William Giannobile, DDS, DMSc - Dentistry as a healthcare profession

Disclaimer: Unedited AI transcription

Announcer (00:06):

You are connected and you are listening to specifically for seniors, the podcast for those in the Remember When Generation. Today's podcast is available everywhere you listen to podcasts and with video at specifically for seniors YouTube channel. Now, here's your host, Dr. Larry Barsh.

Larry (00:39):

Today's guest on specifically for seniors is Dr. William Giannobile. Dr. Giannobileis the 11th dean of the Harvard School of Dental Medicine and professor in the Department of Oral Medicine, infection and Immunity. Dr. Gino's continuously, n i h, funded research program over the past 25 years has focused on oral and periodontal regenerative medicine, tissue engineering, and precision medicine. He currently serves as co-principal investigator to the N I H N I D C R supported Michigan, Pittsburgh, Weiss Regenerative Medicine Resource Center. He is the editor and co-editor of nine books focused on clinical translational research, periodontology and regenerative medicine. Dr. Giannobile recently completed a 10 year term as editor-in-chief for the Journal of Dental Research, the official journal of the International Association for Dental Research. He has president of the American Academy of Periodontology Foundation and Theology Foundation. In addition to his, his administrative responsibilities as dean, he practices periodontics and implant dentistry at the Harvard Dental Center in Cambridge, Massachusetts. Welcome to specifically for seniors Will. It's my distinct honor to have you as a guest on the podcast.

Dr. Giannobile (02:37):

Well, thank you so much for Larry. It's, it's certainly my honor and privilege to have this opportunity to be a part of this podcast today. So thank you so much for the, the kind invitation.

Larry (02:50):

There is a phrase that's always bothered me since graduating from H S D M that's in common use in the public, the phrase doctors and dentists. This has annoyed me for the past 60 years because it implies that dentists are not real doctors. Would you like to comment on that?

Dr. Giannobile (03:14):

Yes. it, it, it, you know, Larry, it bothers me as well when I hear people say that I cringe. But I, you know, the way I always explain it is as physicians and dentists and we're both doctors we really focus on the oral cavity. Many have even used the term physicians of the oral cavity or of the mouth is oral physicians. And so dentists are critical oral healthcare providers, and we really collaborate with the rest of the medical enterprise. So there's so many collaborations with our colleagues in medicine, and it's, it's so very important. So I think the terminology, obviously some people will stumble across it. It, but, you know, I, I think it's, it's important to, to get that nomenclature right. So,

Larry (04:09):

Which brings me to the difference between Harvard School of Dental Medicine and many other dental schools.

Dr. Giannobile (04:20):

Yeah. So, you know, I would say, you know, we were, we've talked about this and as you look at the Harvard School of Dental Medicine and our history, so I'll give you a bit of a snapshot. You're an alum of our class of 1961, so you're one of our proud graduates, and I think you're aware of that one of the unique aspects of the Harvard School of Dental Medicine is our students go side by side with their medical colleagues. And actually, when we even have our white coat ceremony, our students wear the jacket that says Harvard Medical School, because our students train with the medical students for the first 14 to 16 months of their training. And the Harvard School of Dental Medicine originally started as the Harvard Dental School back in 1867. And at that time, we were the first dental school associated with a university.

Dr. Giannobile (05:16):

And so very soon after that, the dental school became a part of the faculty of medicine. So since 1899, the Harvard School of Dental Medicine has been together with the faculty of medicine. So I'm a member of the faculty of medicine as well as a professor in oral medicine, infection and immunity. And so we have that connection with our, with our training and that critical linkage between medicine and dentistry. And that's why, you know, many of our students, quite honestly, they choose to come to the Harvard School of Dental Medicine because of that very close link. And as we look at the future of dentistry, I think it only becomes more and more important that we collaborate more closely with medicine.

Larry (06:06):

Definitely. but I don't think still that most of the public fully understands what a dental degree entails how much of a total health profession it really is, both based on their experiences in dental offices and what advertising in the media talk about.

