your AsktheDentist.com, that's why I asked you to come on the show. Even as a dentist, I can stay ten hours on that site, just reading articles. Job well done and you probably do more marketing for dentistry than any individual dentist I know.

Mark: Well that last sentence I really like. That's what we're trying to do. Thank you, and coming from you Howard, thank you. That's our intent.

Howard: Well a rising ship lifts all tides. I remember when Clear Choice came into Phoenix here and a lot of the oral surgeons and periodontists were all nervous that they were going to steal a lot of their business. All they did is a gazillion dollars to television advertising. I've had more patients ask me about dental implants since Clear Choice got here, and that's what they always say, a rising tide lifts all ships and man, you are a B to C educator.

Mark: Good. Well that's the definition of doctor, isn't it? It's the Latin root of the verb to teach.

Howard: Absolutely. So how did this journey start? What was going on in your mind in 2010, eight years ago, when you decided you were going to start AsktheDentist.com?

Mark: Right. It's a good question. I actually had another website before that, before I even had Catherine, my oldest daughter who's helped me found and create AsktheDentist.com and that was called thevirtual-dentist.com, and that was something I did on my own. That was back in the nineties. I've always been intrigued by the web; it's a great funnel. It's a great mouthpiece for getting information out and I like talking to my patients, but sometimes you want to go beyond that. You want to reach out to a lot more people. The web is the best thing for that. And of course now it's huge. The exposure, if you have a website that reaches out to millions of readers a month you can certainly make a difference. And again, doctor is an educator first and then a healer.

Howard: You and I both graduated in 1987 even though you look about ten years younger than me; you must have some good clean living out there in Silicon Valley. Do you prefer to go by Mark or Dr B? 

Mark: Mark. Mark's fine.

Howard: When I read your book, The 8 Hour Sleep Paradox, which you can get on Amazon, I don't think anyone even mentioned those words when I graduated in '87. I don't even think it was a concept. By the way, I don't know anybody in dentistry who wrote a book. The 8 Hour Sleep Paradox, all your reviews are five star and you have a hundred of them. My gosh, you must come from a very big family and have a very big family reunion to get one hundred.

Mark: We tried that. We've got a few reviews on there, but we had one bad review. The book binding was off; that's Amazon's fault. So thank you.

Howard: Did I go to the wrong dental school? In UMKC did they ever teach you about sleep apnea in Dugoni when you were back there? 

Mark: No.

Howard: When did this become a thing?

Mark: Well for me personally or? It's not a thing. 

Howard: When did it become in the public's mind? I mean, when did you hear about it first? I mean, we didn't hear about it in 87.

Mark: No we didn't. And it's not in the curriculum. When I go to dental schools now and ask them, essentially the reply's the same: the curriculum is full, there's no more room for anything else. For me, it was when we dropped off my oldest daughter at college, we were in the same room, hotel room, my three daughters and I literally woke up with them bumping elbows into my face, telling me that I was snoring and I was noisy. The short story is it turned out to be my wife, but I had no idea about sleep apnea. My parents had it, they didn't know, it runs in the family. It was a personal experience before it became known to me and I think that's how we learn these things. That's how we become good learners is if it affects us, then we absorb everything we possibly can. I had to learn it on my own. The dental curriculum is weak and now you're seeing it in continuing education and you've got the AADSM, which is a wonderful organization and I think that's where I learned most of my information on sleep apnea. That really changed my world and of course, treating my wife who was my first patient, she had an AHI score of thirty-four and a half and we got that down to zero and that was with an oral appliance. This was sitting under my nose the whole time: a Herbst appliance. First time I heard Herbst was in the orthodontic curriculum. That's what it was. It was a device to help class two patients, but now it helps open up the airway and bruxism. I was always very keen on bruxism. That always fascinated me and frustrated me at the same time because I never thought stress was the modality or the etiology for it, especially in kids. So when I heard that connection of trying to keep the airway open by bruxing, sleep bruxism, grinding at night that was a big tipping point for me.

Howard: So podcasters tend to be young. Guys like you and me, we read a bunch of books. By the way, is your book available on audio?

Mark: It is not, and we've had that request and I think we're going to do that. Would you like to be the reader for it?

Howard: Absolutely. I'll tell you what, seriously, I was listening to Jeff Bezos couple of years ago and I keep it out my book and he said that he wasted a billion dollars in ten years because he had an inventory problem with books because when you come out of the book, he doesn't know if he's [inaudible 07:16] a thousand, five thousand, a million and he has these warehouses and the more books he sold, the bigger his warehouses were. So he wanted this one size fit all print to order book machine, took him a decade, a billion and he said, damn it, by the time it was all right. That's why when you go to those bookstores, they're all the same size. It's because of that. And he said, by the time he got it all done, the whole market went to digital, Kindle and audiobook. And I put my book up there and gosh, Ryan made me sit down one day for five and a half hours and just sit there and read my own book and it's 90% of sales. Just like this podcast. People are going an hour commute and they're listening to audiobooks and.

Mark: That's the key word right there. We're sitting a lot in our cars or walking for exercise, we have a lot of downtime where we're moving and, that's the perfect time. I mean, I'm an audible book club member. When I drive, I'm listening to books and podcasts and that's the way we get information now. Written word in a book, a book like this, it's maybe an endangered species.

