232. Dr. Linda Niessen: Cost of Dental School & Caring for Underserved Patients

Hey, welcome to Dental Digest, I'm your host, Dr. Melissa Cyber. This is a podcast with a mission of enabling you to stay on the cutting edge of evidence-based dentistry. In this week's episode, we're going to be talking about everything from geriatric dentistry to community health to what it takes to run a dental school. My guest this week is Linda Neeson. She joined Candid City University in 2020 as a professor and founding dean for the College of Dental Medicine and vice provost for oral health affairs. Prior to joining KCU, she served as dean and professor at Nova Southeastern University, College of Dental Medicine from 2013 to 2019. Dr. Neeson is authored over 80 peer-reviewed publications, numerous chapters, and a textbook geriatric dentistry. So, pleasure to have you here. You have an extensive background in education, so formally before the position you're in. Now you were the dean and professor at Nova Southeastern University, and now you're the dean for the first inaugural class at Kansas City University, Kansas City University Dental School. And so, so often, just like I was talking before, we started the episode is that we has done this so often here, the other side of the story. We are the story of the recent grad, or someone who's left dental school within the last ten years, and times are very different. Perhaps 30, 40 years ago, maybe Dennis felt a little bit more prepared to go into the private sector, but now often times, graduates feel that dental school is so expensive and they don't feel like they're being prepared to be launched into the real world. They're not getting enough cases before they graduate, and they feel like they have to go take all this teaching education once they graduate to be prepared. But there's always a second side to the story, so I would love to hear your perspective. And one of the first questions I have for you, something you can certainly shed light on, is, why is it that some people, when they feel that they graduate from dental school, they just do not have enough cases. They didn't do enough, and no, they didn't do enough, indirect restorations, all of those sorts of requirements. You know, the number of clinical experiences, whether it's endo, implants, and vary from dental school to dental school. It depends on where you went to dental school, what the curriculum included. And I laughed when you say, oh, and I went to dental school, so yeah, when I went to dental school, we didn't have implants, you know, we were doing endo, but it certainly wasn't rotary, and nickel titanium rotary endo with, you know, a gutter perchah type, you know, the, with the filling material was, you know, got a perch on a stick, is like, I'd call it, but, you know, we didn't have that. So, so the clinical experience I graduated with, I had to learn, you know, we barely had composites when I graduated dental school, so I had to learn all of that. You know, the goal of the dental school is to graduate a safe beginning practitioner. And you're, so that you have sufficient clinical experiences where you do, do some endo and you place implants, and you may or may not have any digital dentistry experience, depending on the dental school you went to. I mean, you know, we're unfortunate that I make Kansas City University College of Medicine, it's a new dental school, we built in digital dentistry when we built the program. So all of our radiographs are digital. We've got the digital design, we've got the intro scanner, we'll have the digital design. But, you know, if you've been a dental school for 100 years, you don't always have that technology, and it's hard to build that technology in, and, you know, modify the curriculum to include that. So, dental school is very, from state to state, location to location, and, you know, it depends on where you are, what you have to keep in mind is you're a beginning practitioner. And you've got to start learning the day you graduate, and I'll just give you the best example I can give is I graduated in June, and you know how we always study the American Heart Association's the prophylactic, you know, recommendation for antibiotics for the patient, you know, to prevent SBE, that changed in September. I graduate in June, it changes in September of that year. Now nobody's making me memorize this because there's a test. I have to decide if I'm going to use this new protocols, which the American Heart Association's recommending, and I want to maintain my evidence-based approach to clinical practice, or if I'm going to be that dentist that never changes. And it's in the first three months of my practice, and it's like, okay, there's some learning I'm going to have to do on my own that no one's going to force me to learn. So probably the best gift we can give to our students is the interest and the willingness and the desire to continue learning, because the technology is going to change throughout your career. And so I have to tell you, when I hear dentists graduate, and they say, oh, I'm really unhappy with my dental school, I just didn't get enough clinical practice. That's a great sign. That's a great sign because they're hungry to learn. And that's wonderful because you're going to be a better dentist because you want to continue to learn, and you're going to look at patients and the clinical diagnosis that they have and the treatment that's available for