Dr. Giannobile (06:30):

Right. You know, there have been, and we've talked about this before, I think, Larry, you see how there are many facets of dentistry, just like in medicine where there are many elements within, in dentistry, of course, part and parcel with it is healthcare and healthcare delivery. So looking at promoting health of the oral cavity, we have many of our specialties that are focused on diseases and conditions of the oral cavity. Very common ones are dental decay, dental caries, periodontal diseases. There can be cancers of the, the oral cavity in the jaws. And so we have both our general dental colleagues, specialists in oral medicine, oral maxillofacial surgery, periodontology, many of these different specialties focused on diseases and conditions. Whereas just like medicine, we also have those, those aspects that are a bit more focused on the aesthetics and the physical appearance, because we know how important it is to have a beautiful smile in how it really helps a person in terms of their overall sense of self and wellbeing. And so many in the media see you know, you know, the various aspects of dentistry really focused on the cosmetics side, which indeed is important. I mean, in medicine you have plastic surgery, dermatology, these are fields that crosscut through the aesthetics and in the healthcare space. And so that's what we see within dentistry. And sometimes folks really focus on that aspect. But many different elements form function, aesthetics,

Larry (08:18):

And the integration of oral health with total physical health. This was really demonstrated during the H I V crisis in the early eighties.

Dr. Giannobile (08:33):

Right. So, you know, Larry, I'm, I'm glad you bring that up as well. And it's, you know, continuation of your earlier question about, you know, the Harvard School of Dental Medicine. And so I I quote you our mission and vision you know, the, the mission of the school is to foster a community of diverse global leaders in education, research, and clinical innovation dedicated to improving human health by integrating dentistry and medicine. So that that linkage between oral, systemic conditions becomes very important. And then, you know, our vision of the, the school is to transform access to healthcare in advanced science, to prevent and find cures for oral diseases and conditions. So I think for the future of dentistry, we're, we're seeing more and more of this integration. And you know, to extend that a little bit further, we're seeing that, you know, there have been a lot of discussions on Medicare as a part of this podcast, you know, the importance to elders and with aging, we see that it's important to really integrate Medicare with dentistry.

Dr. Giannobile (09:49):

And we've had one of our faculty members, Lisa Simon, who's been very focused on this and looking at Medicare and providing that coverage. But as time goes on, that will be important for the coverage of seniors, but also when we talk about a, a field in education called interprofessional education on how dentists can collaborate with nurses social workers, physicians as a part of providing that quality care for our patients. So this interprofessional aspect is important actually. Just recently I've had some discussions with our colleagues over at the Mass Massachusetts college of Pharmacy and Health Sciences. They're located right across the street from the School of Dental Medicine, and they have the Forsyth School for dental hygienists. They also have radiology programs and other types of programs that are very important in cross-cutting and collaborating with dentists. So I think it, we're only going to see more of this collaboration.

Larry (10:59):

That's, that's a good thing. I, I remember that was one of the problems being educated at Harvard Dental School. So feeling comfortable with discussing problems with physicians who did not feel comfortable discussing problems with dentists.

Dr. Giannobile (11:20):

Right. Yeah. And I think, you know, it, it's a reciprocal relationship. I think it's important for us to help educate our medical colleagues. And, you know, one critique I think of I have of the, the medical dental education process at Harvard is, I think we could do much more to support our medical colleagues in educating them on, you know, the importance of oral health. So, you know, you take, for example a very common bone disease osteoporosis that tends to affect, you know, post-menopausal women significantly leads to decreases in bone mass. And oftentimes we look to collaborate with our physician colleagues to let them know that women and men with osteoporosis, low bone density that can have impacts within their oral cavity, those individuals who might have reduced bone mass due to periodontal diseases that can lead to destruction of the, you know, destruction of those osteo structures around the teeth.