Howard: Yeah. I hear it all the time. I routinely have people say that they do all the cleanup of their house on Saturday morning and it takes about four hours and they'll wake up and find a four hour book or they'll listen to podcasts or commute or it's everything but I swear, whatever your sales are to date on your book, as soon as you come out on audio, it'll be times five, whatever you got now. But it's just a modem. Tell me this, so they're coming out of school again, they're young. Every time I tell people to send me an email, Howard@dentaltown.com, tell me who you are, where you're from, all that. 25% are still in school, the rest are all under 30. Maybe one guy a week is our age. But anyway, so she comes out of school and she's going to say, look, I don't know anything. Where would she begin? Where should she start a journey? You mentioned the American Academy of Dental sleep medicine. Should she read your book, start her out on her journey? What would her first three steps be? 

Mark: That's a great question because I think the sooner a young dentist gets up to speed on sleep, it will enhance their practice, it will kind of reinforce this whole root cause of where bruxism comes from and damage to the dentition, kind of a secondary way of getting periodontal disease. So I would read the book. I wasn't saying that a year ago, but now I get these dentists emailing me and they're going, thank you for writing that book; it was a great introduction. Even for me, a health care professional and that's not why I wrote it. I wrote it for the lay person, but I would start with the book. It’s a four and a half hour read and it gets you up to speed, and it will point you in different directions. The next thing, and you mentioned it already, would be the AADSM, the American Academy of Dental Sleep Medicine. For the membership costs of $350, I think it's $350 a year and then the cost of the yearly meeting, I would go to the first yearly meeting of the AADSM and I tell you, that will get you up to speed. They have introductory courses, they have it well segmented. Then you can take the more advanced courses. You can talk to all the professionals in this arena and then you're done. I mean, you're, on your way and it's a fascinating area of dentistry. And I'm not saying medicine. You heard me right. Of Dentistry. Of course it is a medical condition. So that would be my reply. Those two items alone. I mean, I can go on and on.

Howard: Their headquarters is, how do you pronounce that? L-I-S-L-E, Illinois. Lisle, Illinois, their headquarters? 

Mark: Yeah. I don't know. I've been there, it's outside of Chicago. It's nice.

Howard: So if you're wondering why there's so many set ups in Chicago because the American Dental Association is 211 East Chicago Avenue, so everything's down there in Chicago. So when they have their annual meetings, is it always the same place or same time or same bat station?

Mark: No, this year, this June, which is in a few weeks, it's going to be in Baltimore and then it's always in Seattle. I love the Seattle meetings. Actually they're all good. Baltimore's wonderful. That town is gentrified. The Boston meetings are great and then I think there's one in Minneapolis, I think. And then they have half meetings: Vegas, which covers the west coast. That's an easy trip; you can just go for the day. So it's easy, it's very approachable. If you don't know anything about sleep, it doesn't matter. And then you can get accredited through the organization and they'll get you up to speed quickly. This is a group of dentists and physicians working together to educate and to illuminate that this is something that dentists should be included in on. And again, recognition of sleep apnea or sleep disorder breathing occurs decades earlier when, when a dentist sees it in the mouth, than a physician sees it externally, like with a co-morbidity of sleep apnea, like high blood pressure or insulin resistance. So we're in the driver's seat here. Every dentist needs to get up to speed on this because it has dental implications and there is a fix for that. It's a root cause of so many things that go on in dentistry.

Howard: I've been on dentaltown several hours a day since, we actually launched it on St Patrick's Day, 1999 since I'm 100% Irish. But this is Dentistry Uncensored, so I don't want to talk about anything anyone agrees on. So I want to tell you the bad talk about this, that so much of the training is just trying to get you to buy a machine and there are so many people say, 'I went to a course and as soon as I bought the take-home machine,' it was all about the take home sleep machine. True or false, is that a real concern or do you not believe that?

Mark: Well that's an interesting point, I haven't heard that but I've seen it and you're right, a lot of these courses are overpriced and that's why I recommended the AADSM and then they do sell you or try and sell you, not only the machine but a yearly or monthly subscription. It's basically a pulse ox and an, I don't subscribe to that. In fact, in my training I was told that you don't have to have low saturation of oxygen to have sleep apnea. I know a lot of medical institutions use that as well. These are the home studies with a home test. So in my book I wrote about my frustration about not having an accurate way of knowing if my oral appliance is working or whether my patient does have sleep apnea and we now do have a test and it's a company that I was hired by as a medical advisor and it's called knithealth.com. Its knithealth.com.

Howard: That's your website?

Mark: It's a hundred [inaudible 14:22] dollar exam that anyone can take. They send you a device and it's a high res measurement of your breathing patterns. We're here now, we've got that, but stay away from those courses that try and sell you something that's antiquated and old. That went a long time ago. I know some physicians that do that. You need a PSG or something newer than that. The PSG is the attendance sleep study. Those are still hard to get, but it's getting easier. It's an incredible device, and it’s touchless; nothing gets wired to you. I can't tell you how many people come back from that sleep study, the attendance, sleep study where they glue electrodes to your face, your chest. Accelerometers, measuring airflow through the nose and I've had that test on many times and you're a little hesitant to roll over or sleep properly, but this test is just something you mount on the wall and you just jump into bed and that's it. And it's in your own home, in your own bed, your own pillow.

Howard: Wow. So you're saying you can do all of this without owning any take-home equipment.

