As you all well know, I like to document our treatment by using an MRI to determine if the discs in the jaw joints are out of place, and to what extent they are out of place. This gives us a great way to track progress and determine if the discs have improved over the course of a year in treatment.
Recently, I had a patient who was one year in treatment and it was time for a new MRI to see if the discs had improved in position to make sure we were on track basically. Her symptoms were most certainly a lot better- i.e. much less pain and better range of motion. Unfortunately, the original MRI showed very prominent displacement of the discs in both joints- i.e. it was bad. The day that we reviewed that MRI I told her that her risk of needing the microsurgery to fix the damaged discs was relatively high, but we needed to ‘work the joints’ as I call it, for about a year to see what can improve.
The original MRI showed the right disc had ‘prominent medial’ displacement which is about as bad as it gets. And the left joint had both ‘prominent anterior’ and ‘prominent lateral’ displacement- again really a lot of displacement. Both discs did not reduce on opening – i.e. they were stuck there and probably had been like that for many years. Another thing that I order on my MRI’s is the angle of the jaw relative to the central axis to determine how out of alignment the jaws were. Those angles came in at 76 degrees on one side and 62 degrees on the other- again, not a good situation but very important information to have to compare for the future.
Back to the story at hand. At one year into treatment, I ordered the new MRI for comparison purposes and told the lady to go back to Novant imaging- the same people who did the first MRI so that we could get a good comparison done. You already see where this is going: She went to a different imaging center for the new MRI and the report came back stating there was no longer any displacement, nothing was out of place, all was well. Hey folks- I think I am pretty good at this, but not that good! In all the years I have been doing this work, I have never had such severely displaced discs go back into proper position completely- in other words it’s simply not likely. It’s the same odds as winning the lottery, imho.
This is why good data is so very important. When using an imaging service for the MRI’s, it is really important to maintain consistency and use a company that does these images all day long. Most imaging companies only do MRIs of the TM joints once in a while, whereas I send oftentimes 3-4 patients daily to this one place- and they have become very good at reading and producing good data. So when I got this new report for this woman, I knew right away that the results were nearly impossible and if indeed the report was correct, this classifies as a small miracle! And since I have not seen such a miracle in the past, it was not likely that the discs recovered as much as the report stated- i.e. they did not read it well.
As I sat back and thought about this turn of events, I understood why the lady went to another location for the imaging- it was near her home and they were in network- i.e. insurance paid more. But then as I further reflected on the situation, it made me realize how easy it can be to entirely misdiagnose a TMD case. If the radiologist cannot read an MRI properly, that means there are many cases out there that are being misdiagnosed. So imagine if this lady had originally gone to a TMD doctor more near her home and if she had the imaging done at the same place as she had done, then it is likely they would have missed the problems and her course of treatment might have gone a lot differently.
This is why TMD treatment seems to be a ‘hit or miss’ kind of thing. Over the past years I have had countless new patients show up here telling me they have been to ‘dozens and dozens’ of specialists- Mayo clinic, Harvard, UCLA, and Hopkins as well. A good MRI proved that the discs were displaced and allowed us to begin proper treatment. Without that MRI to prove what I thought to be true, treatment would never have begun. So therein lies the rub as they say- taking a shortcut on diagnosis does not benefit anyone.
Here we are starting a new year folks- it’s 2020! As I look back on what happened in 2019 I realize that our practice has hit some new highs that really need mentioning. My team and I have helped thousands of people over the years to improve their health and well being and I am extremely proud of my team for making this happen. I feel very blessed to have such a group of people that I call friends, and even family. Together, we have made a positive difference in many, many lives and I am truly thankful they are with me.
And now for 2020: we are going to help more people this year than ever before. I am currently heading to another dental sleep medicine program this coming weekend and it is geared up for both myself and my team members. This is one of those ‘few and far between’ programs that is designed to have the doctors train at reading various graphs and sleep studies while team members learn about how the lack of sleep affects a person’s life and how we can really help them get better.
As for me personally, I am in the middle of my studies to become a Diplomate of the American Board of Dental Sleep Medicine. This is quite a large amount of work. I fly to Boston every couple months, study articles and reports, write a synopsis of everything I study, and I just passed my first exam. This program is being done through Tufts University and already has given me new insights into how to better treat our patients.
One interesting thing that I learned from the Tufts program is that more emphasis needs to be placed on the TMJ and how dental appliances might help or hurt the joints. I have already brought this up with the directors of the program and they are considering making a few changes here and there. I personally believe that the ALF appliance that I use every day is the best course of treatment for sleep apnea because it makes very slow, very gradual changes that improve the shape of the jaws for better breathing. These days, when I deal with sleep apnea patients, I offer them the dental sleep appliance if they just want something to get by for now, or, alternatively, I offer them the ALF appliances to actually fix the apnea. That’s right folks- I am talking about really fixing the apnea situation once and for all. What the ALF does is that it widens the upper and lower dental arches which makes more room for the tongue, and it slowly lowers a high palate which means you can breathe better through your nose. This is really important because nasal breathing promotes the formation of nitric oxide which helps you to heal better.
This year I am planning to teach in a few locations to help spread the word about what our practice does. If all goes well, I will be teaching in Warsaw, Poland, in the fall and plan on showing many of my own cases done in this office. It should be a fun journey and I am quite sure the doctors that I teach will be able to help their patients in a better fashion. Overall, it’s going to be a busy year with much more education and changes in our sleep protocol that will improve more than ever before!
As another year comes to its end, I am just sitting here thinking of how very blessed I have been. I truly am thankful for all the people that have trusted me over these many years and I am thankful that I have been able to contribute to the betterment of their lives. Although what we do is not an easy process- it does take time to unwind the pain that has been there for so many years- we have proven that this process works really well and we have many successes over these past years.
One of the main reasons that I believe we are so successful is because of my team- they are the best! I am very lucky to work with a team of seven people who run this office like the well oiled machine that it is. These folks are hard working and really understand that our patients need to feel cared for and appreciated at the same time. My team members exude confidence in what they do and the patients really pick up on this. Our patients know that my team knows what they are doing and know that I trust what they do! By having such a highly trained group of people working with me, I am able to focus on taking care of 20 patients each day and never have to rush through our discussions and planning sessions because I know that my assistants are just down the hall taking great care of another patient and I know that my front desk team is handling everything else. This great group of people makes sure that my day is productive and the patients are well handled at all times.
