Dentistry Uncensored with Howard Farran
Dentistry Uncensored with Howard Farran
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1079 Discussing Silver Diamine Flouride with Steve Duffin: Dentistry Uncensored with Howard Farran


8/29/2018 4:00:35 PM   |   Comments: 0   |   Views: 559
Steve is a general dentist in Keizer Oregon. His background is in microbiology and public health dentistry with an emphasis on the care of patients with special needs. He was involved in the early development of the dental program-serving clients for the Oregon Health Plan and served as dental director and CEO of Capitol Dental Care for ten years, before returning to private practice in 2005. In recent years Steve has focused on introducing caries management programs utilizing silver ion products in countries in the developing world.

VIDEO-DUwHF #1079 Steve Duffin

AUDIO-DUwHF #1079 Steve Duffin

Howard: It's just a huge honor for me today to be podcast interviewing Steve Duffin DDS he's a general dentist in Keizer Oregon. His background is in microbiology and Public Health dentistry with the emphasis on the care of patients with special needs. He was involved in the early development of the dental program serving clients for the Oregon Health Plan and served as dental director and CEO of capital dental care for ten years before returning to private practice in 2005. In recent years Steve has focused on introducing caries management programs utilizing silver ion products and countries in developing world and my gosh it's so amazing because the whole 31 years that I've been a dentist you know the the pediatric dentist there are no controversies of them, endodontists I never I never sat at a bar with two endodontists violently arguing about something, all the dilemmas were always an occlusion and the occlusion cams neuromuscular though they're like world religions and they just weren't ever gonna agree but now pediatric dentistry has come under this deal because of silver diamine fluoride it's now an official controversy. We had I'm one of you're one of our mutual best friends Janet MacLaine and she was very upset with some of the remarks that Gordon Christian made about silver diamine fluoride on my podcast and she was like I mean I think that it gave her a heart attack listen what Gordon says so we have a full-fledged controversy in pediatric dentistry and you have to be one of the top five experts on the planet in this arena and for a long time you made a us a CE course all the way back in 2011 which is still relevant today so so why is silver diamine fluoride a controversy in 2018?

Steve: So I believe that it's a controversy because people don't understand it they don't understand the history how GV black introduced silver ion compounds a hundred years ago and there the dentist's used medicine to treat caries and so we're taught to cut it out surgically and put in a plastic filling material and so this philosophy goes contrary to that training that we've all received.

Howard: Yeah I am that was the biggest expenditure I made of could not justify some guy was selling the first three books autographed and signed by GV Black that he found it in the state cell and I paid way too much money for him but it's amazing how dentistry they're still engineers. To me dentists have always been building this barn out in the middle of the farm and then they screaming you out the patients because it's always fails eaten by termites and it seems like the Japanese and other people in history have not looked at dentistry as an engineering firm we build bridges we construct crowns they look at as a biology issue that the mouth has got you know ten billion micro and per CC of microorganisms fungi viruses plaque all this stuff like that and it seems like the Japanese you know they always looked at fillings like glass ionomer more than and an amalgam in my lifetime it really does seem that dentistry has been moving backwards in restoring dentistry because when I was in dental school 83 to 87 everybody had amalgams and gold and those amalgams the last 30 years hell the amalgam was half mercury you'll never find mercury in a multivitamin the other half was silver which is your expertise silver diamine fluoride, tin the hygienist used as fluoride. Every ingredient in amalgam is antibacterial and those things last 14 to 38 years depending on the research now we would taking them all out we replace it with inert plastic, not only does the data show that they're averaging a six and a half years but the recurrent decay hell you take it out with the number four round but it's mush and when you tell that to dentist it's like a religion oh well maybe your maybe your composite last long but my composites last forever it's dude are you out of your mind and so do you think it was a great idea to switch from amalgam to inert plastic composite fillings and do you think the composite fillings last as long as the amalgams?

Steve: So I bet I definitely do not believe that composite fillings last as long as amalgams the question of is it good that we took amalgams away and is the mercury in amalgam actually toxic is a very controversial subject and it's probably outside of my wheelhouse I had the good fortune of training in microbiology before I went to dental school so I'm always thinking about the bugs and I'm thinking about the biofilm in the physiology of bacteria and the role of sugar and acid and demineralization of tooth structure and how can we intervene to stop that process and so silver has come along and given us another tool to take us down to the level of the microbiology.

Howard: Well I'm gonna hold your feet to the fire them move back to silver diamine fluoride but do you think a silver mercury filling is toxic to a human the way it's practiced in America today?

Steve: So I would say I don't have the answer to that I'm not an expert.

Howard: Dude you're the smartest guy I know on the subject, quit being Oregon humble.

Steve: I stopped placing amalgam restorations about 13 years ago exactly and I fell into the resin camp but then I also saw the development of the glass ionomer materials the early ones caught my attention but they didn't work, I'm fascinated with the newer glass ionomer materials and the combination of silver treatment plus glass ionomer that's really where my attention is.