Mark: Exactly, right. And as a dentist, you can use it. You just have the patient call knithealth, we'll have a program specifically tailored to dentistry, where the reports come back and that way we can, you know, look at our results with the titration or calibration of an oral appliance. That coming, but we'll wait till we get FDA approval, which we'll get. But there is no monthly subscription service and just a very accurate test that a patient can, can do, without too much resistance. A lot of patients don't even want to go into an attendant sleep study because the door doesn't lock, it's an unfamiliar place, and there are people next door sleeping and snoring and being tested. That's not a conducive environment to get a sleep study. It really isn't. And it's expensive. It's expensive. I mean, what's your deductible on your health care plan on medical? Most of us have, I mean being self-employed, $4,000 to $10,000, maybe $20,000. Well you're going to pay for that sleep study out of pocket $3,000 to $4,000.

Howard: Yeah, I went and had it done. And she said, I was her favorite patient because all the strands on the, being bald, she said that the most annoying thing for her is someone with a bunch of hair. So I was her favorite patient of the day. So another thing, a negative. They're saying, well, if I do this, am I going to have to learn medical billing? And is that hard? Do you do this medical billing? Is that a hurdle to jump?

Mark: At first it was maybe for the first few, but you learn to basically bill twice. The first time they're going to ignore it and it is a medical code. There are no dental codes for anything to do with TMJ and sleep and that kind of thing, as you know. It's simple. There are courses on medical billing and then they had these programs, software programs where they do all the medical billing for you, but they take a big chunk. So I would learn how to do it.

Howard: What is the chunk on that?

Mark: It's high. I don't know, but it's high. I've talked to some sleep dentist and they're like, oh my God, they're taking a big chunk and you don't need to do that. You can learn how to do this. This is as simple as billing just about anything else. You just have to learn how to do it, it’s one medical form. You can learn how to do this in a matter of hours and your auxiliary can do it and then it's out of sight, out of mind. You're just going to treat the patient and it gets billed. I collect upfront because you never know if the insurance is going to pay. Of course you're going to educate the patient. If the patient has the sleep study or recent sleep study at least five years or younger or more recent, and the prescription from the physician, which is being readily done now, physicians are on board now with the oral appliance. They've been educated. They used to think it was a TMJ device that would make things worse, but now we know, the studies are there that this can work and have a higher compliance rate in someone that has mild to moderate sleep apnea than a CPAP or EPAP. And the physicians love that; they're okay with this. They need to write a prescription for it. Those two things are needed before you bill the medical. Now Medicare is something different. I don't bill Medicare: that's a tougher, that's a different animal. But billing someone's medical plan, I would say 80 - 90% of it, we get an 80 - 100% coverage on a $3,000 to $3,500 oral appliance.

Howard: Now are you working with just one lab to make these appliances or do you use several different labs?

Mark: I use one lab, I used several in the beginning, and I've now found my favorite lab. Actually it was a Canadian lab, Strong Dental, 'Strong' as in 'strong', but they sold the American rights, Randy Strong, who modified the Herbst, it's called the Suad, S-U-A-D,  it's very strong, very robust. All the early appliances that I made weren't as robust as this one was and also this has a lot of adjustability, and I also liked that it doesn't have a lot of internal volume. It doesn't fill up the mouth. You need room for the tongue, you've got to let the tongue spread out, move forward and relax. Now Somnodent, sorry, Somnomed, Somnomed bought the rights to making the Strong or the Suad in the US So I use one lab. 

Howard: S-O-M-N-O-M-E-D?

Mark: Yes.

Howard: Is that the number one player in making these appliances, do they do the most units? Are they the four hundred pound gorilla?

Mark: Well, I wouldn't call them the number one player, but they're up there. They're definitely making a lot of appliances and I think that's why they bought the right to make this Suad because it's such a good device.

Howard: Yeah. And there's [inaudible 20:34] a device. I like to get specific because that's what they always asked me.

Mark: Right. I have it right here, I think. This is a model of it. I don't know if you can see that. It's basically a chromium cobalt kind of partial denture framework.

Howard: Raise it just a little higher.

Mark: And then they.

Howard: There you go, perfect.

Mark: It's got rubber bands, it's got the Herbst struts on it. The struts come in different sizes. You advance the device by adding little Delran spacers, you can use it with or without rubber bands. You can adjust vertical by adding acrylic or not. It's a thermal plastic material that of course will, as it warms up grips more but less tightly. I've had great success with this device and I've tried a lot of other ones. The Somnomed Fusion is pretty good. It has a lower lab fee, but there are certain things I don't like about it. So that's currently my favorite device. I'm always looking for a new one though.

Howard: What is that device called?

Mark: That's called the Suad.

Howard: Okay, that's the Suad.

Mark: Suad Elite.

Howard: Suad Elite? What is the lab bill roughly on something like that?

Mark: Good question. It's about $650, I think. $650.

Howard: And then what are you charging for this service?

Mark: $3,500.

Howard: And so that's definitely in the profit zone.

Mark: It makes you look like the hero. I had two follow-ups today and they're smiling, they're happy, they'll give you hugs, you've changed someone's life.

Howard: That is truly neat. So I'm trying to make a cookbook for them. So basically, your latest, you've got the book for them, The Eight Hour Sleep Paradox, how we're sleeping our way to fatigue, disease and unhappiness on Amazon. Ryan, can you push that out on social media? So on dentaltown, social media started with email groups and you'd open and you'd subscribe to dentistry@compuserve or dentistry and you'd open up your email, just crazy.

Mark: Bulletins?

Howard: Well that's what the scientists did, the Internet did on a computerized bulletin board services. That's what Dentaltown is. Dentaltown has fifty categories and the fiftieth one is TMJ Sleep, and we'll post it on that, we'll start a thread on that. So that's good. Then you're talking about, you've got the book, and then join the, AADSM and they have a meeting in Baltimore, June one. Are you going to that, this June one?