I would like to also point out that I am ever so thankful to the many patients of ours who have referred their friends and family to our office over the years. It is truly remarkable to meet a new patient only to have them tell me they are related to Mary or Sam who I treated years ago! As I look back on just today for example, I can look at the schedule and feel thankful that so many of our patients said “Thank you Dr. Brown” as they report feeling better as each month passes. It is I who is thankful for all those people who have put their trust in me and will give me the time it takes to make them feel better.
And so another year comes to an end, another chapter in the life of ‘Sleep and TMJ Therapy’, and a few more gray hairs show on top of my head! 😊 The journey has been amazing and shows no signs of slowing down anytime soon and I am right there having fun every day of the week! Thank you all for all that you do!
The purpose of this blog is to inform our potential new patients how we do the initial examination and consultation, so you know what to expect when you come in for your visit. First of all, many of our new patients already know that they have some kind of TMJ problem- i.e. their jaw joints pop and click or get stuck open or closed. Many of them also have pain in their joints as well. This is usually what prompts a person to call and come in to see our office. And so when that first visit happens, it is a screening process to determine whether or not you really do have an underlying TMJ problem and whether or not you are in the right office.
When a patient first comes to our office, they will find the exam a bit interesting because they sit in a bar stool, not a dental chair. After a few minutes to review their symptoms, I will actually ask the patient to sit up straight and look directly at my nose to give them a focal point. I will then look at that person- I look at the eyes/eyebrows/ears/nose/shoulders/neck/etc to determine if there are any imbalances present. And in almost all cases I see that the ears and eyes are not level. This means that the bones inside the skull- the cranial bones- are not level or balanced. After the initial observations, then I will glove up and start pressing on many of the muscle groups that are attached to the TM joints. If these are a bit sore or painful, it leads me to believe that the discs are out of place. If you have popping or clicking in the jaw joints, this also means it is likely that the discs are out of place and further examination is needed to determine the extent to which those discs might be displaced.
If I suspect an underlying jaw joint problem, then I will order an MRI of the TM joints. This means that we are not ‘fixing’ anything on that first visit. Diagnosis is critical! If you follow me on Facebook I am constantly preaching that you MUST take the time to figure out the real problem and document it carefully. So, 95% of the time, I will send you to another location to get an MRI of the jaw joints. This requires that you schedule your MRI with either Novant or Inova Radiology and you will either pay them directly, or your insurance will cover this procedure.
Once the MRI is done, it takes a few days for the radiologist to review it and come up with a report. At that point, you are ready for visit #2 with our office- the next consultation and the MRI review. This is the visit where I will personally review the findings of the MRI and show you what your joints look like on the imaging that we pull up on the computer. I have direct doctor’s access to both Inova and Novant imaging services so I will be able to show you exactly what is going on. It is important that you as the patient understand your situation prior to treatment. At the MRI consultation visit we will discuss the options you have on your course of treatment and I will provide you with the information you need to make an informed decision. At that time, you will understand the appliances that are recommended and what they will do to help your condition. Again- at this appointment we are not actually ‘fixing’- we are talking and planning. If you are ready to begin treatment right away, we will take the actual impressions that day to make the appliance(s), however, most people want to know what insurance will cover. That could take weeks or even a month or so since insurance companies do not react very quickly.
As you can see, this is not simply a process of walking into my office and I get right down to fixing the problem. It takes time to diagnose the problem and to document it carefully. Now we have a baseline to work on getting you better! Ideally, we would like to have a three dimensional x-ray as well, but most patients want insurance to pay for that, so we do not take the x-ray unless they are really ready for treatment.
There you have it- two consultations visits to gather information and formulate a plan and from there we are able to begin the actual treatment.
As November rolls around, I have been made aware that it is officially TMJ awareness month. So, what is this TMJ thing? What does it do? Why is it so important? Well, it all begins with a little piece of tissue that is on top of your jaw bone and is supposed to cushion the jaw as you open and close. It’s sort of like a knee cap on your knee, but it’s on top of your jaw bone. When this little piece of tissue slides off the jaw bone, it can literally wreak havoc with your entire body! Let me explain. First of all, TMJ refers to the Temporo Mandibular Joint. Inside this joint is where the top of the jaw bone (the condyle) resides, and on top of the condyle rests the articular disc. There you have it folks, all the anatomy you need to understand TMJD (temporomandibular joint disorder).
So now let’s talk about displaced or slipped discs. Imagine that your doctor informs you that you have a slipped disc in your lower back. The light bulb goes off in your head and now you understand why you have pain in your legs and/or back. It just makes sense because we have all heard about slipped discs all our lives. Very few people, however, understand that slipped discs in the jaw joints can cause all sorts of health issues like headaches, migraines, neck pain, back pain, and even tics and numbness. Most of the patients who come to my office have already been to ENT’s, neurologists, regular MD’s, dentists, and even psychologists to figure out what is going on.
A really good way to figure out if you have TMJ disorder is to measure how big your mouth opens. Measure from the tip of the upper front teeth to the tip of the lower front teeth at the most you can open your mouth. This should be around 50 mm. If you only open to 35 or 40 mm, the odds are that the articular discs are likely out of place and will block your ability to open your mouth widely. And if those little discs are out of place, they are going to pinch blood vessels and nerves that travel through that joint- and there are so many of them!
So many people suffer needlessly from slipped discs in their jaw joints. It is relatively easy to take the pressure off the joints and promote healing, however, many people do not deal with the problem while it is easier to fix. Many folks wait until it is quite painful and are hoping there is some kind of quick and magical cure for this problem. There really is not- it takes time and patience to give the discs a chance to get back into proper position. Many times, we are able to move the discs into a better position and that is when the patient notices the relief they have been wanting for so very long.
By being aware of the TMJ and the various problems slipped discs can create, you can help yourself and others who are close to you. If you or someone you know has popping or clicking in the jaw joints, this indicates that the discs are out of place and need treatment. In my office, the first thing we do is assess the situation and see if a problem actually exists. If there appears to be a problem with the TMJ, then an MRI of the jaw joints is ordered to determine how displaced the articular discs might be. At the next appointment we review the options and show the patient the MRI findings. From there, a plan for treatment is developed. Generally, we work with our patients for a year or so to help the discs get back into proper position. This is Phase I as we call it and the goal here is to help those discs get back into place if they are able to. From there, we will figure out how to finish up, so you no longer need to keep up with our office on a regular basis. Our success rate is extremely high, and as with all things, the sooner you deal with the problem, the more likely we can get you better. So now you know a little more about TMJ disorders and what to do about it. Schedule a consultation for a screening so we can assess the situation and get to the root of the problem.