Howard: I stopped 99% of my amalgams day one when I got down school Phoenix wanted whiter brighter fillings I mean there and it was weird I'd say would you want a silver filling or our tooth colored filling well which one lasts longer oh the silver one lasts twice as long as a tooth colored okay I'll take the tooth color okay why did you even ask what does. So I have stopped it from a demand issue but I want to make one clarity because you you traveled the world teaching people preventive dentistry you're on your way to Bolivia now and when I'm in I've lectured in 50 countries and I've been saying 50 countries Ryan my son Ryan says dad you wouldn't say in 50 countries since I was in grammar school and he was due to list one day he got he got 50 countries and he was only done with like a couple of the continents so it's a much bigger list but you could only do tooth colored fillings if you have a dental assistant the high speed evacuation and rubbered damn stuff and I'll never forget I don't want to throw a country under a bridge was in Africa from this dentist he prepped the tooth he asked it at stead then the patient stood up and swished and then spit in a pickle bucket and then he put on the resin and cured it and then the patient sat up against wished spit in the bucket then he put on the composite cured it then he spent like this 20 minutes putting the most elaborate polish on there and I'm just sitting there like okay this whole thing is. So I have never seen composites placed correctly unless you're in a dental operatory with high-speed suction and a dental assistant so when a bunch of rich dentist in the 20 richest countries get on Facebook and an Internet and social media and slam how they don't like amalgams they're really doing injustice to 4 billion out of 8 billion Earthlings who live an environment where that amalgam I mean you could place an amalgam that when you condense it Bloods coming up out of the top of it and it'll last 20 30 years.

Steve: Exactly precisely so if you can imagine we one of our projects were conducted in Ghana. Ghana is a African country with 28 million people living there and about 200 dentists so essentially there are no dentists in this country and so we went to a rural area of Ghana and used silver to stop tooth decay in children that with no electricity no sophisticated equipment whatsoever we returned at six months and 12 months to collect the outcome data on the progression of tooth decay and the prevention of new tooth decay and it's dramatic more than 90 percent. So we showed that we can go to where we don't have all of the sophisticated equipment and we can at the very least stop the progression of the disease.

Howard: So to put that in perspective Ghana's got one dentist for every one hundred and forty thousand people.

Steve: Exactly

Howard: America's got one dentist for every 1850 lets just say 2000. So wow that is amazing that is just amazing yeah so that is a that is a beautiful story. So we have 70 times the concentration of dentist in Ghana so it's really hard to make macro economic or macro dental statements when you're dealing on a planet with eight billion people in over 200 countries, where does this come from in you why have you been taking dentistry to the underdeveloped world for your whole career what does that come from?

Steve: So I've been very interested in public health dentistry from the very beginning and I got involved with the development of the Oregon Health Plan in 1994 which was a reconstruction of the Medicaid program in Oregon and they completely turned it inside out and from the dental perspective we those of us that were interested in low income and Medicaid we said how can we reinvent this so that we're not just throwing more money away and when you think about taking tax dollars and putting it into systems that don't work that's silly. So we talked about how can we achieve healthy people as the outcome rather than a filling that lasts more than five years and so it's amazing that I was kind in the middle of this process when I heard a lecture by Peter Milgram where he talked about this product that's being used overseas called silver diamine fluoride, I had never heard of it before and this was about 2006 and so I got on Google and I got on PubMed and I got some papers about silver fluoride and I contacted a colleague in Japan and I had a mail me a bottle of saferide and I sat there and I looked at it and I thought about it and I read papers about it and then I eventually got out of micro brush and started treating some cavities and I was absolutely blown away by what I saw in the early cases and the cases that I started using silver on were the ones that were going to the OR. So these are children with massive advanced early childhood caries scheduled to go to the OR, I had a wait time of 3 to 6 months many of these kids were getting abscesses and so I had just hoped to just slow the process down but when I took the kids to the OR to restore all their teeth what I found was astonishing. The regenerative tertiary dentin that had formed underneath the active cavities allowed me to dramatically reduce the amount of restorative dentistry that I was doing and eventually I quit going to the OR, I haven't gone to the OR in over ten years with these children.

Howard: Well that's where our buddy jeanette mcclain I mean she's so passion people don't really think that kids die from anesthesia I mean we're out here in Arizona just one city alone in Arizona Yuma they lost a little girl in December and three years ago same damn city lost another three-year-old I mean there is a rift and then and then to put this in a legal esk to point away I'm not a lawyer but I am a dentist with an MBA and there's only three publicly traded dental companies in the world two are in australia 1 in 300 smiles and pacific smiles and in Singapore Q&M and when they went public the The Wall Street boys made them say they can't do any anesthetic on anyone under 16 or over 65 because that's where all the risk occurs and Wall Street didn't want to have some you know one three hundred smiles have a hundred locations and doing pediatric dentistry and putting kids to sleep because because want one loss of a child not only is that just horrible it's just even an economic disaster and so what did you think of so what do you think of when these pediatric dentist says I'm sorry see if it doesn't work and I just listened to Gordon Christian and he's the god of dentistry and he said it doesn't work, what do you say to that?

Steve: They're simply wrong or they have no experience with the product and so we've been using it for over 13 years on thousands of patients both within my general practice here in Oregon which is a typical general practice seeing children and adults of all age groups we have about a 30 percent medicaid population so a lot of that all the way around the world. You know you ask back to your question why do I go around the world because I see the opportunity of using the medical management of caries with silver ion compounds as an opportunity to address this global pandemic of caries in a novel effective and in a cost-effective manner. So I'm really excited about the future of this approach to care.

Howard: Okay so let's pretend I'm sure all the Millennials listen this all know what's going on but the older guys I mean when I go to the bar with my alcoholic dental friends they're all gonna be in their 50s and 60s and eat cheeseburgers drink beet, none of them have ever used silver diamond fluoride so let's start from a what is it how do you use it how do you recommend learning it are you gonna build us a new course on dentaltown about this? Your last course was caries medical management was an outstanding course I absolutely loved it it's the medical management of caries you put it out in 2011 it's still just as good I watched it to review for this one but do you think you'll never make another silver diamond fluoride lecture course?