Mark: I am not, unfortunately I won't be able to go, but I will be going to the next one and I think that is going to be in Minneapolis, I think, or Boston.

Howard: And then you take a group, how many people are members, do you think of the AADSM, American Academy of Dental Sleep Medicine?

Mark: Oh, that's a good question. I'm sure it's thousands. I can't say more good things about it. It's done so much for me personally, health wise even. It's totally professional.

Howard: But the point I was going to make is: you want to go to Baltimore, June. Yankee is in Boston and it's in February. Boston is one of the greatest cities in the world, but not in February. And you go there and they say, 'well, you know, attendance isn't very good.' And you're like, 'well, yeah. Did you go outside? Do you think anybody wants to go to Boston?' And then you go to Chicago, Midwinter meeting. Chicago in mid-winter, just from the cab to running into the Hyatt and your bones are shivering. I think it's so funny how all these smaller groups all go to great destinations at the right time of year. It's like London. Do you really want to go to London in February and then see what the North Sea is all about? No, but London between May and October is one of the greatest cities. London might be the greatest city in the world for five months of the year and then the other eight months of the year you were wondering what you did in your previous lifetime to deserve this treatment. So you're saying they don't have to need a machine that knithealth, K-N-I-T, I wonder where that name comes from? Knit, like knitting. I grew up with five sisters. 

Mark: I wondered about that. I've been working with him for almost two years now and I never really asked but I sometimes wonder about it then I forgot to ask. Maybe it's knitting things together. There are a lot of things you have to pull together to have or to achieve overall good health. So I don't know, it's a good question. It did start out as a baby monitor, a very overqualified baby monitor.

Howard: So you started out with babies. I think it's funny because when I started getting into sleep years ago, you learn something, you never see anything the same. It wasn't that long after that and I was at a friend's house who had a five year old and I watch this five year old on the couch, he was grinding his teeth, he's kicking his leg and we all remember grandpa sitting in the rocking chair, snoring loud and being all weird, but my God, that kids only five. And then you started looking into it, and there's people saying that if he breathes like that through his whole development that he wouldn't have been maximum developed in brain and size and fitness. I just looked at him and think how many vaccinations he got, how many pediatrician visits. He's already been to the dentist every six months and he's five years old and nobody's picked up this kid can't breathe.

Mark: That's very well said. That's a great little story that everyone should keep in mind, and so I treat a lot of children. Again, I cannot diagnose sleep disorder breathing, but I can screen for it and I worked with the ENT's that are knowledgeable in this area. You can't just refer out to any ENT. Some of them will just turn around and say, forget it; the kid's fine. Even though they're mouth breathing, tonsils and adenoids are swollen. They're acting out, they're not sleeping well, and they’re bed wetting. It's amazing. But you're right. Again, as a dentist, you see kids at what age, one, typically, sometimes by age two or three, and you can make a big impact on their lives, especially if you catch a sleep disorder, breathing issue, mouth breathing because it leads to poor development over time. Crowded teeth and then they get the wrong type of Ortho and then they have sleep apnea for the rest of their life. So let's fix it before it starts. And that's a great opportunity for us dentists.

Howard: But what you're doing, it's not the American healthcare system. The American healthcare system, you see your doctor, you got a five minute appointment. 'Well, I'm having trouble sleeping.' 'Okay, here's Ambien. I got your blood work back. You got high triglycerides, here's a statin.' You go in there for ten minutes and he tries to write you five prescriptions and that's the US healthcare system. And we spend twice as much per person. I was born in '62, 1962 was the last time that the life expectancy went down two years in a row and the last two years. And now this is 2018, 2016 and 2017 it went down. You would have thought fifty- five years ago by now it'd be going up, up, up, and it's gone down the last two years. And then the stat that just blows my mind is that Americans are 5% of the world's population, which is nearly eight billion people, and in 2017 we took half the prescription pills.

Mark: That's shocking.

Howard: But if you really want to cure sleep apnea you need to just make a pill. Have you thought about that? Just making a pill?

Mark: Well, yeah, of course. I mean that's how we're wired to think and we're no better than physicians. I mean western dental care is reactive. In other words, if there's a hole, we can fix it. If there's a missing tooth, we can fix it. Medicine is the same way; medicine is great at patching you. Let's say you break an arm or you bash your head in. We can fix all that, right? But no one's looking for root cause and prevention. I don't know what you were told in dental school, but we were told that we were better than physicians in a way because we were more preventative orientated. And I don't see that in dentistry. In many ways we're just like modern Western medicine, is that we are reactive; we fix things. We don't talk about a dysbiosis in the mouth and how the oral microbiome is causing cavities and diet. We're just talking about acids dissolving calcium and we can go in there and fix it. We've got plastic, we've got metal, we've got gold, and we’ve got cubic Zirconia, whatever, porcelain. And that's got to change. We need to be more comprehensive healthcare practitioners. So physicians don't get paid to look for root causes. They've got their fifteen minutes and you can write meds and prescriptions in those fifteen minutes. That works and you can bill for it. So it's a flawed system.

Howard: Now, you don't take Medicaid, Medicare, PPO's or Delta, you don't take any of that do you? 

Mark: No, I don't take any of it.