Here are some of the symptoms you might want to look for to help you in understanding TMD Disorder:
- Locking of the jaw and inability to open or close your mouth
- Pain in and around the ears
- Jaw pain and tenderness
- Headaches and/or Migraines
- Neck/Shoulder/Back pain
Some of the causes of TMJ Disorder include the following:
- Poor posture- in today’s modern society we are notoriously hunched over a computer all day and this is highly contributory to TMJD
- In the event of an injury the discs are more likely to be knocked out of proper position
- A misaligned bite or previous orthodontic treatment that did not pay attention to the articular discs
- Teeth grinding and/or clenching
- Bony defects like arthritis
In my office we also coach our patients through the process of treatment and teach many different exercises to alleviate tension through the head/neck region. These exercises (https://sleepandtmjtherapy.com/treatment-stories/) are posted on our website and include head movements, tongue exercises, and even meditation.
Spread the word about TMJ Awareness Month by sharing this blog!
The heart attack, that is. When a person has sleep apnea, their entire body no longer functions the way mother nature intended. The hormones do not recharge properly, the body does not have the ability to heal correctly, and you just plain feel awful most of the time. As someone who has in the past suffered the effects of sleep apnea, I can testify that it really is not much fun waking up tired, waking to a head ache, and feeling like you just cannot get out of bed some days. And now that I treat these cases, I hear these things every day in my new patients. They feel awful and just don’t know what to do about it.
Well folks, at this point I might as well add on another little concern. When a person has sleep apnea, their body is simply not getting enough oxygen for the body to heal. They are in a state called ‘hypoxia’- which simply means the oxygen is too low in the body. There has been a fair amount of research into this area and we have now learned, much to my chagrin, that sleep apnea now directly correlates to cancer risk. OH CRUD! The research indicates that the low oxygen allows the cancer cells to thrive better than they can in a high oxygen environment. So now, let’s review all this. Sleep apnea not only leads to heart disease and high blood pressure, but it also correlates to diabetes, and now to a high risk for cancer.
And now let me add on some other observations that I made recently. Just yesterday I went to the grocery store to buy more organic non dairy creamer for my team (they refuse to put the regular junk into their coffee) and I just started looking at the other shoppers- 90% of their were actually obese. I was thinking- is this the new norm? Is this what people look like now in general? I recall a photo from Facebook a few weeks ago. It showed a picture from the beach at that time. NO ONE was overweight-everyone was generally normal sized if not thin. A few months ago I noticed that more than half of the beach goers were extremely overweight over at Fenwick island- near Ocean City, MD.
As I thought about all this, things started to come together even more. Hmmm- sleep apnea means that your hormones are not able to re-charge properly so the hormones that control eating are out of whack. You can’t control your eating habits very well due to the apnea, this makes you eat more, you feel like crap from over eating and now you can’t even sleep well at night. What a vicious cycle this is! Pretty soon you are on medications to control the high blood pressure and the weight and now you have to worry about cancer as well! It really stinks having sleep apnea, doesn’t it?
So what can you do about it? Well, because I see so many apnea patients each day, I try to have a nice little chat with them about what is going on because I think understanding the problem is the first step toward fixing it. One of the first steps toward a real fix is exercise- simple as that. I now tell, not ask, all my patients to get out there and walk at least 20 minutes each day. This is where they start the process. Of course, we do a sleep study and analysis of their sleep patterns, but this needs to begin with something in which the patient takes charge of their condition, and I think walking is a great start! From there, we have lots of work to do, but let’s keep it simple for now and I’ll see you in the next blog.
When it comes to TMJ disorder, there really is no contest here. The Xray AND the MRI are critical to a really good diagnosis. First of all, when the jaw joints pop or click upon opening and closing, it is likely that the articular discs are out of place. The discs are made of soft tissue, basically like cartilage, so only an MRI would tell you if they are in the proper position or out of place. Over the years I have learned that the MRI is quite difficult to get done properly unless the MRI center has a lot of experience at doing this. I only allow our patients to go to Novant imaging for that reason. They have a dedicated Tesla coil for this imaging and know what I expect. In addition, I only have my colleague, Dr. Nick Patronas, do the reading. I really do not allow any other radiologist to look at the MRIs because I have found that Dr. Patronas does the best, most concise reading that I have ever seen. And this is what allows me to know the status of the discs in the joints. This is the view of the ‘soft’ tissue.
The view of the ‘hard’ tissue, i.e. the bone, is done through the xray. Xrays are designed to view hard tissue and will not allow you to see the disc tissue. The distinction is quite important. Xrays are indeed radiation so you want to limit how much you allow in exposure to the patient. The MRI, however, is magnetism so really no worries there. When it comes to xrays, you want to be sure you get a lot of bang for your buck here- i.e. minimal radiation exposure but maximal information gain. For this reason, I am luck to have the VA Tech i3D machine. It basically does 3-D imaging of the head/neck region so I can view not only the jaw bones (the condyles) but I can also see the cranial bones and the cervical spine. This is a lot of information that helps in the diagnosis and treatment for our patients.
So as you can see, dear readers, the twain are indeed not at battle with each other, yet they must coexist together on the same plane (wow, that was rather eloquent if I must say!). With both the xray and the MRI, we are able to view both the hard and the soft tissues in the jaw joints and the skull. With this knowledge comes a better understanding of what is happening in the TM joints and then we can better formulate a plan to help you. I often have people ask why they cannot just do an MRI, or just an xray, and this is because the two work together – i.e. no battle!
This was sort of a frustrating one that happened the other day. A perfectly lovely woman came in for a consultation for TMJ disorder, because that’s what I do, and her comments were very interesting. She explained that she went to someone else nearby for a TMJ consult and the doctor was bragging that not one of his patients ever needed surgery! She was surprised that I told her that surgery was always a possibility and that is why I do an MRI to understand the status of the jaw bones, the joints, and the discs. She also told me this other doctor never does MRI’s because he does not feel it to be necessary. To me, this was a dangerous position to be in- not being aware of the status of the joints and just assuming all was well. You know what happens when you assume (you make an ass of u and me).
Well, dear readers, as you well know, we ALWAYS do an MRI. And as you already know, the reason for this is that we must establish a good baseline to compare how we are doing during the course of treatment. It is important to document the position of the discs in the joints so that we know if things are improving. In almost all cases, the discs do improve and this is what we want to see.
The problem with not documenting with an MRI is that if the condyles (jaw bones) are eroding away and you do not track the progression of the disease process, you are not doing well by that patient. In so many of our new patients, the MRI shows long standing degenerative arthrosis and condylar erosion. So let’s imagine you go to the dentist who does not do an MRI. Even though the patient might be feeling better over time with the appliance therapy, the erosion continues and gets worse, yet the patient does feel better overall. Without the proper tracking mechanism there could be catastrophic failure one day. What that means is that the eroded jaw bone is so damaged that if the patient fell down on the ice, slipped in the rain, got hit in the head with a soccer ball, well, you get the picture, then that already eroded jaw bone could snap or break. And this means a major surgical procedure to fix it.