Steve: Sure I would and a couple of things have changed one in 2011 the FDA had not approved silver diamine fluoride for use in the United States so you could obtain it and use it if you wanted to but it was not FDA approved and my presentation had to do with using silver nitrate and fluoride varnish as sort of a combination therapy because we had no silver diamond fluoride. As of 2015 that's changed and we do have the product, the product was developed in Japan in the 1970s by combining the effects of silver nitrate which is essentially the silver ion antimicrobial properties of the product that GV black introduced 100 years ago with fluoride. So they combined it they marketed it as Saforide it took a long time to come to the United States but now it's here.

Howard: When do you think they wanted to get FDA approved here because there was just what's the name of that company in Florida?

Steve: Elevate Oral Care markets a product which is called advantage arrest which is an identical product to Saforide which is produced in Japan.

Howard: but but just very recently only Saforide was selling it but now you're saying only Elevate was selling it but now you're saying that I'm that now the Japanese product is for sale too so there's competition?

Steve: No the Saforide product has not attempted to enter the American market yet there is one other manufacturer from Australia SDI which has a product called Revsstar, Revastar is a combination silver diamine fluoride followed by potassium iodide which is kind of a novel approach to minimizing the darkening that happens when silver ion is in contact with decay however I will let the marketplace decide who wins out I personally continue to use silver diamine fluoride.

Howard: From who?

Steve: I used from elevate so manufactured right here in Oregon.

Howard: Its manufacturer in Oregon elevate is what sold out of Florida?

Steve: So you know they're a national distribution company but they at first brought the Saforide product and distribute it and then manufactured it and I suspect there will be a lot of other players in the marketplace the important thing is that silver is very effective in arresting tooth decay.

Howard: It's called safer wide one-word?

Steve: No saforide right

Howard: Saforide

Steve: Correct

Howard: I just want to say one thing about this I mean I don't like to talk about religion sex politics or violence because it's so polarizing I want to keep it on dentistry but these are strange political times right now and even if you don't like it you you have to understand where is all this anger coming from and as a dentist this anger is coming for me like the FDA they you know the abuse of government like the lady I bought this house from she had to move to Scandinavia because an American company she had brain cancer an American company had a medicine they started an FDA test she couldn't get in on the test the only place she goes she had to move to Scandinavia so she does she was an American and then here's an American PhD that comes out the chemotherapy but it's the government who made her leave her country and made her go die in another country I mean that is so sick and if the government was on your side the FDA could just say I don't care what you buy but it's not FDA approved but they're not they're not good with that they're saying hey hey we haven't approved it you haven't given us the millions of dollars in the five years so we don't sell it. I remember sitting with John McCain at a fundraiser with his wife Cindy and I told him I said you got these Indian reservations and there's all these Mayo Clinic's and hospitals why you make the Indian reservation instead of just having casinos why don't you make them an FDA free zone we're screw the FDA. So that people dying in America they can't get on some damn lists can volunteer with their own money drive to the Indian Reservation and and I'm telling you the healthcare system is a cartel and when you tell dentists that they don't like they don't they don't like to hear it but I think it's insulting that as an American I can't buy silver diamond fluoride from Australia or Japan and use all my patients I mean I can tell my patients this is a new thing it's they do this in Japan and Australia it's not FDA approved by the American government but it's just over the top abusive.

Steve: Howard I think it's important that we clarify that what FDA approval means the FDA has approved the importation and distribution of silver diamine fluoride for use as a desensitizing agent and a cavity liner they have not approved it for caries however there are large trials being conducted at NYU and the University of Michigan which hopefully will move the bar so that we can get SDF approved for curious use. Now you and I can get SDF and we can treat caries in our practice today okay and it's called in an off-label manner I've been doing off-label procedures for years when I think they're in the best interest of my patients.

Howard: Okay so are you but you're not using the Saforide from Japan on your patients?

Steve: I'm currently using Advantage arrest.

Howard: Advantage arrest out of?

Steve: Florida

Howard: Okay and what you say the name was the one in Australia?

Steve: So the product that has just recently received approval is called Revastar by SDI don't know what that stands for but if there were an Australian company.

Howard: I've been there I've lectured in Melbourne and spent I went to dinner with it's a family business the old man's turned over to his daughter SDI southern dental technology and they used to make over half of the world's amalgam and just an amazing company but the dentist down there told me that they like their product down there better because the the American product turns it really a darker color black and there's a way it sets up with the phosphorus and everything it's more of a charcoal white. Do you agree or disagree with that?

Steve: I disagree with it, I do not support the use of potassium iodide after silver application because what happens as you create a silver iodine compound which removes the silver ion from the ability to interact with bacteria. So in my view I want to put as much silver in front of those bacteria as possible because it's going to kill them and then when the lesion turns dark I can fix that I can cover that dark cavity with a nice white glass ionomer cement there are a lot of things I can do but I don't want to minimize the antibacterial properties of the free silver ion.

Howard okay so talk about what the general dentists do now he's a three year old she needs some pulpotomy and chrome steel crowns she what would her what are you doing differently now?

Steve: Unfortunately if we see the three year old and they need pulpotomy and stainless steel crowns it's too late, I mean the nerves are involved there's infection they need pulpotomy and stainless steel crowns that's not going to change that if we can see the child when the caries is in enamel or in dentin and the pulp is not involved it's time to get silver on that lesion immediately and so the protocol is very simple you basically dry the tooth dry the cavity you apply the silver compound directly to the lesion and then the protocol that I've been fond of is to then cover that with fluoride varnish because that prevents saliva from contaminating the treated area.

Howard: and why do you think this has made a reduction in emergency room visits?