them in a different way because you want to continue to expand your clinical experience. What would you say as well? One of the common concerns is that some people graduate from their dental school feeling like they didn't get enough clinical experiences. So crowns that's a common one, people will feel more and more like highly graduate dental school, having had done two crowns or three crowns, that's what you might hear people say. So you provided a really good explanation for me, though, for why this might be the case for some schools. So one of the things we're doing is we're going to send our students into community health centers for two 12 week rotations. So there has been 24 weeks they're senior year in a community health center or a hospital or a tribal facility to basically practice dentistry. And when you go into those kinds of real world settings, they're much more efficient. They see more than one, you don't have to see one patient in the morning or one patient in the afternoon. I don't know why dental educations are organized like that. You shouldn't have to, that's kind of really arbitrary. You can see a patient every two hours or every three hours. You don't have to see one patient in the morning or one patient in the afternoon. And in a community health center, you don't, you're going to be a little bit more efficient. So I think that gives students a little bit more real world experience. Again, just depending where you are, you may not have a patient pool that needs crowns as odd as that sounds. No, that's very fair. I happen to go to dental school at the University of Louisville, Kentucky itself, unfortunately, because the state that financially struggles a bit. So there were a lot of patients that couldn't necessarily afford that. However, I did do an oil rotation at one point in my dental education, which was very beneficial because finances weren't the issue, it was painful by the state. And this was a great opportunity to be integrated into a real world scenario. So I saw a much greater volume. But my question with that, though, is how is the dental school? Do you calibrate the sort of preceptors that are overseeing these dental students to ensure that everyone's on getting the same sort of feedback? That's a great question. And that's a good accreditation question, too. The commission on dental accreditation always asks that question, too. We've developed rubrics. We've developed a rubric for every clinical procedure the students are going to do. And these rubrics, or their clinical procedures, will use when they're in the SIM clinic, will then use them when they're in the clinic. And we will send them to the dentist in the community health centers. The dentist in the community health center will become an adjunct faculty member, and we'll invite them for faculty meetings and standardization sessions. But the rubric helps them see how we're going to grade and evaluate the students on the various procedures. Now, in the school, we'll use certain materials because we'll teach the procedure and usually just teach it one way with one material. In the community health centers, they may be doing a different material, which is fine, because it expands the student's clinical experience using different materials. So that's a good thing, and we're going to work with the preceptors at the clinical sites to make sure they understand what we're teaching and what we're looking for. When they grade the students in terms of their clinical care. What would you say as well to the cost of dental schools? It is amazing just how much it costs to graduate from dental school. Perhaps in some regards, I think the profession might be hurting a little bit because people graduate with all this debt. They feel this enormous pressure, and some jobs pay while some jobs don't. So what is the underlying root behind why dental schools are so expensive because you can graduate from some of them a half million dollars in debt, that's pretty doable. No, you're absolutely right. Dental school is expensive. Tuitions have increased. But the difference between dental and medical school is that. But when the medical students go to the hospitals to do their medicine rotation or their surgical rotation or their dermatology rotation or their OB/GYN rotation, the hospitals underwrite the cost of that. In the dental school, you know, the medical students still paying tuition to the medical school, but they're in the hospital for those last two years. In the dental school, we're running the dental hospital. So we're running that dental hospital and paying the cost for it. So that's why dental education is more expensive. And basically, the difference, the state schools, you know, I like to say the state schools run about $50,000 a year, and then the private schools are like $100,000 a year. And the differences, the state schools have state support, you know, the state provides some support for them to lower the cost of tuition. Fortunately, fortunately, students have loans available. And some of the loan repayment programs now, I mean, you had the best program. I'm willing to bet you had a military scholarship. So that is the best scholarship to have because you graduate and don't have any debt. And then, you know, having opportunity to get amazing experience throughout the world. So I think the military scholarships are fabulous. And we're fortunate that we're seeing kind of an interest in more loan repayment