Dr. Giannobile (12:28):

You know, some of the, the impacts of that, if someone has low bone mass due to osteoporosis, if they lose teeth, they're more likely to lose teeth more quickly. Postmenopausal women tend to have fewer teeth than those who don't have osteoporosis. And if they ever need a tooth replacement dental implant, we've heard about these very common with aging for tooth replacement, it becomes more challenging to place these orthopedic fixtures in a patient that has reduced bone mass. Another example, working with our medical colleagues, cardiovascular disease, diabetes, to very common diseases that have impacts on the oral cavity. And oftentimes our, our medical colleagues are unaware of oral infection and periodontal disease has a very close association with cardiovascular disease. If you're infected with periodontal bacteria, those that get down between the tooth and the gumline, some of those bacteria, they're eliciting a systemic inflammation that's associated with a variety of heart diseases. And diabetes also exacerbates the condition. So this crosstalk, this, this conversation with our medical colleagues could go could go a distance if we got together more frequently.

Larry (13:55):

You brought up osteoporosis that brings up the discussion of Prolia and some of the medications to treat osteoporosis and the possibility of interrelationship with jaw problems.

Dr. Giannobile (14:12):

Yes. So that's interesting you bring that up because we've been involved in some of the fundamental research with Prolia, the bisphosphonates, some of these parathyroid hormone analogs. Many of these different drugs have been approved by the Food and Drug Administration to either reduce, you know, stop the progression of bone loss and osteoporosis, or some of them are more anabolic agents that rebuild bone. And it has been noted that, I mean, you can't disconnect again, the head from the rest of the body. Patients who have untreated oral infections are at risk for developing a condition called medication associated osteonecrosis of the jaws or O N J. And patients who've been on those drugs for a long period of time are at risk if they haven't had their oral cavity checked and to, you know, relieve some of the symptoms of, of some of the infections in the oral cavity teeth at risk for tooth loss for example. So, again, that, that is a, a very good example that we've done some work looking at working with key opinion leaders in the as bone health specialists to better educate them to be aware of dental conditions so they there can be more of a collaborative care.

Larry (15:42):

I introduced you and your work on regenerative and regenerative medicine and translational research. Could you explain that for me? That's way beyond my <laugh> education at the school.

Dr. Giannobile (16:01):

Well you know, Larry, as you, you brought that up in the introduction, I, I've been involved with this National INS, institutes of Health center that's, that's been funded by the Dental Institute called the N I D C R. And Regenerative Medicine is something that's, you know, it really cuts across the whole biomedical research enterprise. And this program that includes the Vase Institute at Harvard University is one that looks at rebuilding bones, soft tissues in the oral cavities specifically. So rebuilding bone around teeth, patients afflicted with periodontal diseases, helping regenerate the pulpal tissue. So within the, the pulp, the inner nerve component of teeth, maybe to help reduce the needs for root canals there's other work that's been done as a part of the center to try to regenerate nerves other structures within the whole craniofacial complex. Maybe someone has a developmental defect due to a c craniofacial anomalies, such as a young child with a cleft palate cleft lip.

Dr. Giannobile (17:19):

How can you regenerate some of those structures? So regenerative medicine is an approach where you, you, you take living tissues, you might take cells or you might take biological growth factors that have been produced in the laboratory and use those to stimulate new tissue growth. And oftentimes they're combined with a, a matrix or a scaffold that can hold these cells, hold maybe even genes or biological factors that can be placed into the defect to promote tissue regeneration. And you know, Larry, as you asked the question, translational research, what that really what that really means is we can take something discovered within the laboratory and translate that to apply it into a patient to advance a patient's health. And so, a a lot of my research from my career has really focused on that translational research from the bench to what we would call the bedside or the chair side. And then eventually we would hope that it would be clinically adopted by patients and clinicians because, you know, sometimes we can develop a new mouse trap or a new, you know, technology that seems like it's going to be transformative, but, you know, patients have to be willing to accept it. Clinicians need to identify that this new therapy is made, is easy to use, and can be cost effective and improve a patient's quality of life. And so much of what we've done in the center has really been focusing on those elements

Larry (19:09):

That broadens I think the public's conception of what dentistry really involves beyond what they see on television, what the commercials imply. But now let's switch over to dentistry. Dentistry. Sure. Specific oral problems you alluded to that affect older adults. What, what do you perceive as the common oral health issues?