Steve: oh it's just in my practice okay after using silver compounds for a couple of years we eliminated Hospital dentistry we dramatically reduce the number of emergencies that were being seen in my practice because we were able to just put out the fires earlier.

Howard: So you were putting out the fires earlier that would have led to pulpotomy crome steel crowns?

Steve: Exactly, precisely

Howard: So what should the dentist do how should they learn about this today they get done listening to you what's their next step to learn about this?

Steve: So number one I would recommend visiting our two web sites okay the first website that we developed and I want to give credit to my son Marcus Duffin who's the scientist and technology guy builds a...

Howard: Is he right next to you?

Steve: Yeah he's here

Howard: Well get his pretty face in,  how are you doing

Marcus: Howdy

Howard: My god you got a face for YouTube why aren't you sitting by your dad the whole time. So what www to that website?

Steve: Okay

Howard: and what's the MMC stand for?

Steve: Medical management of Carries so

Howard: Nice

Steve: and we have placed a huge amount of literature on that site scientific evidence references we have interviews with patients we have a lot of content.

Howard: and what percent of it is fake news?

Steve: Zero sorry thanks for asking but no it's a very good place to learn about this and then the second website that I recommend is called WWNODK.

Howard: Right okay I went before I go there I'm not smart enough to go I want to go over search for medical management carries library medical management carries library .com.

Steve: Correct

Howard: You got the home the home page then the third button is smart what's smart? I clicked on that I thought I'd see a picture of myself and I did not.

Steve: We can change that Howard.

Howard: So what's smart?

Steve: Smart is an acronym which we're hearing more and more about which stands for silver modified atraumatic restorative treatment. So Jeanette has also promoted this idea a lot and so we're talking about smart treatments.

Howard: Okay say it again.

Steve: Silver modified atraumatic restorative treatment

Howard: Damn and who thought that you're Jannette?

Steve: well let's give Jennette all the all of the credit for that there I don't remember but smart dentistry and and let me say Howard we are writing a book and the book will be called smart dentistry.

Howard: Steve Duffin, Jacqueline Jewell and Joseph swab.

Steve: Yeah we're the editors and this book will come out probably in November and it's a comprehensive textbook Jacqueline and pardon me Jeanette McLean is a chapter author in the book and so we'll let you know when that occurs.

Howard: Well I would love to push I hope maybe you could do online CE course and then and promote the book there or just posting on it send me the pictures and all the information I'll push out in dentaltown and social media and all that stuff I'll try to market the hell out of it for you.

Steve: We'll send you the first book.

Howard: Yeah well I mean it's so important because you know it's like my two older sisters are nuns and they're really traumatized by all this stuff going on the Catholic Church has been in the news and in fact being a hundred percent Irish you know I know you know supposed talk about religion sex politics violence but I almost wish everybody would give Sinead O'Connor an apology for how they treat her on CNN 20 years ago because she's from Ireland she knew what was going on and so you got to look at your own industry dentistry and this is where people die, this is where little kids die and everyone is my age I mean I would donate my kidneys to my five-year-old grandson I mean I would rather die in a minute than my grandchild and these grandchildren I mean when you see someone die especially in Arizona when they die in a damn dental chair they're almost always under six and that is just it's horrible.

Steve: and the thing is we can stop that because we have a new tool that allows us to treat the disease atraumatically without sedation it's very effective and it can help every kid in America that is being traumatized by what we were taught to do.

Howard: Yeah which is an engineer physically mechanically cutting everything out of Iraq and restoring it with you know wood and lumber and all this stuff as opposed to treating it as a biological infection.

Steve: Correct

Howard: Kind of like substance abuse they treat that as a religious moral issue instead of the medical management of disease I mean someone it does it doesn't do any good to go sit in prison for five years because you got caught with meth but it makes really good sense 30 60 90 days with therapy you're in I mean anything after that now you're just being mean. So you're saying we really need to switch more from being an engineer dentist to a biologist a microbiologist.

Steve: Exactly we need to bring biology back into our profession in a big way okay.

Howard: Well let's let's talk about my buddy Gordon Christianson who I love but disagreed with you did you get to hear that podcast or any of his comments or or is there any any specifics you could address on that to educate Gordon and Rella you think differently?

Steve: So we apparently think differently but let me just tell you a little story soon after I discovered the miracle of Saforide in my practice and I was so excited about what I was seeing this is in about 2008 or 2009 the first thing I did was get on an airplane and fly to Provo Utah with a bottle of this product from Japan and handed it to Rella, Gordon wasn't available and told her about this miracle that I was seeing in my practice and with the hopes that they would study it and look at it and apparently they have and we've come up with different opinions and you might say that I'm supporting the opinions of the clinicians like Jeannette McLean and John Forshell etcetera and we have scientists like Jeremy Horst who is strongly advocating for this so you know Rella and Gordon are gonna take their own path and I respect them but hopefully they'll come around.

Howard: Yeah and that's where I love it you know dentaltown is a lot of people don't understand freedom of speech a lot of people get really upset when we edit or ban the remark and they say he's freedom of speech between you and the government you have the right to go hold a sign in front of the White House but if you walk in my house either I have the right shoot you and on dentaltown we have a report abuse button so when you guys good people good honest good moral people disagree and but it's when it goes below the belt I mean it and that's why but you know these debates are healthy is that's what I love about dentaltown, someone will just post something obvious to me and then the next guy will disagree with a point that I never even thought of and it's like the more I read dentaltown the dumber I feel because the dentists are so damn smart and they just tear this stuff up and shred it to pieces. Sometimes I'm reading these threads it's like I'm not even smart enough to be in reading these debates and it's amazing how they shut us up up go back you said you had two websites you talked about the first one.