programs. You know, whether it's National Health Service Corps or some of the community health centers now are providing loan repayments. Some of the states are even looking at loan repayment. We have a couple faculty members who have loan repayment because you can get loan repayment if you're a faculty member. So and then, you know, the new loan repayments that they're looking at at the federal level is where you pay the mint, you pay in an income-based repayment. So whatever your income is, you pay, you know, a percentage of that. And then, after 20 years, whatever the principal is left, it's wiped out. You know, it's, so that's a great opportunity. You know, my feeling, you know, we have, we have a number, we have 21st year students, we have 21st year students who are first generation college graduates. Okay, they're the first in their family to graduate college. So those are often students who have to borrow money. And they're often worried about this, you know, she they're borrowing $120,000 a year. So at the end, so I always say, look, there isn't a better investment than yourself because you know you're going to be able to pay it back. And you're going to have a career that helps you make a difference in people's lives. You're going to help people get healthier. You're going to have an influence on people in ways you can't even imagine yet. And just educating them, helping them think about, well, if you became a dentist, maybe they could become a dentist too. So, you know, I say, yeah, it's a lot of money. I mean, I borrowed a lot of money when I was the first generation to become a dentist in my family. I wasn't the first generation college. My dad went to college. But, you know, you pay it back and dentistry is still a wonderful career. Hi friends, Melissa here. I am finally starting Journal Club. This is a once-monthly meeting where you can earn continuing education credit. And when we're going to talk about new and noteworthy updates in dentistry that are relevant to your practice. Dentistry is evolving so quickly that a lot of information that you might be getting from textbooks or continuing education is outmoded. We're going to be talking about topics such as men and women-based carries removal strategies, vital pulp therapy, strategies for bleaching, et cetera. Even if you can't make the once-monthly meetings, you'll still have access to the recordings and article notes. Thank podcast listeners for sticking with me all these years. Use the code podcast14 for discount. Follow the link in the show notes to get registered. Who would you say, though, because, you know, I know that you would never do this, but nothing is worse than in dental school where some of the faculty would joke about how cheap it was when they went through dental school compared to now when we're in dental school. And I know you would never do that because that is just terrible here. But why, though, has it the price also increased? So, and that's, you know, the cost of the dental school is really determined by the university. You know, it's not the dental school saying, yeah, we're just going to arbitrarily increase tuition. The tuition increase is really determined by the university as part of their overall cost. You know, heats increased, you know, electricity increases, the cost of, you know, personnel, you know, health insurance is probably the biggest driver of cost increases in industry as well as education. So tuition has increased. There's no question over the past 30 years, probably at higher levels than we've seen the previous 30 years. But it probably reflects some of the cost of education, you know, building dorms. If you have to, you have to run dorms for students, you know, that's, you know, if you have to run, you know, the undergraduate schools, the dental schools that have undergraduate schools where you have dorms and food service and, you know, that it's probably not a surprise that those tuition are increasing. I think some dental schools are bit better than others at retaining talented faculty and attracting talented faculty. What's the recipe for success for finding the right kind of faculty? Because that, that will really largely influence the type and the quality of personnel graduate from that school. So, for example, I would say dental schools like University of Washington and NYU Penn, they seem to really attract and retain very talented people. And often those are the schools that do the most research, you know, the schools that have stronger research programs often have faculty who are doing the research who are clearly contributing and making a difference. So, I think that might be, you know, one reason for different levels of faculty. So you would say it ultimately kind of comes down to research, does it also ultimately come down to salary or is that not nearly as important as we once saw it? So salary, so, you know, I'm recruiting a lot of faculty these days. So, I always saw them, so here's the deal. And the faculty that I like, that I think have wonderful potential in dental education, are the faculty kind of 50, you know, 45, 50, 55, 60. They've been in clinical practice for 25, 30 years. They've made money. They've, you know, they built up their 401k. And now they might be bored. You know, they might be bored doing clinical practice. And I say, look, you've got a lot of clinical experience that you can contribute to the next generation. However, you're going to have to take