It would have been so much, much easier to just do an MRI at the beginning and redo that MRI every year or two to make sure things are ‘holding their own’ and not eroding. As you all know by now, I see about 100 patients each week who have TMJ disorders. Of those, 1 person or 1% will need surgery. That’s a pretty good percentage I believe. But I do have many other patients who I am ‘tracking’ over time. They have some erosion of the condyles due to the displaced discs, yet they do not want to do surgery or simply cannot do surgery for whatever reason. My job is to keep them well informed of their situation by periodically doing the MRI and monitoring the status of the discs, the joints, and the condyles. This way, if and when we see erosion or break down occur, we can discuss the surgery option and let the patient decide what they want to do. That’s all I’m saying folks- track the progression and keep the patient informed. You never want to learn that you did not know something that you should have known.
Every day in my practice I meet new patients who have what is called FHP (Forward Head Posture) and realize this is starting to become the norm, not the exception to the rule. We are all so attached to our little phones and hunch over them all day long that our necks are now out of place all the time. Just yesterday I had spoken to a young lady about her rolled shoulders and head craned forward as she texts her friends and watches videos. She then straightened up nice and tall…for about 30 seconds…and then re-hunched (this should be a real word!).
A few weeks ago I was at Dulles Airport on my way to Toronto and was noticing how most people were hunched over their machines- phone or tablet or computer. I thought gee, maybe I could invent a device that they rest their head into to make the ‘hunch’ more comfortable. Think of something like a chin rest where you lean forward and rest your chin into a cup like device so that the neck does not get too sore for the hours upon hours of doing your work or just surfing on your devices. Would I really make such a device- no! Just kidding folks.
As each day goes by and I meet my usual 3-4 new patients, I am noticing a trend. More and more of them are slouching over at our initial consultation meetings. Most of these folks are on the computer all day long and it just becomes a habit to hang their head forward. This forward posturing will also tend to make your jaws slide forward, which in turn will close down the distance between C-1 and C-2 in your neck, which will adversely affect the TM joints. When I see this happening, I explain to the person how they really need to work on posture and be aware at all times. It’s not easy, and I am the first to admit that it kind of feels good to lean forward while on the computer, but hey, it is not the healthy way to go!
So, dear readers, take a look at yourself in the mirror. That’s right, stand up and take a good look at yourself from a side view. Are you bent over? Do you look like the hunchback of Notre Dame? Maybe you could even take a look at your fellow workers and help them as well. Maybe, just maybe, you all should look at each other and practice good posture and getting that neck more upright. I even have some neck stretching videos on my website that will help- check them out. So take a good look and make yourself better!
The other day I was talking to a patient of ours about the promises of Medicare for all Americans according to the recent political debates. It seems that our politicians, who know nothing about what healthcare is all about, have determined that good health is just a commodity- something that you bargain for to get lowest price. Well, dear readers, this is not the case. When I explained to this patient that what they would end up getting is some poor, overworked doctor who really does not care about their health, and only cares about getting that co-pay or whatever compensation they can get, she did not like to hear my words.
I gave her an example. When I make a sleep appliance for a patient, the cost to that patient is around $5000. Currently, Medicare would only pay me $1100 for that appliance if I was a provider. To be honest, that $1100 does not even cover my costs to make this device. So what happened? What’s wrong with this picture? I called my lab one day and actually asked if I could somehow make a super cheap appliance and was told yes, it can be done. When I saw the device I told the lab guy it looks like a piece of junk and I would never allow a patient of mine to wear such a crappy device. He agreed, but said this is what dentists with Medicare provide- a piece of junk. Our government has boiled health care down to a commodity- i.e. provide the cheapest of the cheap and ignore the quality.
And now, this will reflect with the kind of doctors you see. If I was such a provider of Medicare services, then doing work at nearly a 75% discount would mean I could not provide quality service and high quality treatment- that is just the way it would have to be. My patients know that I travel frequently to train in physical therapy and osteopathy and now sleep medicine training. I am able to help so many, many people get better because I am highly trained in the field of craniofacial pain. If I was to participate in Medicare or other discount plans, then you as the patient would suffer.
Heck, I know everyone wants a good deal, but healthcare is no place to cut corners. The numbers just do not make sense and the politicians who think they can promise free health care to everyone are not making sense either. To have the government tell us what they are willing to pay for a procedure forces the doctors to bid themselves downward to the point where they not only do not make enough money to survive, but now they are forced to cut corners and do the LEAST (Least Expensive Acceptable Standard of Treatment). To me, this really is NOT acceptable in any way at all. This approach demeans the quality of care in this country.
Currently, the US is no longer one of the top 10 for quality healthcare in the world. We are not even in the top 20 any longer. I attribute this to the fact that healthcare has become a low quality business in this country where ‘cheap’ is the ruling factor, not quality. Do you folks remember that East German car- the Yugo? Well, that’s what we now have in the US- it’s still healthcare, well, sort of, but instead of pride, prestige, and quality we are now more like that Yugo. Low quality and run by a bunch of mechanics (politicians) who could care less about value.
The other evening, my wife asked me to meet up with her and the kids at the mall for dinner. My daughter had a bunch of her friends doing the shopping thing and they all had dinner afterward. The other kids were to be picked up by their parents. One of the parents showed up very early to say hello and just catch up. She was concerned her daughter might not be doing so well since she had been hospitalized two days prior with a severe and debilitating migraine. She started getting migraines a few years ago- around the time she started getting braces. You already know where this is going, don’t you, dear readers?
The mother told me and my wife that her daughter had just finished braces phase one, and now was ready for phase two and another two years and thousands of dollars worth of treatment. I looked at her daughter and could not figure out from a cosmetic view point why she needed more time in braces. Then the mom told us she went to a ‘cheaper’ orthodontist who also could not figure out why the girl needed more braces. The mom just wanted to save money, thinking all orthodontists are basically the same. This is where they went wrong- mom thought buying braces was like buying soap or a toothbrush- basically it’s all the same- just a commodity in other words. WRONG!