Steve: Right the second website is and this is again a very rich source of endemic...

Howard: NODK stands for no shots no pain or where do you get NODK?

Steve: NODK is the name of this little device which was invented by who come on Marcus this guy right here.

Howard: Well you're such a good dentist why is your son wearing a denture because his teeth look too perfect to be real.

Marcus: Because he's a dentist.

Steve: So I said mark Marcus was in graduate school in Connecticut and I said hey Marcus we're just having this amazing experience in the dental practice and I want to be able to take it to the rest of the world you know where there's no electricity and no dental offices and that sort of thing and I asked Marcus to to figure out how to do that and so he invented this device that contains silver diamond fluoride and fluoride varnish and it allows an operator working anywhere in the world to treat cavities atraumatically inexpensively and so my new passion is to take this message and this product NODK to the rest of the world.

Howard: Now what's your son's name?

Steve: Marcus

Howard: ma rcus?

Steve: Yes

Howard: Is that because you're a big fan of Marcus Welby the show when you're a little?

Steve: His mom named him.

Howard: Well we'll just say it was Marcus Welby that was one fine show and he's handsome is Marcus Welby. Marcus email me any of these YouTube videos that you want taped onto the end of this podcast because a lot of people are driving there you know a podcast is a multitask so probably 85% are on our commute to work and then the rest are the poor bastards on a treadmill or a Stairmaster and I pity those guys but anyway. So like a video on this NODK or any videos you want your, your dad sent me one YouTube video link but I mean I would personally want to see a YouTube video on this so any videos you want just email it to me and we'll attach them on to that deal and then we post and when we post one only post us on dentaltown. Have you post it in these videos on dental town Marcus?

Steve: I don't believe so, no.

Howard: Marcus?

Marcus: Yeah I'm back sorry.

Howard: Though if you went to pediatric dentistry you can make a thread on your dad and what he's done and then when you make a post to youtube when you go to youtube when you hit share you know how there's a link a YouTube chair there's also another one embed and has the code. So then on the message board you click the youtube link drop the embedded code in there and now your youtube video is is there in the message board and then with YouTube when the YouTube video just gets played inserts from people that live around your house or your office your business it doesn't get good SEO but when dentists start clicking that YouTube video from all around the world that SEO will go crazy so then when some dentists is searching YouTube or is on YouTube, Google is gonna show them those videos and thank you to the eighty two hundred dentists who have subscribed to I mean that that's like doubled in the last year from like four thousand eight thousand. So yeah so post all those videos start and start a thread under pediatric dentistry because Janette I feel sorry for Janette MacLean because she's been on on dentaltown standing up to all these old guys and she needs some help and you're no spring chicken see I'm 56 how old are you?

Steve: Yeah I'm 63

Howard: Well the guys throwing off it crap are our age say it'd be really great if you went in there and helps it of them because I think you sometimes it's just tough for young Millennials to stand up to a bunch of prestigious you know 50 60 year old pediatric dentists and stand up to them and I love your YouTube videos in fact by the way if you go to your  youtube and just type in a Steve Duffin God yeah how many videos you have on there?

Steve: Who knows a lot

Howard: Yeah well you ought to put them all on one thread you gotta call it the Steve Duffin thread I'm dead serious it'll explode your views your information they need to hear and and whenever you get inside a tribe you know a tribe always has their leaders their cultures their customs and their followers and they don't like any change and right now the pediatric dental tribe is a bunch of old guys like us and a lot of them are not listening even now their God Gordon Christian I mean if you're Muslim you go to Mecca if you're dentist you go to Provo I mean I've been there a dozen times and to go kneel at a Gordon and Rella's feet love him to death they're like my dental mom and dad in fact he's got three kids to her dentist ones a hygienists I'm the same age as those guys and he's not buying into this and so it's a tough fight and that's why who's that other guy you said?

Steve: This book we gotta have the book

Howard: Yeah I know market the crap out of that for you, that other guy Jeffrey Horst?

Steve: Yep Geremy Horst at UCSF, amazing guy.

Howard: Can you get him you know maybe we should do a one, two , three punch the podcast next should be him and then the one after should be that, Who's that other dentist you said from University of Washington Peter Milgram?

Steve: Yeah

Howard: Yeah are you are you friends with him?

Steve: I'm friends with Peter and Jeremy Jeremy studied under Peter at the University of Washington and they're both very influential in bringing this product here to America.

Howard: Well let do a one-two-three punch let's just boom boom boom let's do Jeremy and Peter you know following up because again what makes me just sad is that in my sacred sovereign professional dentistry when I see a three-year-old die because they had to drag her to the OR I mean that's just that's horrible and that needs to stop first who cares if you do a composite on mom in the last six and a half years is tooth colored instead of 38 years because it's silver colored when she's wearing silver earrings a silver band and as a silver bar through tongue but gosh darn when her kid dies in the OR.

Steve: So we need a hand piece down and picked this up.

Howard: Nice

Steve: 19:1 microscope

Steve: So when we were little and got out of school Dr. Keyes was going around the country and he was setting up these light base microscopes and we were taking swabs out and I did that in 87-88 and I was there thinking how did why did we stopped it I do remember we moved it to the back room it was in the lab and it said but what did you think about the keys method and because when you would do that and it'd be the first time like when you use an intraoral camera it's the first time the patient's seen the back of their own teeth when you do a digital x-ray and samite and that's so much better than a little film but man when we used to do the key technique and they would see all these things running around and crawling around and live bugs in their mouths they became microbiologist so what do you think of Dr. Keyes is technique and why did that leave dentistry?