an income cut. It's probably going to be half of what you're making in clinical practice. Because we don't, we don't always have the benefits, you know, we have some benefits, but not all of them. We're the dentist or a little older who might be 55 thinking about retiring from clinical practice anyhow. I say, okay, we've got, you know, you probably have a number of years that you want to contribute that you have expertise that you can share with the next generation. And the benefit of being in dental education is you don't have to withdraw as much from your 401k, you know, your dental education salary will supplement what you withdraw from your 401k. So, so, you know, nobody's going to get rich in dental education. It's a mission. You do it because you love the next generation. You love the profession. And you want to make a difference and help the next generation of students become the professionals that you know they can be. I love that's awesome. So, one of the things that you've devoted your career toward is not only education, but also helping to treat an aging population. And so, there's perhaps a lot of oral health considerations with treating an aging population that are oftentimes overlooked. So, let's think about that. What are the treatment considerations for geriatric population? So, so yeah. So, I spent my life as a, when at my clinical life as a geriatric dentist, I, you know, I'd have friends and families, they all want to come see you and it's like, oh, you're a little too young and you don't have enough dementia yet. So, just because you get old and you have various medical conditions, it doesn't mean your oral health has to decline. And that's unfortunately, it often gets harder to maintain good oral health because all of those chronic conditions have chronic medications associated with them that usually dry out your mouth. So, you got to work a whole lot harder at maintaining your oral, your, the oral health of your older patients. So, the older patient that comes in, so I don't know if you see retirees, you see retirees. So, you know, they may have, you know, maybe they've, they got, they got a little heart disease, they have a little arthritis, they get some hypertension, they're on a statin, you got, you know, you have a list of, you know, six or eight medications, that doesn't include the antidepressant that they're on, you know, all of which dries out their mouth. And then, you know, they're retired, maybe they don't feel like doing much, don't want to brush their teeth. So, so you've got it, my key is prevention isn't just for kids. No one's ever lost a tooth because they had a 75th or an 85th birthday. You lose just to tease because you've been Tuesday K or yay. you've got carries or you've got periodontal disease. So we need to have to prevent those diseases. We know we'll have to prevent those. So just because somebody's 65, 75 or 85 doesn't mean they have to get carries. Now I've spent a lot of my time in a sea of root carries because root carries was the culprit. You know, you have a little genital recession, dry out the mouth and man, you see the roots disintegrate. And if you have a patient who does have dementia, it's in a long-term care facility, then they are much more at risk of losing the teeth. So my feeling is, think about prevention. Think about risk assessment. This is where risk assessment really plays a role. When you get to the older, you know, you've got the kids, then you've got the older population and risk assessment on both ends of the spectrum, really makes a big difference. - What are your thoughts on the quality of care that a geriatric patient might be getting in a sort of retirement home? Because it's my perception that it's really not necessarily idealized care. And especially if they do have dementia, Alzheimer's, any sort of cognitive impairment that they're not really able to advocate for themselves. - So you know, when you ask your principal, what do you think of the quality of care that they get in a retirement home? Well, that's easy, they get no care. Most retirement homes don't necessarily have a dentist on staff, or even though they're supposed to, they may be supposed to, depending on the nature of the home. And you really need an older adult, really needs a patient advocate. You know, you need a family member to be the patient advocate to say, "Hey, my mom needs to see the dentist." She has a dentist, she needs to see the dentist. And you know, just having the patients see the dentist and get to your teeth clean, you know, a little scaling and root cleaning goes a long way in patients who are older. If you want to keep those teeth in their head, in fact, Walter, oh gosh, who is the, Walter, was at Walter Loach, the professor at the University of Minnesota, or University of Michigan, excuse me, who did the study and he took like the 90-year-olds and took, basically, said, okay, these are like 70, 80, 90s with teeth that had periodontal probing depths of 7, 8, 9. And, but they wanted to keep their teeth. And he said, okay, I'll see you every three months and I'll scale and root plant your teeth. And guess what? He kept the teeth in their head until they died. So it was like, okay, if you have teeth in your head, even with, you know, 7, 8, 9 millimeter probing depths, a little scaling and root planting can help the individual or keep those teeth. So I thought that was really, that was like my faith, that was one of my favorite