Howard: Dr B. Does the B stand for Unicorn? Because a lot of them were really burned out and what's neat about looking around the world, I always tell people that you don't need an original idea with the SMP500, with the Russell 2000, we're two hundred countries. No matter what problem you have, why would you need an idea? There's two hundred countries, somebody's got a better outcome than you and it looks like to me, America and it's PPO looks like England when I got out of school thirty years ago when everybody worked for the NHS. And every year in [inaudible 30:42] your costs would go up and they would lower the reimbursement. And finally those two lines had to merge and now five thousand of the UK dentists flipped him off and said, I can't treat my own child like this, so I'm not going to treat people like that. Because it's very confusing when they come out of school, when they see people buy a Honda, the median average price of a new car in America is $33,500 a year and the average American will buy thirteen cars between the ages of sixteen and seventy-six. And they've got an $800 iPhone, they've got a $33,000 Honda or Toyota, and I'm supposed to do this filling for $100. Were you always off the grid with that or did you finally, like the NHS doctors, say enough's enough and walk away?

Mark: Yeah, it was the latter. But it happened early in my career because I was limited, my hands were tied and I agree with you and I hear a lot of complaints about the cost of dentistry. I think we're undercharging and I think we need to charge more and provide more of a service. I think our clinics, I think dentists need to practice together, my physicians do in group practices. And to lower the overhead and I think we need to provide more, and more of a hospital-like environment where, when we look at periodontal disease, we're looking at it in terms of a root cause kind of way of thinking and we're giving nutritional advice, we're measuring the type of bacteria and the flora or the biome in the mouth, and we're making decisions based on more data. Right now, we see gum disease, we see deep pockets, somebody go in there with our lasers and our scalers and there's really no way of knowing except over time, that we're doing the right thing, but it's not very evidence based. There's another term that gets thrown around very loosely, but I think we need to bump up our game here and go more clinical, more high end and then insurance has to follow us, hopefully, with that. They won't, they'll fight us on that, but right now we're just basically filling holes and scraping teeth. I'm exaggerating a bit but that's why sleep is so important. That's why you have to incorporate that into your practice. Also nutritional advice. I know that smoking cessation is a required thing now. It's a standard of care thing, but I don't know how many dentists do that. So it's something that we need to work on. Does it start in CE or does it start in the dental curriculum? I don't know, but we're talking about it now, which is great. And then there are millions of hundreds of thousands of dentists listening. So that's a start.

Howard: What I can't understand is that the person who holds all fifty-two cards of this deck are the dentists and they just fold to the insurance, the Medicaid, the Medicare, the lawyers. If the world's two million dentists all disappeared tomorrow, eight billion people will say, oh my God, where's my dentist? And dentistry is very different. Only 5% of Americans will see a chiropractor this year. But every single human on earth at one time in their life is going to need to see a dentist. So I want you to put your dad hat on. You're giving the graduation talk at Dugoni and they're coming out of school. They've got $400,000 in debt, they're twenty-five years old. What would you want to tell yourself if you were at that commencement hearing? Give advice to the kids in dental school since that's 25% of the people you're talking to right now.

Mark: Boy, that's a good, compound, loaded question. First of all, I feel I would say I feel bad for them. I mean, I came out with a lot of debt but not that much debt. I mean, that's a big chunk of debt. I would say, first of all, stay away from the big corporate dental concerns, you know, Western Dental, Smile Care, Smile Centers. The minute you step foot in there, you're going to be practicing dentistry, not the way you were taught in dental school and you're going to start feeling bad about yourself and you're not going to necessarily learn that much. I did that for about ten months and I learned a lot, but I learned what I didn't want to do and I think that was part of my decision not to take all these insurance plans. So that's the first thing, just don't get tempted or pulled in by a salary job that will start maybe beginning to pay off some of your debt. I would find a dentist that you admire, someone who's doing a good job where patients, they're getting good reviews, they're not necessarily dealing with insurance or they're managing it properly and they're treating their patients well. It may even be your dentist, your childhood dentist, maybe it's that. I get a lot of that from my patients. I've seen them grow up, they become ENT's and dentists and that's very gratifying of course, but they know your style of dentistry and that's something, maybe that's the reason they became a dentist because they thought that all dentists were that way. So I would, like in the old medieval times, there was an apprenticeship and, I forget what the analog to that is, the person who does the training and lock in on that person, and do an associateship, and with an option to buy, and work with that person for ten years or five years, however long it takes. But that's the only way to learn something properly, is to emulate and learn from someone who's done it. Don't take advice from people that their actions aren't speaking louder than their words, in other words, only take advice from people that you like what they've done and you admire what they've done. So I would go that route, again stay away from those big corporate clinics, where you can't put your name on the door. If you can't put your name on the door, walk away.

Howard: I always look at my dental office and say, okay, if I die tomorrow, how would this treat my grandchildren when I was six feet under ground? You know what I mean? What, what is the corporate culture of this place? So she's coming out of school and I'll tell you, whenever you get to a place and they're telling you, well if they have over five millimeter pockets, you've got to have these [inaudible 37:17] chips and when they say things like, well, 60% of your new patients are supposed to have periodontal disease. It's like what? I thought only people that had periodontal disease had periodontal disease, I didn't know there was a quota. So as soon as you start treating other people in ways you wouldn't treat yourself for money, you're going to feel bad, you're going to feel dirty, you're going to do depressed. And when you do things you don't like to do for money, it leads to disease and depression. I mean even the constitution says you have the right to pursuit of happiness. No one ever talks about that. They always talk about this amendment or that amendment. You've got the right to pursue happiness. If working in these clinics was a great idea, then they would all be happy and people would stay there for five, ten, twenty years, and is that what you see? Do you see a bunch of people going in there and staying ten, twenty years?