I have tried for years and years to explain to parents that orthodontic work must be done three dimensionally. It really does a patient no good if you are just making their teeth straight and you ignore the vertical height of the teeth, which are critical to support the TM joints. You ALL know this, don’t you? For all the years I have blogged onward and upward, I have once again encountered a parent who ‘just doesn’t get it’. So as I sat at this restaurant, I looked across at my wife and asked “Should I tell your friend the truth or just shut up while I’m ahead?”. Her friend then piped up and said “Give it to me”, thinking she could handle the truth. So, as you all know dear readers, I told the truth. I explained that when the vertical height of the teeth is ignored, the jaw bones (condyles) jam the sockets and impinge on those little discs that cover the condyles and the discs get pushed out of place and can pinch blood vessels and nerves- VOILA!: Migraines.
And so as I did my thing and explained to the mother that all orthodontic work is simply not the same. Basically, I let her know that she was not buying a product, she was buying a service and with that service comes either very basic knowledge, or a very high level of understanding of the various systems in the human body. I explained that if the cranial bones are distorted, then this is contributory to headaches as well, and most likely we would need an MRI of the TM joints to check for disc displacement. The mother was basically dumbfounded at this point, saying no one told her any of this, and she had no idea all of this was connected. At this point, I told my wife and her friend that I was glad to talk more but we should probably continue this at my office with a real and proper exam for her daughter.
I guess the motto of the story should be you get what you pay for. But that’s not fair since neither the mom nor the orthodontist is trained in this field. I have the same problem with other doctors as well- little to no understanding of TMJ disorders or cranial bone or cervical spine distortions. As time goes by, I am sure the knowledge will spread and I am trying to make it happen one patient at a time.
I’m giving that patient a DUI citation next time he comes in! This is what I am thinking of telling folks who come see me as a new patient and I see them yawning, there are circles under their eyes, and they look like they have not slept in weeks. Well, as it turns out, they probably have not had good, high quality sleep in years. Unfortunately, the effects of sleep apnea and sleep disordered breathing -SDB- tend to catch up with us so slowly, that by the time we ‘get there’ it is often late in the game. What I mean by all this is that SDB problems creep up very slowly on us and we pay a big price later on. At first, it’s just a little trouble falling asleep so we sleep in on the weekends to compensate for this. Then, our spouse notices that we are snoring here and there. Then the restless legs kick in (get the pun?) Then one day the spouse notices the outright gasping for breath or the total stoppage in breathing (this is the real serious stuff folks- being just about dead cannot be very healthy!)
So if you notice in your family members the above symptoms- restless legs, snoring, gasping, trouble sleeping, and outright stoppage of breathing, then DO SOMETHING about it. Get them help. A child who snores is not very cute in my world- this is a dangerous thing. We can help these kids so much with their breathing by wearing ALF appliances. These devices open the airway and give more room for better breathing. With adults, the same appliances are very useful in reducing SDB- they are how I can actually cure sleep apnea.
As it turns out, most cases of Sleep Disordered Breathing are totally ignored. I am not talking just the apnea cases, I am talking about the other symptoms that I mentioned. Since most doctors out there have little to no training in this area, they tend not to address the obvious problems. Then, as the years go by the patient develops cardiac problems – otherwise known as the silent killer. Let me explain. With apnea, the patient gets less oxygen in their system than what their body needs. The heart rate increases to pump more blood to the brain, so blood pressure increases to make that happen. After enough years of this, the heart gets damaged- it just was not designed to work that hard during the nighttime.
In my office, we have just begun a new program to help analyze sleep apnea and what to do about it. I am in the process of setting up a meeting with my friend, an MD who is an internal medicine specialist. The plan is to have his office do the needed bloodwork to analyze Vitamin D-3, B Vitamins, and other indicators that correlate with SDB. The research is so far quite promising since once get the vitamins balanced out, this will help the patient sleep better, not to mention grind their teeth less. Yes indeed, dear readers, SDB directly correlates to clenching and grinding your teeth at night. Go figure!
So now that you know more about SDB, tell your friends, tell your neighbors, tell your family members and get them some help. As always, my team and I are there to help you figure things out.
So, what am I talking about here? Well folks, I am doing today’s blog to talk about insurance companies and how they promote the lowest cost options available, and the reason why they would do this. You see, it turns out that most patients dump their insurance and change carriers after just a few years, so from the insurance company’s point of view, it really is not a good idea to pay a lot of money and cover that patient for high quality treatment since they will not likely recuperate that expenditure as the patient will not stay with them long enough and pay enough in premiums to make high quality/higher cost treatment practical.
This is where we talk about LEAST: Least Expensive Acceptable Standard of Treatment. This is a really good acronym that explains how insurance companies operate. You as the patient would like to have high quality care, of course, yet the insurance company just wants to minimize their own out of pocket costs. The two goals are not in synch with each other, quite obviously. Therefore, when a patient comes to my office they are sometimes in a conundrum. They want the best care possible. They want to actually FIX the problem, not just put a band aid on it. And then when they find out that it will cost a lot of money out of pocket to work with us, they tend to have second thoughts.
And this is where the concept of ‘in network’ kicks in. A ‘participating provider’ is simply a doctor who is willing to work for a lot less money in most cases. And to do this, they make up the difference in volume. They do what I call the Costco approach – pack in as many customers as possible because profits are so low that the only way to make any money is to jam in as many patients as possible. You see this routinely at the dermatology office. A few years ago, I sat in my daughter’s dermatology office for an hour and a half waiting to be seen. When I told the receptionist, we did not have all day, she told me she would still charge for the appointment when I told her we were leaving. I told her the doctor would have to pay me for my down time as well. It was a stand off and I never went back again.
So here I am comparing the concept of selling a product, Costco that is, to the concept of selling a service, and that is where the problem comes in. Insurance companies are trying to commoditize health care and make you think it’s basically all the same, so it does not matter who you go to. Well, dear readers, there is something truly wrong in the state of Denmark if you believe them. This is what my blog is all about. I CHOOSE not to do the lowest standard of care for my patients. I CHOOSE to provide a high-quality service at a reasonable cost. I could easily just write prescriptions all day long for pain killers and drugs that reduce dizziness or drugs that make you sleep better or drugs that do whatever you want done. But I do not do this because drugs do not actually fix anything. They simply mask the problem.
In my practice I have chosen to actually fix problems, not to cover them up. And this costs money. And this is often not well covered by the insurance carriers because it is simply not the LEAST available. This morning alone, I have been told by ALL my patients that their head pain is less, the tinnitus is better, the shoulder pain is gone, the neck pain has lessened, and the dizziness has reduced. Those who were taking drugs are now taking less drugs. This is how it should be. And let’s talk cost. Yes, it is somewhat expensive to have me make these devices, however, it is far less than the cost of not wearing them over the long term. When a patient chooses the insurance company over me, they end up on drugs that they will eventually become intolerant to or they end up with liver and kidney problems from the medications. There are other more numerous side effects to drugs, but we all know that. So, let’s also look at a little thing that I call opportunity cost- the cost of what you missed out on.