studies, along with Van Haywood, the whitening guru at Medical College of Georgia. He has whitened everybody's teeth at every age and whitening works, you know, works regardless of how old you are. And it's just a matter of time, you know, it's a matter of concentration of the whitening agent and time in contact with the tooth. And, you know, even then, but the interesting thing, here's, here's why I think every patient over 65 needs to whiteen their teeth because they had less root caries. Because the whitening agent, see the whitening agent is so basic, you know, it's got a pH of nine or 10 that caries can't grow. And it's like, oh my gosh, Van, you're genius. That's a genius idea. So just whiteen all of your older adults teeth. - 100%, I'll actually say as well, along those lines, for my ginger vitus patients that we're having a bit of trouble kind of getting it under control, getting them to kind of see what health can look like. I have dabbled in giving the whitening trays and I have seen an immense benefit. I think that's like, sometimes gets a bad rap when it comes to a high-carriage risk patient because perhaps older, historical whitening agents were very acidic, but the modern hydrogen proxies, carbonoproxies that exist today out on the market, whether it's an office or a direct consumer, 99% of them are very basic. - Yeah, exactly. You know, it's like they used to tell you, you know, when they're teaching, you know, treatment planning, like patient comes in with like the missing front tooth, but has lots of caries in the back, oh, fix the caries in the back. And it's like, no, the person wants the front tooth fix, fix that and maybe go come back and get everything else done. But if you don't fix what the person's asking you about what their chief complaint is, you know, it's like, oh, if they fix my tooth, they'll never come back. It's like, you know what, let's give it a shot. You know, I'm willing to see if that's really the case. But I think that's great, white and dirty. - What can be done though to improve the state of oral care and access to oral care for geriatric patient in nursing homes? - Well, in nursing homes, the best thing to do is have oral health sessions for the nurses. The nurses have to have a number of inservices. And, you know, I've spoken to Dennis, you know, and lots of CE courses and say, look, adopt the local nursing home and go in with you or your dental hygienist and do an annual inservice. Maybe do one every six months and teach the nurses, you know, how to brush the patient's teeth and take toothbrushes and toothpaste and give them to the staff because the nurses' aids are the one brushing the patient's teeth. Now, the nurses' aids often, if you look at their teeth, they don't always have a lot of teeth. And these are, you know, individuals who may not have graduated high school. So go there and then the other thing I always say rather than do something just in a classroom, I say, take them on rounds. Take them on rounds and say to the nurses' aids, take me to the patient you're having the most difficulty brushing his or her teeth. And I'll show you how I would approach the patient. And they're like, ooh, Dr. Neeson's gonna see Mr. Smith, you know, like the patient that hits, you know, or does all sorts of things. And it's like, sure, I will show you how I will approach that patient. And, you know, I'll go and I'll, you know, I approach from behind so that, you know, if the patient's gonna do this, they're gonna have a hard time getting to me. And then if they're right-handed, I'll approach from the left side. So, you know, it's like it's hard to see if I had the patient sitting here, you know, if the patient's head's here, I'm gonna approach from the left side if their dominant hand is right because the left hand doesn't come up as far. Range of motion is gonna be limited on the non-dominant side. And then I cradle their chin, you know, between my shoulder and then brush, you know, with my right hand and just show them how I do it. And I basically show them what I would do it, how I would do it. And I said, if the patient yells, it's good because then you can get on the inside, then you can brush, you know, the lingual surfaces. Yelling is always good. What if they bite down on the toothbrush and they don't open? Trust me, they will open their mouth. Remember those actin and bias in fibers when they contract, when the muscle contracts and then all the little calcium channel bundles deplete and when they deplete, the muscle relaxes. So the mouth will definitely open. It's not gonna stay closed forever. And then they say, well, what about it? If the toothbrush, they bite down and the tooth comes out 'cause that has happened too. And you say, well, then that was the tooth that was meant to come out. If it was came out with just biting down on the toothbrush, it would have come out, biting down on food. The good news is you caught it and the patient didn't swallow it. So don't worry about, you know, about that. So I always say, if adults learn by doing, they learn by doing and, you know, take them, make it relevant for them. So teach the nurses how to improve oral health and brush the patient's teeth. That's a start, you know. You know, my dream is that every nursing home has a dental operatory and a dental hygienist that goes in and, you know, looks at the patients and does the scaling and replaning and just by looking in the mouth as the ability to refer