Mark: No, they branch out or they work for insurance companies. They sell out. Medscape today, I don't know if you saw the Medscape feed, physicians have the highest rate of suicide now, of professionals and I think it's just what you said.

Howard: Wow, can you find that on Medscape? About the highest rate of suicides?

Mark: Yeah, they've got their fifteen minutes to write a prescription and they know deep down that that's not going to fix things. It's a short term, it's going to make things worse, even. I mean the side effects and they're a part of a system that I don't think they were aware of before they went to medical school or they don't want to be a part of. I know a lot of physicians personally, I've done TEDx talks with them, I've talked books that we've written and everything and they're kind of in the same position we are. Oh, who's that? Is that your granddaughter?

Howard: Yeah, she just came home from school. Yeah.

Mark: Oh cool.

Howard: That's the thing, your granddaughter. You should be doing dentistry like you'd want to do it on your granddaughter. And once some big corporate things says, well, no you can't sit down with your granddaughter and tell her about lowering cholesterol with exercise and diet, or talking and you got to see a quote and you only get ten minutes to see a patient. Once you cross that line, it's not going to be good.

Mark: Right. Well, I came out of dental school and the first time I had to put an alloy into a kid's mouth, I kind of thought, oh God, I don't know if I can do this. And so I went exclusively to composites, even though back then they weren't perfect, but it all worked out. They lasted, they worked, and they were fine. There's no reason we should be putting a neurotoxin into the young people of America. That's just ridiculous.

Howard: I want to add another thing. I know how they think. I'm in a lot of dental schools each year. Here's what they come out with: Rome wasn't built overnight. They come out of school, they say, okay, I've got a limited budget and time, they've got to work, they've got to sleep, and they’ve got to eat. And I'm going to talk about the ugly. They have $400,000 of debt; they have to make money. Should she learn Invisalign? Should she learn how to place implants? Should she learn sleep medicine? Should she go to these institutes and learn TMD and occlusion, like Panky and Cois and Spear? She's got so many choices. Where do you think sleep medicine fits in all these decisions? And if you were twenty-five and you had $400,000 student loans, where would you begin? In what order would you learn it in?

Mark: Oh boy, that's a really good question, Howard. Well, the easy answer is all of it, but that's expensive and it takes a lot of time. I would work with sleep and Invisalign. Implants, I think that's something you can work on a little later. I would learn how to restore implants, that's not difficult to do and work with a good surgeon and then transition slowly, maybe after you get your practice going. As an associate, it's hard to do all this, because you don't own the practice. So I would work on sleep and Invisalign. Because it's easy, you're not buying a lot of equipment. When you buy a lot of equipment, for implant placement, and by the way that could all change. I think titanium is probably on its way out and that's going to be a big equipment change. I mean if we go to ceramic implants.

Howard: Okay. So what you're alluding to is, the largest implant company in the world, Straumann, as far as units bought, that's the high dollar. They bought the value system, Neodent, but they just bought Sir Calcium and then, and then Danaher, which is the largest dental company world, $17 billion. They had their high end Nobel Biocare and their value implants Drag. But everybody's coming out with a ceramic because there is no consensus in the marketplace because ceramics aren't even 1% of the market yet. But there's a lot of people that say well implants at five years, 20% have Peri-implantitis and in nine years the research shows 40 - 60%. So you're saying, you're one of the believers that the titanium metal is doing something and is part of the problem with Peri implantitis?

Mark: Yeah, I do. I think I'm seeing an immune response. Definitely. I don't see it that often, but I see it 20% of the time, maybe 25% of the time and know I don't like it. I don't like seeing pus coming from the focus.

Howard: Do you see any connection with race? Because if you came out thirty years ago, remember thirty years ago when they had PFM, they had the value PFM is a precious metal, porcelain depressed metal, that was the premium and then the value was porcelain the base and if they look like you and me, the skin would acid leach like costume jewelry, there'd be like green tattooing around the finger under the costume jewelry and there would be a tattoo around the gum. But I didn't see that in my American Indians, my Mexicans, and my African Americans. It just seemed to be northern European. Do you see that same association with titanium, that it's a northern European thing or do you think that Asians, Africans, and Latinos are having this too?

Mark: Well with the crowns and, I guess you're talking about metal poisoning, which is kind of a strong term. I think it's more readily viewable on skin that's pigmented lightly, oral mucosa that is pigmented lightly and I think I've seen it. You just have to look a little harder or provocate the tissue and you'll see the bleeding. So I see that little purple corona, I call it a purple corona. I mean there are many different terms for it and I stopped using Base and Nobel metals, if I use metal, only High Nobel. But with implants, I don't have enough information on that, but I see it. It's prevalent and I'm tired of seeing it.

Howard: Well the other thing, let's not kid ourselves, those implants aren't pure titanium because that's not ideal. So there are other elements in there and it might be just one of those little trace elements in the alloy to make it do what it needs to do. It might not even be the titanium because there is no such thing as a pure titanium implant.