Dr. Giannobile (19:45):

So, Larry, I would say some of the common oral he health issues, you know, there's, we can look at it from both the preventive side and the therapeutic side on how we address them. But dental caries. So this is tooth decay that can affect children very early on in in their development. This is one of the most common diseases along with in more in older adults, those age 40 or older periodontal diseases are sometimes called gum diseases. These are two very common ones. But then there are plethora of other oral conditions. You know, there can be diseases of the soft tissues you know, the inner lining of the you know, the, the tissues within the oral cavity, the tissues surrounding the teeth or the gingiva. And then there are injuries or congenital defects within the jaws that dentists are you know, collaborating with either oral surgeons, oral maxillofacial, pathologists, or other physicians on, you know, patients who might have had traumatic injuries to the face and the jaws.

Dr. Giannobile (20:59):

How do you repair those? Tooth extraction itself, that's one of the most common surgical procedures that afflicts humans. And you know, oftentimes it's the dentist that's removing the tooth. And when patients lose teeth prematurely, so we're not talking about the baby teeth in the primary dentitian, but when people lose teeth due to either the, the periodontal disease or the, the dental caries or injury of some sort patients with missing teeth, you're looking at how do you reconstruct them. And so much of that relies on reconstructive dentistry, restorative dentistry. So the specialist prosthodontist are very well trained and equipped to build crowns and bridges to span these gaps that might exist after a tooth loss or peridontist and oral surgeons who may be placing the dental implant that is basically a titanium screw that goes into the jawbone where there the tooth had been lost.

Dr. Giannobile (22:11):

And then you can build on top of that, that titanium fixture, a crown that can either be screwed into place or cemented. And these are some, you know, therapies that have become more and more common for our elderly patients, but we even have young people that are losing teeth earlier and require this reconstruction with dental implants. So that's another, that's, that's been a big change within dentistry in advance over the last several decades in terms of the tooth replacement, dental implants. But those are a couple of common procedures. The other one tooth these aligners for patients who have tooth mal position. So it used to be, you know, probably when you graduated from dental school, and even when I graduated from dental school, Larry, most of the patients who had braces and had orthodontics to straighten their teeth tend to be adolescents. Young people that was 75 plus percent of all the patients were young people. Now people at all age categories are, are having orthodontic therapy done, and they're oftentimes, they're using these custom fit aligners, these clear trays that can be used to align the teeth. And now we're seeing that adults are just as common and in, in some practice settings being the larger patient population, those individuals over age 18. So that's where we've seen a tremendous amount of change in advancements within orthodontics.

Larry (24:02):

One of the things that faced me in practice with orthodontics in adults at the time was repositioning teeth prior to preparation for restoration.

Dr. Giannobile (24:17):

Right. Yeah, I mean, I think it it, it makes sense to, you know, before you start to do those irreversible changes to the teeth, you know, cutting those teeth down to place a crown, let's first position those teeth in the more ideal position. Usually that can be done non-surgically. But there have been a lot of different advancements within orthodontics collaboration, collaborating with oral maxillofacial surgeons where they can do a procedure called ortho surgery where they may do cuts in the jaws and reposition the jaws in patients that have, you know, their teeth are really not coming into alignment, and there's really not a feasible way to move them with braces. So it'll be done with a combination of surgery and orthodontics to better position those teeth. And now they can even use three dimensional modeling to capture the images of the patients. They'll take optical images of those teeth of the entire face, and they can model that and demonstrate that to the patient to do you know, basically show what that surgery would likely look like at the end. And so it's, it's really been remarkable what oral surgeons and orthodontists have been able to do for those types of tooth movements.