to you and say, ooh, Dr. Seber, would you come in and see Mrs. Smith? She's got this funny lesion. I like the looks out, you know, and then you go in and you say, okay, look, it's a denture, so we're, let's adjust this or, you know, this is a broken filling that's, you know, it's rough on her cheek, you know, let's replace the filling. We're a long way away from that. - No, I appreciate your enthusiasm for this patient population because I will be honest, this is a patient population that it's kind of really sad oftentimes to work with, perhaps. And sometimes it can be a real challenge, perhaps, typically if they are mentored or have Alzheimer's, they've lost, they're, I mean, they're cognitively impaired. And so what then is your next piece of advice for dealing with that subset of geriatric patients, the cognitively impaired ones? - So the cognitively impaired population, particularly the dementia patients with dementia really are a difficult population. So Judy Jones and I wrote a couple of articles and we were the first to actually publish on dental care for the Alzheimer's patient in Jada back in the 80s, you know? So it was even before anything was online and when they put all the articles online, they didn't even go back that far. So you can't even pull it up. You have to actually go to the stacks of Jada or find an old dentist that has Jadas from the 80s. The issue is, you know, demanding illnesses, you know, go through a stage. You know, there's stage one, stage two, stage three, stage four. Stage one is when you're, you know, first identifying it. Patients are still pretty normal. They can still follow commands. So what we've figured out was the sooner you have a diagnosis of dementia, the next day you need to make the dental appointment and get into the dentist, make sure everything is healthy because you got a demanding illness that's only going to go downhill. World Health doesn't have to go downhill at the same time. Again, we know the risk factors. If we keep the teeth clean, if we watch the diet so that it's not an overly carbohydrate-loaded diet, we can keep the caries down and maybe even prevent it altogether in a little scaling and replaning. We can keep the periodontal disease down as well. So stage two patients have a little bit, they're a little bit more cognitively impaired, but they can still respond to commands. They may not be able to be historians, so you may need a spouse to come with the patient to give you the history, but they usually can sit pretty much and you can do restorative dentistry. What they don't do well is they don't manage sensory input well. So these are patients you may do hand-scaling instead of the cavern because the cavern is too much water and too much noise, and that scares patients. The sensory overload is what they don't manage well. So you know, you keep it simple. The drilling for restoration, that may be difficult, but you usually, you might be able to do it for just, you know, we don't spend a lot of time drilling, but you can manage it. It's, can they sit still? Can they sit still so that you can place the restoration in a reasonably dry field? So it makes composites more difficult, because they might not be able to do that. I mean, I still use a mahogany as it is. It's still, you know, I can get in and get in at the Parkinson's patient who's moving, who has, you know, head tremors, I can get in and get out in, you know, a couple minutes and do a decent restoration using a mahogany. I can't use composite because there's no dry field. So that's, you know, our dental materials have gotten beautiful and precise, but they also are a little more demanding in terms of a dry field that we can't always use. I'm a big believer in rubber dams. I love a rubber dam, and I always use it particularly in geriatric patients because they choke very easily. So having a rubber dam in place for restoration actually contributes to my mental health more than anything else, you know, if all of a sudden they start choking, I know it's not anything that, you know, they swallow that it is, you know, could be detrimental from the dental procedure. So, and then, you know, the third and fourth stages, the third stage, they usually get a little bit more incapacitated, may not be able to come as an outpatient, maybe bed ridden, you may have to go see them, you know, or they may, you know, come to you in a, in a litter, you know, maybe. So, you know, it's, it gets harder, the more serious and severe the dementing illness becomes. It's, it's a tough disease, I'll tell you, you know, it's hard on the individual and just as hard on the family. Do you think that smart type restorations, these atraumatic type restorations might have a place with the geriatric population? Absolutely, absolutely. I mean, SDF, I think SDF is like awesome. I, you know, it's like, oh, I love SDF, you know, it's a, you got root carries in a, you know, patient with a dementia, dementing illness, it's like, oh, let's, let's paint a little SDF on there. Yeah, the atraumatic restorative technique, great, great place and has a, you know, definite, has a place in carrying broader adults. Do you think that it's under utilized and under appreciated with this population? Because I have yet to hear a presentation or see an article on this technique being used. So, it's not safe to not out there, but it's not very widely recognized. I think it's underutilized. Well, it sounds like there's an article