Mark: Exactly. And then there are coatings and all that, but it could be the titanium as well. And have you ever thought of this, Howard, that the reason the bone integrates with the titanium is that it's an immune response? In other words, it's grabbing the implant because it's afraid of it or it's reacting to it. It's not necessarily a good reaction. It's a negative reaction, but for us, because it integrates, we can put a tooth on it. I don't know. That's just metaphysical kind of stuff. And root canals kind of have the same reputation. A poorly sealed root canal is basically a kind of a sepsis machine, right? I don't know. We need to redefine what we consider to be a success with an implant. And right now if there's no mobility, that's a success. Well what about the effects to the oral microbiome and tissue, and what about systemic effects? Are there systemic effects down to your big toe and to your heart, and to your liver tissue and is the kidney responding to that? Is it having to work on fixing that reaction? The big problem has always been, and dentistry knows this, is inflammation. We die of that. Chronic inflammation is a real big bad boy and we need to deal with that. That's what perio disease is. That's what a cavity is. And we talk about it, but it's all kind of lip service I think. And I think implants do create a systemic effect. It does activate the immune system. I mean, the studies are out there. I've read them. I mean, I'm not an expert on that level in microbiology and biochemistry and all that, but I've seen it.

Howard: I am so into research that I've never told Ryan this in twenty-two years, but you had an identical twin brother and I gave him up for adoption at birth for the control. And then I figured you guys could meet up when you're sixty and see what was DNA. Ryan just sent it to me on Medscape. Physicians experience highest suicide rate of any profession. Holy moley. Holy moley.

Mark: Holey moley, it's managed care. It’s managed care.

Howard: I want to say another thing that a lot of people don't think about, especially the young ones listening to us under thirty about sleep medicine and Invisalign, and that is when you're doing molar endo and you're placing implants and you're pulling wisdom teeth, you need some really exact vision, eye-hand motor skills, whatever, and then something happens to them. They can have an injury, they can have a car wreck, they can have a stroke, this and that and this and that, but doing hygiene checks, Invisalign checks and sleep medicine checks, don't you think that's a lot less technical motor skills? Eye-hand surgery than molar endo and removing wisdom teeth? And there are a lot of dentists that I know personally that when after they had the carpal tunnel syndrome, after they had the ski accident, skied into a tree, after they had the car wreck, said thank God I had Ortho skills, sleep apnea skills, hygiene check skills, because some of them forever lost. And it might have been just be psychological confidence where something happens to them and they just don't feel like they can go back and do that because it is more of animal spirits, eye-hand surgery to do molar endo and pull wisdoms and even implants then do Invisalign, sleep medicine, bleaching, bonding, veneers, and hygiene. Do you agree with that?

Mark: Absolutely I agree with that. And I think even for older dentists that aren't handicapped, if they want to continue to practice, sell a portion of the practice, or sell the practice,  work in your own practice on your patients and do a little sleep dental work, do some Invisalign, you could do a little consulting. As you get old and you've seen a lot of patients and results and all that, you're experienced, don't go away.

Howard: Come on, we graduated the same year, in eighty-seven. What is your definition of old now? I'm just curious where your number is?

Mark:       Well, I just turned fifty-nine, but I see a lot of dentists in my area working into their seventies, but their clinical skills. We wear a lot of hats in dentistry and after a while you slow down and you don't have the dexterity or the eye sight or even the core strength to bend over and lean over the patient and get in and so loupes have helped there. But let the young guys come in, let them buy your practice, help them, kind of foster them, nurture them, and you can still do some of things you really enjoy like sleep dentistry or Invisalign. Although Invisalign, how do you. Let me ask you a question, Howard, what do you think of these Smile Direct Clubs? How are they going to get away with that? They're not seeing the perio, they're not seeing the contraindications or the issues. I mean, how is that happening?

Howard: It blows my mind. So if you just got to the United States because a lot of dental students, they just got the United States freshman year. They come from all over Asia, Africa, everywhere. In my fifty-five years, the Washington DC Federal Government has always been pretty much useless with about 11% approval rating for decade after decade after decade. The game changer always comes from a renegade Attorney General straight out of school, wanting to make a name for himself and takes on big tobacco, takes on something. So what I am predicting is that, like even the Facebook, security deal and Cambridge and all that stuff; there's no way the Congress or the Senate will do anything. Did you see Mark Zuckerberg trying to explain that to a bunch of, it looked like he was at a senior citizen care center. The questions they were asking. I'm surprised he didn't bust up laughing. There are fifty states and there's always one renegade Attorney General. They did it with Microsoft, remember Microsoft, some guy went after them, the next thing you know he had twenty-two states sign on behind him. So, what's going happen is they're going to trip up and fall down on one patient somewhere on a Smiles Direct Club where some girl in a mall scanned the tooth, she's probably got a long face, jacked it all up and then they're going to have a Tyrannosaurus Rex because he wants to build a career for himself. They come out of law school and before they go and develop their big, expensive private practice, they want to go to the other side first and they want to cut their teeth on the government side. And so a lot of people think those government, they're all young and lame and all that. No, there's a lot of really ambitious young attorneys at these Attorney General's Office in fifty states. So that's my prediction, because that's all I see; you see patterns. I want to go back to where we started. We started this thing. I can't believe we've already done our hour. I want to go back to AsktheDentist.com because when I read AsktheDentist.com, you know it's funny for me. I was born and raised in Wichita, Kansas and I went to college, Creighton in Omaha and went to dental school at University of Missouri, Kansas City. And everybody in the Midwest knows that all the smart decisions, they start in California and they slowly roll over, everybody in Kansas [inaudible 52:27], they say, well, if you want to know what it's going to be like in ten years, just go to Disneyland and talk to someone in California. When I talk to dentists and I read AsktheDentist.com, you guys are in the middle of Silicon Valley. And when I read all your AsktheDentist.com, I like natural mouthwash, you don't like Amalgam, and you’re already backing out of titanium. My dad always said you guys were first because you were all hippies. Berkeley; it's a culture of innovation, Steve Jobs. Why do you think that people like you are already thinking about: I'm ready to go from titanium and ceramic when you know nobody in the Midwest is thinking about it and it'll be ten years. Why is California always ten years ahead of the United States? And if you're young and you think they're all a bunch of crazy bowl of granola, I used to always hear in Kansas: California are full granola; they're just a bunch of nuts and flakes. Well go back through history every ten years. Everything you guys did that was nutty and flaky, eventually ended up in Kansas. Why do you think that is?