Steve: I love it and I think the reason it left is because the economics did not support it. Now what we're suggesting now as we approached it we're trying to reintroduce prevention okay we need to have the correct financial support for doing that and in the textbook we have a whole section on policy and economics and there has to be a shift away from procedure based fee for service revenue to capitation based outcome measurements so when dentists are making the same amount of money and they're not at risk and they can do something that's better and say the children we all win.

Howard: Okay but now I got a call baloney felonio on because I lived through this just like you do so basically in a nutshell the insurance companies are not at this table with the dental, like even the American Dental Association I podcast the executive director their head economist they don't even have access to. Delta Dental probably files 20% of all the claims in dentistry and that data is not transparent to the providers and that's because it's kind of like the israeli-palestinian issue they've just never had a good-faith open talk relationship and that's been really sad but when the insurance companies evaluated capitation at the time it was pretty much a good round number that the dental insurance was costing $20 a month per person and they wanted to switch from this procedure or fee for service to an overall health model where we'll just give you a lump amount and then that would take away the incentives to drill fill and bill procedures and now you'd have an incentive just to keep your pace and happy and I lived through when they did this but they cut the money transfer from $20 a head per person which is averaged to eight and even around that to 10 and I would go around to these insurance guys I'd say man I loved all the philosophy what you said quit giving them incentives to drill fill and bill and place fillings and crowns and just give them the money to keep them healthy so they're incentivize for preventive but you cut the revenue and a half it's like they never ever tried this system. I mean no economist would say that that was a test model I'm capitation was tried and failed miserably but it says guys they cut the revenue in half.

Steve: Because the insurance companies that were still in control of it and you're absolutely correct they cut the revenue in half and the provider did not get the $20 so what did I do when I went into practice in 2005 I cut out the insurance company, I as a dentist went to the state of Oregon and said if you will it take the $20 per month you're paying the insurance company and give it to me and cut out the insurance company I will take care of them and I will guarantee that they will be healthy and that worked I did that in 2006 twelve years later we're doing the same thing we don't have an insurance company involved.

Howard: Why don't you write an article that for in dentaltown magazine.

Steve: So there's a whole chapter I'd be happy there's a whole chapter the book coming out.

Howard: or maybe write an article on a book review. Why don't why don't you write an article for dentaltown magazine I think it's so funny how people say that print is dead it's always the nuances you know what's dead is people paying for a newspaper why would you pay for a newspaper when you can open up your iPhone and go to Google News or Apple news but I tell the local newspaper here I said what I you're going the wrong way your subscriptions are going down so now your circulations going down advertised going down if I want a newspaper today I'd start throwing the Sunday newspaper on every house in the city they're monkeys you throw the damn Sunday newspaper out there they're gonna go out there and pick it up and if there's interesting stuff they're gonna read it they're just not gonna pay for it and that dentaltown magazine I cannot believe how the viewership just keeps going up and up and up and up and I think a million years from now monkeys are still gonna want to sit in rocking chairs drink warm liquids out of a cup and hold stuff with their their little sausage fingers and read it if it's engaging, so write an article about write yourself a book review of your new book and then we have the podcast and all push it all out on social media and we'll try to we'll try to get this this pediatric dental ship to start slowly turning around and going the other way and back to the insurance companies I just want to say one thing with the insurance companies. I learned it for my father you network with a value chain you'll go like I'm lecturing in Ohio next week and my god I the whole room not one person will know who the Delta director of Ohio is you know you're going you'll go into a dental office in Arizona and say okay the Arizona Delta Dental of Arizona last year gave you two hundred fifty thousand dollars who's the director I don't know have you ever had lunch with him no, oh well actually you communicated with him three times this year and here's the three letters you wrote to him because he didn't cover whatever the hell you were saying and look at the profanity and look at the meanness and then I'll never forget walking into CDA I almost cried because the night before I was drinking with the CEO of Delta Dental an amazing guy who who was so happy because he passed selling 1 billion dollars a dental insurance and CDA but when he opens up the program they got Bill Dickerson speaking and guess what the name is lecturers Delta or the devil and they have never ever once asked him to speak at the CDA tell him what it's like on his side. I mean if dentists want crowns covered a million dollars great will you go to Intel and Oracle and Microsoft and you sell them the damn dental insurance where they're gonna pay a thousand dollars a week per employee and I mean I mean didn't notice her they're just irrational but when you go outside of healthcare and government you worked the value chain when my dad had restaurants he bought a million dollars a year a meat from a guy will help we went on family vacations with that guy we I knew his wife and kids and you all work together on the value chain and then in dentistry it's like maybe me so self self me cell cell me me me self screw the insurance companies screw everybody it's all about me and then they want to know why insurance companies and then here you are were you actually picked up the phone and went and met this guy and he trusted you and you trusted him and you guys did a deal together.

Steve: Yeah and it's still working 12 years later.

Howard: Yeah because we'll still be humans a million years from now that's what works. What doesn't work is when you've never pressed the flesh of this guy you're never running for mayor you never took him to life I remember the first time I took the Arizona Delta Dental exec director to lunch name was Ed Judd and took me like five calls and they they wouldn't even push me through them he thought it was some kind of trick and he said he said what why do you want to meet me I said dude I mean I it's 1987 I've only been opening a year I mean you've given me several hundred thousand dollars I want to have lunch with you he said meet you black-eyed peas and he was brisk and then we went to black-eyed peas and the whole time he's feeling me out like and then finally he realized this is a 24 year old punk ass kid and he's truly grateful and recognizes what we do for him which is going around all these companies in Arizona and selling them dental insurance and and and dentist just need to get their head screwed on. I want to talk about another black eye for dentistry eight percent they just came out with another study in Arizona eight percent of emergency room visits several years in a row now in Arizona our odontogenic in origin I just I went to dinner with Chris Vogel's a dentist in public health for 30 years why are eight percent of emergency room visits in Arizona odontogenic origin and he told me that the numbers were pretty much the same nationally?

so people are not going to the dentist they're either afraid or they don't have the money for it or what the dentists are doing is not effective and so they go to the Oz the hospital is a last resort it's sad.