For this discussion on opportunity cost I am going to recall a wonderful lady from Florida who I treated for dystonia a while back. She had literally spent over 20 years in bed she told me, due to pain from having her neck pulling all the time. She lost out on life basically. Well, when she met me, she was understandably skeptical that a little device in her mouth would fix most of the dystonia. She took the plunge, paid the cost, and now let me tell you about her. She has two wonderful daughters who she spends every evening and weekend with now, instead of curling up in bed and in pain. She has created priceless memories with her girls. I was able to give her back her life, instead of taking pain meds that were the only things ‘authorized’ by her insurance company. So, she lost a lot of years from being in pain with dystonia, but today she feels great and is living her life to the fullest. There is no price you can put on this.
So here we are folks, the year is 2019, and I get emails almost daily from patients asking me to participate in their so-called network. My response is basically what you have read above but I also add this in as well: How would you like it if next year your employer told you that you are going to work for 40% less pay, take it or leave it? This is the kind of doctor you are dealing with when they participate. You are now going to an office where they need to see you quickly and get you out the door so they can make their money and move on to the next patient. Dear, dear people- that’s just the way it has to be. You are now a participant in the commoditization of health care! All doctors are the same and all treatments are the same!
In reality, that simply is not the case. Like I said, it’s 2019, and it’s also June 19 today. Because I do not believe in the principle of LEAST, I spent last weekend at the ALF Academy/Interface meetings in the exciting town of Columbia, Illinois (let’s just say the most exciting thing I saw there was the local carwash). That weekend was both my birthday and Father’s Day and I spent those days training at the Academy meetings. It was a choice and a choice that I would do again and again. It was all about becoming the best that I can be. And Monday morning when I returned to the office, that training came in very handy once again. It seemed that most of the new patients early this week had already been to many doctors and simply found no relief. It literally took but a moment or so to figure out that they had cranial bone distortions and/or slipped discs in the TM joints. But, in addition to all that, it was painfully obvious that they were not sleeping well and that was highly contributory to their reported symptoms. Because of last weekend, I am now working with an MD who is checking blood panels for Vitamin D-3 discrepancies which we now know are highly contributory to clenching/grinding and sleep disordered breathing. Because we now have neurologist attending the Academy meetings, those of us who train there are now able to help our patients even more. But that is another blog for another day.
To wrap things up, now you all know that I am not a ‘LEAST’ doctor, and now you know why. I sleep well at night because of this, and hopefully this blog will help you sleep better too. Thank you.
No fancy titles today folks, just something for you to think about next time you see a child who is breathing through their mouth and had large dark circles under their eyes. These days it seems that many more children are experiencing what is called SDB (Sleep Disordered Breathing). The reasons for this are quite varied, but in many cases it boils down to the fact that allergies are more common along with increases in obesity as well. When a child has allergies or is overweight, they are much more prone to snore. The research now shows that a child who snores will have an 80% chance of losing 20% of their mental capacity, and this is a permanent manifestation with no way to correct. Additionally, is a child having a diagnosis of SDB, they are 60% more likely to require special needs education by the age of 8. These are some very scary statistics, dear readers!
Has anyone noticed that there are many more children these days taking ADD/ADHD meds? Well, of course, these kids are not sleeping well and their bodies are failing early in life! Their nasal passages are often being ignored by the ENT and pediatrician in the early years. It is absolutely critical that the young child breathe better in the early years, otherwise they will pay dearly later on in life. As a parent of one of these children, I can directly relate to this. One of my children was truly failing to thrive in school. He slept poorly and was always tired the next day. His grades were simply awful. The teachers suggested medication to calm his mind during the day. I suggested they all take a hike and pound sand.
Our x-rays conclusively showed the nasal septum to be quite deviated. I decided to make ALF appliances. Within a few months my son began to not only sleep better, but he simply ’became’ better in general. Better grades, he looked better, he became more communicative. He is now in college and doing just great! I feel totally blessed for all the years of training I have had in the field of sleep medicine and dentistry. All the time spent away from my family has not only allowed me to help my own family, but now I help others as well. Every day in my office I see both adults and children who can now sleep better and function better- it is really rewarding!
The only problem that I have is that so few people know about our work. We are trying to ‘get the word out there’ but it is a daunting task. Very few MD’s really understand what is happening in my office every day. They have never heard of the ALF appliance or what it can do. When I try to explain how it takes a high palate and brings it down, most of the time they say only surgery can do this. (Bringing down a high palate allows for better nasal breathing which is critical to good health) When I show various doctors the x-rays of how my patients end up with less deviation to the nasal septum, they again say that it cannot be done. Well folks, it can, and it is done! The amazing ALF does all that and more. But as with anything good, it takes time and patience.
My plan is to keep plugging along- one patient at a time and one blog every week- to make changes in how health care is done in our country. I would like people to be aware that we can most certainly help SDB problems with a relatively simple device. Ask me in 20 or so years if I feel like I made a difference. Thank you.
Sometimes I just love the titles that I come up with for these blogs! The reason that I wrote this blog, and the interesting title, was to catch your attention and show you a case that I saw on AOL news today. Recently, a man cracked his neck and ended up with numbness all down his left side due to an impingement on the vertebral artery. Let’s talk some anatomy here folks. In a human being’s spinal column there are seven bones in the neck and they are labelled C-1 to C-7. When there is a lot of neck irritation, a little piece of extra bone forms on top of C-1, and this is called a ponticulus posticus- check out the photo below:
Do you see how terribly straight this person’s neck is? This is too straight for good comfort. When the neck is like this, your body tends to create more bone on top of C-1 to help provide support for the neck. Good idea, right? Wrong! As I wrote about some time ago, the vertebral artery snakes through this area and if you have that little piece of extra bone there, it could easily break if you are undergoing chiropractic treatment where they snap or crunch your neck. This is why I tell my patients that snapping a neck with a prominent ponticulus would not be a good thing. You will in fact have a very bad day if that is snapped and it breaks. Well, this is possibly and even likely that this is what happened when that fellow snapped his own neck- he may have cracked off a bit of that ponticulus posticus and it pinched the vertebral artery and made him numb on that side. It is also possible that an osteophyte broke off and caused this too. This is such a serious condition that the guy should probably get an Xray to see if there is a piece of bone up in that area. I do not, unfortunately, know how to contact him and explain this. I have, however, contacted the news reporter via Facebook and left the message that perhaps I could explain this more. We shall see if she responds.