Mark: Well, that's a good question. I never thought of it that way. I live and work in an environment where everyone is innovating. I mean my patients are BC's, they are engineers, they work at Apple, they work at Google and so I'm just used to that. And then when you have an original thought or you are counter or contrary to the byline, what the profession thinks, then you're not criticized. So I think it's the environment I'm in, I don't know. I was against mouthwash, killing things in the mouth. That just didn't make sense. Putting fluoride into water, that stuff didn't make sense to me early on, but because maybe where I work and live and because of the people, my peers who I'm around, maybe that's where it came from. Maybe I'm comfortable expressing myself and being contrary. Although I'm not always that way, I don't know. My dad was that way, maybe it's a family thing.

Howard: I really don't know if I should say this on my show, but it is Dentistry Uncensored so I'm going to say it. How many times have you heard people say the biggest problem with Google and YouTube and Facebook and all those companies is that there's no way to talk to a human. That you can't get anybody on the phone?

Mark: Yeah.

Howard: You always hear that?

Mark: Well, absolutely.

Howard: Yeah.

Mark: Drives me nuts.

Howard: Every time Dentaltown has ever had [inaudible 55:18] we've got a community, we've got an app and our programmer's like, 'Well we don't know. We don't know anybody at Apple, we just have to submit it and they send it back. We don't know.' And I always say to them, 'Well, just tell me where the headquarters is?' And they'll say it's in Cooperton, so I'll just google Cooperton dentists and I'll just get on the phone and say, 'yeah, this is Dr Howard Farran, is Dr. Mark Burhenne there?' And he’ll get on the phone, I'll say, "hey buddy, I got this problem with this company, this app, do you have any patient that you could give me their cell phone number or I could send you an email with the problem you could forward on?' Every single time your homies in the town, I don't care what the company is, I don't care. You know the President, all the top people in the Fortune500 they all have a dentist and those are the most likely people to go and get their teeth cleaned every six months. What's so funny is because if you just know where the company's headquartered, just get the zip code, and then put zip code, the dentist, start calling the office. What did they used to call that? We are six degrees of separation, that you are six relationships away from the Pope or any leader. So, Dentaltown, we've been saved so many times over the years. Now is that a hipaa compliant deal?

Mark: Well it's always about community.

Howard: It's always what?

Mark: It's always about community. Community works well, it always has. The electronic communities I'm not very fond of, but if we stick together and learn from each other, that always works. It's never failed.

Howard: Now dentists are always looking for articles to populate their Facebook page, all that kind of stuff like that. So is it cool if they post your article? Just links to your articles?

Mark: It's already happening. People do it all the time. All over the world. I'm happy.

Howard: That's great because I've already ripped off all your stuff. So I'm glad to get permission.

Mark: Okay, good.

Howard: It's always better to ask for forgiveness than it is to ask for permission. So is there anything else you wanted to talk about that I wasn't smart enough to ask?

Mark: Gosh, you asked some good questions actually. I'm just concerned for the profession and I just hope that we keep it all together. And again, I mentioned before, I think we've got to up our game. I think we've got to go more root cause and be a little bit more scientific, medical. We need bigger, better facilities and we've got to figure out a way to get reimbursed for it. We've got to stop just filling the holes.

Howard And the bottom line. A lot of times a kid will ask me, they'll say on Dentaltown they posted a case, and they're saying, 'God, Mark, would you re-treat the root canal or would you pull it and do an implant?' And I would say, 'Well, the first damn thing you should say to yourself, what would you do if it was your tooth? Follow your tooth.' You can present the options to the patient, but obviously most people are going to say. My physician says, 'well you can do this or this.' I'm going to say, 'well, what would you do if you were me?' And once you're treating the patient exactly how you treat yourself, are you good to invert that and say exactly the opposite of how you treat one of your children. So once you do that, it's easy. So if you catch yourself in a job doing things that you don't like to do for money, leave, be true to yourself because at the end of the day, the two hundred and eleven thousand dentists and the one million MD's hold all the cards. It's funny, it's the one of the greatest political scientists’ quotes in the world. They said, when you study history, they said all the people always go along with the government until they don't. You beat them up, you push them down, you push them around, and one day they tear down the Berlin Wall and say, we're done. Nobody predicted the Arab uprising. Everybody always goes along with what you're doing to them until they've had enough and then they don't do anymore. So just everyone be true to yourself. Same thing I asked from my four boys, the only thing I want them to be as happy and healthy. Mark, it was just an honor that you would come on and give me an hour of your life to talk to my homies today.

Mark: Any time.

Howard: Thank you so much.

Mark: Call me again anytime.

Howard: All right buddy. Thank you so much for all that you do for dentistry. Thank you for educating so many consumers. Ryan, thanks so much.

 



Category: Sleep Medicine
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