Howard: and all they do is give them pen BK and vicodin and the cost is 1,500 bucks it's like if that emergency room would have sent him to my office and given me 1,500 bucks what's the chance I could have had a higher outcome of treating the disease missing and filled tooth.

Steve: So Howard what we're promoting is the concept that a dental hygienist can apply SDF in collaboration with the dentist of course earlier and stop the disease before there's their need to go to the OR or go to the emergency room and so we want to partner with hygienists in the introduction of this technology.

Howard: Oh my god you sopin up another counter words because now it's dental therapists and then if you support that you're somewhere between a communist a Putin lover I mean you're just just crazy and so I just tell the kids that the only advantage of being 55 is that I'm you've lived through this rodeo so we go back to 50 years ago there's a guy named Barker what was this for example Bob trying to tell everybody to hire these hygienists and that it's the same backlash to dental therapists today as it was then and they're like look I don't have time for this stuff I'm too busy pulling everybody see two adventures and who the hell are you promoting these dental genna's that are taking away our dental rights and and and there should never be dental hygienists and it was just a war and Bob thought that monkeys and now 50 years later if you got into it I'll say hey you want to fire your dental hygienist and do all your cleanings they all say well hell no well that's what you all said 50 years. So now comes along a dental therapist well what's she gonna do she's gonna do some fillings and I go to wherever they're you they have them and dentists say oh my god they're great I used to do all my cleanings and I got to hygienist you know the cleanings and I used to do all my fillings I got to dental therapist they numb they do the damn filling and I'm just over here doing the big stuff 10 molar endo's and dentures and implants and crowns and I have not seen a single dentist who hired a dental therapist who doesn't just love it but my god you go on social media and say that I'm for dental therapists and they would lynch you if they could why is that.

Steve: Fear fear and and it's in your rational fear you know if we can shift our way of thinking about intervening with this disease earlier doing it using a medical model a biological model the benefits go to the patients and if we can stay alive financially at the same time so if we can shift the reimbursement so that it supports that type of intervention then I think the blood pressure and the concern of the dentist is going to go down.

Howard: Man you're a politician you you should be the mayor you called him irrational fails I've just sort of called them Complete Idiot's but I love the way you just stayed somber irrational fear you're polish guy. I'm going to talk about let's see I I've already got 52 minutes I got you for four or five more minutes two other big things and then the news and dentistry gotta cover. There's a big measles outbreak and so now there's some local dental offices here and at Phoenix and on social media that I said if your kids not vac saying you can't bring them in here the anti-vaxxers are kind of in my opinion they're like the anti water fluoridation. I've been involved in two fluoridation campaign for Phoenix in 89 the Arizona State Dental Association gave me the Arizona Award for outstanding contribution to bring water fluoride to Phoenix and back then I would say it was about 70 30 30 % of the Arizona's thought it was a communist plot that I was only doing this because I knew it made the teeth mottled and breakdown and they need a bunch of crowns and all this crap but 70 percent trusted the dentist the center of disease control the World Health the dental schools and then 20 years later we did it again it was the same percentage and now it's the same with the vaccination deal. So when you study any epidemiologist and they go back so this is 2018 so if we went back a century to 1918 we would have already gone through the Civil War I haven't that's aboard the World War one and the Spanish influenza and you would think that today they would be licking their chops thanking that we'll never have that then you know that these vaccines it's been credited as number one public health measure is in the top ten Centers for Disease Control's top ten public health measures last century water fluoridation makes a list and so does vaccinations and now you got 30% of Americans saying that vaccines cause autism and so what are your thoughts on water fluoridation what are your thoughts on vaccinations and what are your thoughts do dentist really what do you think of when a dentist says I don't want your vaccinated child in my office?

Steve: Well so I fully support the science and the practice behind vaccinations and public health interventions. I support the fluoride prop programs that we have in America and the 30 percent of people that don't want any fluoride in their children's mouths those patients come to my office and so I have this conversation I don't want any fluoride you know so what do I do when the parent says no fluoride in my child's mouth I pick up a bottle of silver nitrate just like GV Black did in 1908 and I paint silver nitrate on the cavity and it stops just like it does with silver diamine fluoride. So if you support fluoride do you get SDF if you don't pour that fluoride then you get silver nitrate I have something for both camps, it works.

Howard: Thats nice because the I mean they're humans you gotta love them I mean I do I look my favorite patient my favorite patient at today's settle is when I go to work and she's sitting outside in my office in her wheelchair with an oxygen tube smoking to the last minute and you know some people would sit there and just like want to throw under a bus hell she's the most adorable lady I've got in my whole practiceI just love I love crazy people and they and you know when they they don't understand for it I mean I mean I tell him all the time told the story a million times the whole universe almost all hydrogen and sometimes it gets together in a big ball and it collapses you know like it gets attracted with gravity and it gets so big like the Sun that the gravity is so intense that two hydrogen are pushed together into helium and that causes the Sun it's a it's a fusion reaction and then when all the hydrogen's burned out in turn into helium it's so damn heavy it collapses explodes and that's where silver and fluoride and mercury they're all made and without that you wouldn't exist in fluoride is the 13th the most common element of the Earth's crust it shows up in the ocean at one point for part per million and when we put it in the water just half that amount the teeth are so much healthier.