For those of you who are interested, here is the link to the original article:
Lately, it seems that more often than not, I meet a new patient who has been through tremendous stress, distress, and genuine pain at the hands of multiple other doctors. Case in point- just the other day a young man comes down here from New Jersey and has been told that he needs surgery to correct his very messed up jaw, as he called it. I looked at him and could clearly see that the eyes/ears/eyebrows were not at all level. It was painstakingly obvious. You, dear readers, already know what is going on since you have already read ALL my past blogs ;). But, for the newest of my dear readers, I should explain. What is going on with this fellow is that the cranial bones and cervical spine (neck) are quite uneven and quite out of proper position. There is no way he should consider surgery of the jaws, either now or likely into the future.
I was thankful that he came to see me because he has been to so many other doctors already and not one has done an MRI to look at the jaw joints. No one has discussed the distorted bones in his skull. No one has mentioned the distortions to the cervical spine. All of this was so obvious on initial exam, and MRI and x-rays have confirmed these observations. This is where it all begins as you all already know! At this point, I felt lucky that he had all these bad experiences because now he is finally ready to listen to a different approach- and that is using the ALF appliances. When I mentioned the ALF’s, he told me he already knew about them and had gone to see an ALF practitioner in another state who told him these things just take too long to work with! I was surprised about this. As it turns out, there are a few ALF doctors who have just given up because ALF takes time and patience, it is not a fast appliance. Using ALF’s takes time, using ALF’s is slower, but using ALF’s is safe, comfortable, logical, and it just plain does a really good job!
So when I sat down with this young fellow, I explained that he had been through quite a bit already and it might be good to slow down the pace and just work on his health for a while. He liked what I said. We then agreed that it would be wise to use the ALF appliances and just give his body time to adjust and ‘calm down’. The way the ALF works is that it helps to stimulate the parasympathetic nervous system- i.e. the ‘calming effect’ – by providing support to the bones in the skull and allowing the whole body to sense more comfort in general. I see this all the time folks! Today, as of 11am, I have already checked on 4 patients wearing ALF’s and all of them report less pain and better sleep. And let’s not forget-better sleep means better healing.
I was happy that I could begin to help this fellow, yet not so happy that he had to be treated badly first in order to accept my divergent plan. My plan was not fast and aggressive, it was slow and gentle. It seems that maybe it was better for him to go to all the different doctors first, before finally landing with me- maybe it was better to have all those bad experiences so that listening to me was now easier. Maybe.
I have just started reading an article about the effects of computers and telephones and radiation and suicides and all I can say is: WOW! All this screen time is truly changing how we interact with each other, how we learn, and how we feel. Did you know that suicides are greatly on the increase in our modern society? So why is this happening? What is going on here? Well, basically smart phones emit EMF’s (Electro Magnetic Frequencies) that change how our cells react. Here is a quote, courtesy of Dr. Mercola’s article:
‘Research by professor Martin Pall, Ph.D., reveals EMFs activate voltage gated calcium channels (VGCCs) embedded in your cell membranes. This releases a flood of calcium ions which, through a cascade of effects, result in the creation of hydroxyl free radicals — some of the most destructive free radicals known to man. In turn, this decimates mitochondrial and nuclear DNA, their membranes and proteins, ultimately resulting in mitochondrial dysfunction.’
So every time you fire up your smart phone…wait a minute…mine is ALWAYS on! As I sit here typing this, I am going to take my smart phone out of my pocket and put it up on a shelf, far away from my body. As a dentist, I am all too familiar with free radicals and their effect on the human body. Here is another quote from the same article that scares me as well:
‘Aside from reduced cortical thickness (found in other studies beside the ABCD study), long-term internet use has also been linked to a loss of white matter and impaired cognitive functioning.’
So here we are folks, exposing our children to devices that are reducing their brain thickness, loss of white matter, and impairing their cognitive skills! How about we go back to the old style rotary telephones and stop blasting ourselves with radiation that is killing us slowly? In the article, they mention that we are ‘experimenting’ on our children. Wow, that’s just insane, isn’t it? Every day of the week, I prescribe outdoor time for my patients because with TMD cases, they simply need to get outside, get some fresh air, reconnect with nature, and just get away from the darned computer! Now the research is coming down- we are all way too close to our computers and cell phones. This stuff is pretty scary folks, not to mention downright dangerous. Please take the time to think about how the Internet and cell phone use is affecting yourselves and your children!
When it comes to recommending surgery to one of my patients, it is always a difficult decision. The problem with telling a patient they need to do surgery is that by the time they come to see me, quite often the discs are in really bad shape and the pain has been there for quite some time. What this means is that the discs are usually damaged and quite often the condyles (the heads of the jaw bones) are also somewhat damaged as well. It’s kind of like saying your car needs engine repair and it already has 150,000 miles on it, so it’s a bit worn out. Not the best analogy but that’s what I have for you.
Let’s get a little more into what we have to consider. The TM joint is a three-dimensional structure, which is very unlike other joints in the body, like a finger or a knee, which just bend in one direction. So with the TM joint, you have to consider all angles- literally. When you have surgery performed to put that little disc back on top of the condyle, you must consider where the discs have been displaced and is it really possible to get them back into proper position. Think of a baseball – the interior part of the baseball is the condyle and the disc is the leather covering on top of the substructure. Can the surgeon really get the covering back on top of the baseball? If the disc is really damaged, sometimes it has to be removed, yet there is no way to get the whole thing removed- it is simply too close to the cerebral artery so the whole thing cannot be safely removed. So this is the other consideration: Can my surgeon get enough of the damaged disc either put back in place to give the patient relief, or if removal is necessary can he get enough removed to take the pressure off the nerves and blood vessels to get the relief needed? Doing this kind of surgery is not like putting a new muffler on your car – it’s not a definitive thing that is totally predictable.
When you are considering TMJ surgery, you must be aware that the surgeon is cutting through tissue, through blood vessels, and near nerves. All of this usually goes just fine and with a success rate of around 94% (yes, we have a case study on this) there is little to worry about, however, it’s always those 6% of the cases that I have concern with. The interesting thing with what I do is that as a dentist, my patients expect me to get the job done, and get it right the first time. This surgery is actually a medical procedure – it’s done at the hospital by a board-certified surgeon- and due to it’s complexity may have complications. And again, although very safe, the patient has to be aware that post-surgery there might still be some degree of discomfort here and there. There might also be some degree of numbness on the side of the head due to the incisions and scar tissue that forms. And for some people, it just may not work at all. This is because there was just too much damage to begin with.