waiting for you to write. No, that'll be you. I mean, that's how Judy Jones and I wrote the first article on caring for patients with dementia. We were working in a dementia wing at the Bedford VA hospital in Bedford, Massachusetts, and we didn't know what to do. And we said, well, let's try this. Unfortunately, we had each other. So, let's try this. Let's go to literature. Let's see what the literature says. And we go to the literature and there's nothing. And I said, Jones, there's nothing. She says, Neeson, there's nothing. I said, all right, we had to write something. So, you know, you just learn by doing, you know, just remember that Louis Pasteur quote, "Chance favors the prepared mind." This is a prepared mind issue. You see an issue. It's under utilized. Write about it. Get it in the literature. People, you know, these days, people communicate, you know? So, shoot, maybe you'll write it with me. You have the experience. I will do that. I will do that. That's a deal. That's a deal. Okay. Yeah. I just think it's under utilized. So, as we'll root carries, that's going to be a really common problem with an aging population. What steps and techniques have you historically used to prevent root carries? And do you foresee that there's any new technology on the horizon to better help prevent it? So, yeah. So, that's a good question. And actually, Jane, blocking a wonderful woman faculty member at the University of Iowa, and I'm blocking on her last name. But she had, she always talked about, you basically don't pick the material. This is what makes your dental assistance crazy. Because, you know, your dental says, "Oh, are we doing composite, glassyonomer, amalgam?" And you say, "Well, I don't know. I'm going to wait and see what the field looks like." So, her approach was, you go in, remove all the decay, look at the field. If it's dry field, you can do a composite. If it's not necessarily dry field, but it's moist, you can probably get away with the glassyonomer. And I kind of am a glassyonomer fan, because it has the fluoride recharging ability. And I feel like that's really, you know, what you need in this area. So, I've become kind of a glassyonomer fan. And, you know, that's what I think is the best. Although, if it's, you know, if there's a root carries, demented person, dementing illness person, not really able to sit and comply with treatment, I'm going to use SDF. I'm going to put SDF on it. Yeah. These are, you know, considerations, particularly with restorative materials. I'm all for sort of a defect-driven approach, where the way I prepare the tooth, it's not always even the same. I'm not always preparing a tooth for a crown. Perhaps I might be preparing it for a perhaps a ceramic omelette, or really, it's going to be very, the preparation is going to be depending on the situation, but then so is the material. The interesting thing though, my concern with glassyonomer and making a mistake, I'm a big fan of glassyonomer, I think they're particularly underutilized with sealant. So, is that when it comes to glassyonomer, we often think that it just has this continuous delivery of fluoride, but it's also dependent on being able to have access to fluoride to recharge it. And I think perhaps that goes under appreciated in the profession. So, this is just a further call for people having access to fluoride. One thing that's really interesting is the new medical code just came out so that medical providers can also apply SDF. So, I mean, I think when that be a phenomenal opportunity to see in nursing homes, maybe the nurses applying SDF, and if these glassyonomer restorations are being placed on root carries so that it can have further access to fluoride so it can be recharged. Absolutely. I think that would be fabulous. I think that's great. I mean, having whatever nurses could do in a long-term care facility would help because right now patients in long-term care facilities don't get much oral health at all. So, that would be a huge addition to help. The other thing is thinking about MI paste. And the thing about MI paste is the pH is high. Again, it's basic. So, you know, using MI paste helps patients decrease. It's kind of like the whitening agent. You know, when you're when you're administering a medicament with a high pH, you're lowering the risk and the ability of the strep mutants to attack and create carries. So, I'm paying a lot more attention to salivary pH these days simply because I think that it's really we, you know, saliva is our bodily fluid, right? And we don't do anything with it or we don't have to near the things that we could do with it in terms of its ability to predict carries and perio and yet we use it for DNA all the time. You know, so I think the future is having us understand the role saliva plays in the development of oral diseases. Speaking of saliva, But again, one of the most common problems that you mentioned, that unfortunate plagues in aging population is dry mouth, serious stonia. How were you managing this? What products were you recommending? Anything they will use. It's like I have, so first of all, the dry mouth is really, it's a big problem. And it's often because older people don't thirst. So the first treatment is hydration. Make sure they're drinking water because they don't thirst. And many times in long-term care facilities, they get dehydrated. And they wind up with health issues related to dehydration. So make sure they're drinking. But