Steve: Right

Howard: and then they eat me and then they just say look III hate fluoride and say well they've never found a water supply ever found out for I didn't in fact bottled water made from reverse osmosis has fluoride in it just not at the optimum level of what we've 1.7 and and and I feel sorry for you because you're no I don't mean to throw your bus fee you're an Oregon I've been door again several times those are some of the describe the people Oregon how they're different than the people Arizona is basically the Florida of the West how is so how is Oregon different than Florida Arizona?

Steve: So I think all the hippies you know that are still around they migrated they escaped to Oregon and they have some very unusual political and philosophical views of the world and fluoride is part of that so I don't want to battle with those people I want to understand them and I want to help them be healthy and so we can do that.

Howard: Yeah and and and I also want to tell you about the fluoride toothpaste because all of the news this week about there's a couple of New York Times Wall Street Journal Business Insider that fluoride is basically if there's not fluoride in the toothpaste is not effective and I just want to say that my god look at the research closely because if you just brushed for two minutes without any toothpaste with a soft bristle toothbrush that's really really good and if they don't want fluoride I mean in their in their toothpaste I mean my problem in Phoenix is they don't brush teeth period and they do brush maybe it's every other day but got it I'd rather have someone brushing for two minutes every morning and every night without any toothpaste then come in my office not brushing carrying him out and do in fact when they walk in my office of the Mountain Dew I say do you take your bong to church I mean you don't carry mountain dew into a damn dental office I mean it's so it's so diet what do you think the top major variables of decay is? One of the most interesting threads I only got you up for one more minute but I wish you would weigh in on this and this would be a good place to post your video there there is an amazing thread on dentaltown that's got some of the most smartest people on dentaltown posting on it and they're really having a zen-like discussion based on research and it's called here let me look at it. The question is do you think tooth decay is mostly based on diet water fluoridation brushing to minutes twice per day are flossing before bedtime and a hundred and five dentists have posted what they think really cause decay and they're posting literature and resources and what I love about this and some really smart people are disagreeing and they're really trying to do just go to dentaltown and it's under carryology so and but my god what a place for you to start weighing in I can't believe we've talked for an hour is there any question I wasn't smart enough to ask or forgot or you're wishing I would ask?

 it's a pleasure to talk with you Howard and I will only leave one last comment there's a third website called

Howard: So it's okay

Steve: Yes this is the story dr. David Noel good friend of mine dental director of the State of California's Medicaid program for 25 years, this is an inspirational story about he and his special needs daughter and what we can do to end tooth decay and gum disease everybody should watch it.

Howard: Well let's get him on the show.

Steve: Yeah absolutely he's a lot more famous than I am.

Howard: I don't know man you put out that course on dental town and you're on you're a legend in my mind and you're a legend on so many people on dentaltowns why that course was viewed zillion times and I just saw I love the fact that you know that you have the freedom to stand up for what you believe even though a lot of older pediatric dentists and you wonder about the money involved too I mean yeah I mean there's a lot of money and doing pulpotomy and chrome steel crowns all day long and you know so but thank you for all that you've done for dentistry you're headed to Bolivia when you go into Bolivia next?

Steve: I'm going to Bolivia on next Monday I'll be there weeks and then my next trip is to India so we're going around the world.

Howard: and what are you gonna be doing in Bolivia?

Steve: So we are going to be collecting two year data on a cohort of 600 children who had the worst tooth decay I've ever seen in my life in a small town close to Cochabamba Bolivia. So this is going to be a really interesting data collection truck.

Howard: and that's a tough country because they're poor and their land lock they don't have any access to the ocean.

Steve: THey have the sugar lots of sugar oh my gosh.

Howard: and when you go to countries like China, the people that live within 500 miles of the sea they get all that seafood fluoride protein and the average boy in China within several miles the ocean there's like five nine but by the time you get 1,500 to 2,000 miles into mainland China there are much smaller people because they don't have any of that protein source it's really really it's really really tough to have a really big healthy diet when you're landlocked like Bolivia.

Steve: Yeah

Howard: and then yeah I want to say one thing about actually going to these countries I'll never forget the first time I lived in India I had this thing in my mind that Indians were the healthiest people they were they were Hindus they didn't eat meat and their vegetables and I was just expecting to go there to see all these vegans eating so healthy in the world my god every dentist house you went to his wife or his mom would meet you at the front door with a tray of all these sugar cookies and snacks and sweets when they drank tea they put so much sugar I mean I was blown away and I came back I thank my god India eats more sugar than Americans do I mean so you can think all these thoughts about a country but when you go there and that's why I like going there is I don't want to stay in a Holiday Inns and all that I want to stay with dentists in their house. I'll never forget the first time I lectured in Poland they were gonna put me out of this expensive hotel in downtown Warsaw I told him I said no dude I want to stay at your house and I'll never forget waking up the morning and going to that refrigerator warsaw poland open the refrigerator I was stunned I mean it didn't look like anything I'd ever seen that America is all sausages and tomatoes and it was just it was like I landed on a different planet but I thank you so much for all that you've done for dentistry thank you so much for going back to Bolivia and doing this cohort study and collecting data on 600 children 2 years later. You're just one hell of a dude thank you so much for doing that book write a book review of it we'll put it in dentaltown I will market the bejesus out of that book and hope that everything you're doing can take dentistry to the next level.

Steve: Thank you for all you've done for dentistry Howard and thank you for today.

Howard: All right thank you.


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