This is why I wrote today’s blog: I want my patients to understand that surgery is never definitive, final, or the end of all treatment! After surgery you are going to go out into the real world and keep on using those joints. They can and possibly will, break down again which means that even though you have had the surgery and you feel great, you still need to come back every year post treatment to check the joints and make sure they are doing OK. So if the discussion of surgery is on the table, please read all of this carefully and ask any questions before you consider the procedure.
Recently, a young woman in her 20’s was diagnosed with a fairly severe TMJ disc problem. Basically the discs were already degenerating and eroding away and no one knew why this had happened. I suspect it was birth trauma, but no one knows for sure. I treated her conservatively for many months, trying to get the discs to recapture into position, but it was to no avail. The new MRI clearly showed that I met her too late in the game and surgery would be the best option. When I discussed all this with the patient and her father, it was obvious they were not thrilled. Heck, who wants to hear that surgery is the only option? The father was very upset that insurance would not pay 100% of the hospital costs, nor would they pay for the surgeon’s fee. I figured I would never see them again after that visit since they were quite noticeably upset, disappointed, and distraught. They knew from day one how much damage was there, but they expected me to work a miracle and fix everything non surgically. My consent forms are quite clear- surgery all depends on if I meet the patient soon enough before the damage becomes extreme. In this case, it was a pretty bad situation.
So I wished them well that day, thinking they would find some other doctor who would tell them what they wanted to hear: You do not need surgery. Well, as it turns out, the father diligently went to his insurance company and got the names of 20 TMD specialists who could do the surgery, and it would be covered at 100%! Yippee! And being the very diligent father, he took his little girl to ALL of these so-called participating providers who knew what they were doing. Well folks, as it turned out, 10 of the doctors on the ‘list’ had never heard of TMJ surgery (yet according to the insurance company they did). Another 8 had no idea how to do the procedure (even though they were on the provider list as well). And the other 2 had perhaps done a couple of these procedures. The father already knew that my surgeon, Dr. Gregory, had done thousands of joint surgeries over the years with a success rate of around 94%. Needless to say he was appalled that there was so little understanding about what needed to be done.
A few weeks later I was shocked to see the young woman on my schedule. She and her father had come back to discuss having the surgery with Dr. Gregory. The father basically told me he was disgusted with what the insurance company tried to do- they tried to save money by having an inexperienced surgeon do surgery on his daughter. To me, this borders on criminal intent. The insurance carrier wanted someone to do this surgery when he/she had no right to do this. Did they figure that it might work out anyway? I was shocked when the father told me how he went to all those doctors only to learn that taking the short cut might damage his daughter’s future.
Ultimately, our young woman had Dr. Gregory do the surgery and her pain was literally gone that same day. I have seen her for multiple follow ups since then, I took out her sutures, and she said she feels much better now. Although I am very much against surgery for my patients, I must admit that 1 or 2 out of the 100 patients per week really do need it. This week alone I met several new patients that were fairly warned that surgery might be needed, but I will do all that I can to avoid it and manage their cases non surgically. I am always sorry to report that the insurance company is not really there to help you get better. They exist solely to make profit for their shareholders and are simply a for-profit entity. There is no ethics involved when talking about insurance companies so I do not understand why patients look to their insurance for ‘proper’ care and consideration. The father and daughter learned a lesson from all of this, but so did I! Now when discussing surgery, I explain that you are very welcome to go get other opinions- I wholeheartedly recommend it! However, please be aware that due to the lack of knowledge in this area, you will most likely find doctors who will not recommend the surgery and that is the way it is.
Today is Wednesday, November 21, 2018. The time is 06:30 (that’s like 6:30 am in the morning) and I have been in the office since about 4:45 am working on my MRI’s, reports, letters, and emails. As I sit here, I am thinking how incredibly lucky I am to have a wonderful family -both at home and here at the office. My kids are growing up, three are in college, and the youngest goes to high school this coming year. They are doing great. At the office, my family consists of five wonderful women (and also my beautiful wife, Barb) who do most everything needed to run this office, along with our new guy, Brendon. My team is not my staff- my team is like family to me. We have our squabbles, we have verbal exchanges that leave some of us quite exasperated, but at the end of the day I think we all know that we made a very positive difference in so many peoples’ lives.
Just a few days ago I saw a woman who we have only worked with four months. The day I met her, she was in such pain that she cried constantly, could barely open her mouth, and the family had mostly given up on her and was ready to institutionalize her for the rest of her life. This is pretty sad for a 50 year old woman. When I saw her the other day, she came in with her hair done up nicely, a little bit of make up on, and she could smile easily. I give thanks to Dr. Darick Nordstrom for all the training in the ALF appliance that he has provided over the years. The ALF appliance gave this woman her life back. She now has a chance at a real future and a real life. Thank you Darick.
I would like to thank Dr. Brendan Stack as well. He was my mentor, my tutor, my predecessor, as well as a pain in the butt! He and I would frequently get upset with each other if we did not agree if the appliance should be 5.5mm high, or 5.4mm high. That’s right folks, we were quite anal about things back then. I miss him now that he has retired from the practice, and yet I am still so thankful for all that he pushed me to do. He told me on day one to become the best ALF doctor in the world and I have striven to meet that challenge. I spoke to him yesterday just to chit chat and he sounded great. I even invited him to come back to the practice- he just laughed and said those days are over.
At the office I must give special thanks to Venus- MOM (My Office Manager) who keeps me in check and on point at all times- she is simply awesome. To Meghan, very special thanks for handling the schedule and the marketing programs- I think she has the toughest job trying to juggle patient schedules for the times people want. I thank Karina who has been with me since the days of Dr. Stack- she is perhaps the best assistant I have ever had. She takes the time with the patients and shows how much she cares at every visit. Then there is Jessica – a truly excellent assistant who is extremely dedicated to the job and supports all that I do, even though we have our differences, we still care about each other and our team. My third assistant, Ruth, just seems to adore being with our patients- she has become a truly valued member of our team. And finally, we call him the new guy, Brendon has taken the art of dealing with insurance companies to a new level-he helps our patients get the coverage they deserve and advocates for them at all times. I am very thankful for my team- they show what excellence is truly all about.
And to bring this all together – my wife, Barbara, not only takes care of the house, the children, the cars, and the dog but she comes to the office every week to make sure all is running well here as well. This takes pretty much all the stress off of me so that I can do what I do. I cannot tell you what that means, dear readers, to be able to come to the office each morning and just focus on the patients and not have to even think about the rigors of daily life. Heck, I don’t even gas up the cars any more- Barb handles all that too!
So on this day of November 21, 2018, I thank God for all that I have and all that I have become on the day before Thanksgiving. I truly have so much to be thankful for. I wish you all a most excellent holiday with friends and family!