whatever, there's a number of products on the market that they basically are a substitute so that they have methylcellulose and that that flavoring, and that, that's all fun. Whatever somebody wants to use, they want to use sugar-free candies to stimulate saliva. That's good, that's, so, and I don't, there, you know, there's two prescription medications out there that I don't necessarily prescribe for older adults simply because on so many other medications that are contraindicated with the salivary stimulant medication. So I can't say I use that, it's, it's more like a, you know, sugar-free mint, sugar-free chewing down that that helps, you know, whatever. And then making sure they hydrate, that's, that's probably key. Sort of rounding out this interview, I want to know, how did you learn to become patient and compassionate with this population because a pediatric patient population is also hard, that's not always the most compliant population. But they're a little bit easier to manage whereas when it's a full grown adult, I mean, they can hurt you, you know, just like you're mentioning in the nursing home situation, they can hit you. That's a good question and I don't know that I know the answer to that. I had a fabulous grandmother, I had a great grandmother, so maybe it's just my upbringing that, you know, I grew up with older people in my family and, you know, you were kind and patient, you know, I watched, you know, I had, I had a patient once who, she had Parkinson's disease, she was in one-term care facility, but her daughter was one of my colleagues at the VA and she had asked me to go, you know, see her mom, her mom was in the nursing home, had dentures, didn't want to wear the dentures and she was making the daughter crazy because the daughter said, I bought these dentures, she's not wearing them. I said, let me go see, so I go to see her and I evaluate the dentures and the dentures are fine, but her mom doesn't want to wear them and I said to her, look, your mother doesn't want to wear them, it's okay, you know, there's nothing wrong with the dentures, you could make five more pairs of dentures, your mom's still not going to wear them, don't worry about it. This is your mother's choice and she's like, oh, okay, I just, she said, I just didn't want to think I wasn't doing something, but I wasn't doing enough for her. I said, oh, you're doing a great job for her, you're doing everything you could do. No, don't worry, and then here was the payoff, she said, when you're taking care of your parents, your children are learning and watching, they're watching and learning how to take care of their parents. And I went, oh my word, is that not the best that it's like, when you're taking care of your parents, your children are watching and learning how to take care of their parents. I said, that is the best payment you could have ever given me. So you know, I don't know how I learned it, but it, you know, it kind of comes natural, you know, I can be myself when I take care of patients, so that's beautiful. And so then this is just about a final question, and this is almost nothing to do with dentistry, but I want to know your thoughts. After having decades of experience dealing with this population, I sort of have this theory that perhaps when possible, when reason we possible and a person wants to do that, perhaps it's ideal to actually remain in the workforce. I feel like it keeps you cognitively sharp, it gives you a community, a sense of purpose. Do you, in your experience, notice perhaps that when people retire, they begin to decline a bit faster, or is that there's really no substantial basis to that claim? You know, it's really up to the individual. It's interesting. I've seen, I've had colleagues, you know, vendennas for years, they retire, they got a whole new life. Don't even think twice, you know? It's up to you. I've failed at retirement twice now, so I can't give retirement advice, but my husband retired, my husband's a physician, he retired, took care of patients, he was an outpatient physician at the VA for 35 years, and he retired, and you know, hasn't looked back. So you know, when he, the first year he retired, and I was still working, you know, at the end of the year, we said, damn, and said, okay, you know, let's look at our lives and I said to him, are you happy? He said, yeah, and he said to me, are you happy? I said, okay, we'll go on this way another year. It's just up to the individual, you know, it's really, it's really individual. Some people, I mean, we used to joke with the lottery, you know, well, you know, if we win the lottery, well, John would say, you know, I'll retire because I can do a lot of different things in my life. Well, Wendy, you need work, so, you know, you won't quit your job. Yeah. Then I would say, but John, you've got to play the lottery if you're going to win it. We don't do that yet. Yeah. Oh, that's funny. Well, this has been phenomenal. Thank you for sharing your insights. Do you have any closing remarks? First of all, thank you for doing this podcast. I think it's fabulous. I think it's a wonderful way to communicate with Dennis in the profession. So congratulations on doing this. I just think it's awesome. And I think Dennis trades a wonderful career. We have a wonderful network of professionals in it. And I think the more we communicate with each other, the better. So I really applaud you for doing this. So congratulations. [BLANK_AUDIO]