Larry (25:44):

One thing that we were never introduced to in the late fifties, early sixties, were the specific challenges that we as dentists, dental professionals, face in treating older adults in regard to patients with dementia in regard to patients with physical limitations. What's going on in that area now?

Dr. Giannobile (26:14):

Right. Well, you know, not Larry, that becomes very important as we look at, you know, the population of patients. You look at those age 65 and above, there's 10,000 new adults in the United States going into that age category every day, and we're not producing a sufficient number of dentists to address all of the needs of the age population. And I give a shout out to a program that was recently funded by the Harvard School of Dental Medicine to the Harvard School of Dental Medicine by the Health Resources and Services administration called hrsa, and how we can help train our pre-doctoral students to work with aging patients. So it's a pre-doctoral geriatrics program called pre-doctoral Oral Health Education and Training for Aging America. And we have a, our director of geriatric dentistry at the, the dental school is Lisa Thompson, and she's been one of our local experts who's been working to train the next generation of healthcare providers for our older patient populations.

Dr. Giannobile (27:25):

So you give the example of dementia. We also know with Alzheimer's disease, there is emerging information that shows, you know, when patients lose teeth and become fully Aden. So if they lose their entire dentition and have to wear dentures, there's many more patients with dementia are afflicted with total tooth loss and being aous and, you know, trying to understand what are some of those relationships, you know, there's a biomechanical influence of being able to chew you know, having the teeth be loaded by mastication. And so there have been more and more studies that have demonstrated that there's some association there now with Alzheimer's disease, it's also been demonstrated some early data has been showing that the, one of the, the key bacterial pathogens, one of the bad actors that causes gum disease, it's a bacterium called ponas gingivalis. This bacterium produces something called the gin pain that has been shown to be released within the brains and found in individuals with Alzheimer's disease.

Dr. Giannobile (28:45):

And so, again, as I mentioned with cardiovascular disease, also this slow infection of periodontal disease, which is the leading cause of the tooth loss in the adults and the young people. It's the dental caries. These are, again, two diseases that are affecting the older adults having proper dentures in individuals who have limitations in mobility. You know, as you think about, you know, these, these you know, the, the four MSS that relate to older populations that this framework what matters most medication mentation and mobility. And as we think about those, they apply to dentistry as well. So, you know, for individuals to be able to smile, to be able to chew and eat properly, this becomes important. So prosthetic dentistry and dentures and crowns, and, you know, there are, we have patients into their 100 s that have received dental implants. So you're almost never too old to receive such a reconstructive and ther reconstruction and such a therapy.

Dr. Giannobile (30:00):

And we have to work to train our students to be able to handle these patient populations. Another common situation for patients as we age, we noticed that our salivary glands do not produce as much saliva as they once did. And so having dry mouth becomes more and more common in hydrating and watching the diet, because when you have a reduced salivary flow, dental carries dental, decay can accelerate. So dietary counseling is very important. And I think for our elders, and many of them, if they don't have the support networks, you know, they need to see their dentists regularly. And this becomes very important from a preventive standpoint. And it's been encouraging for me as a dentist to see we have more and more adults that are keeping the majority of their dietician. Maybe 50 years ago it was more common, people will get full mouth extractions, and then they have to deal with this reduced chewing function for the rest of their lives. Whereas now, this, if it does happen, it's much later in life. But as a dentist, you know, one of our major goals is to help preserve and maintain, you know, this dietician for patients to be able to have a good oral health.

Larry (31:28):

That hits home with me. I I interned in oral surgery and decided not to be an oral surgeon, and one of the deciding factors was a general dentist who referred, oh, I think she was about 15 years old, very pretty teenager for full mouth extraction. And I refuse to do it, but it's bothered me and still does when I think about that. Right,

Dr. Giannobile (31:58):

Right. I mean, use that example of, you know, young teenagers. This happened, and and I think in my own family, my, you know, my grandparents both had most of their teeth removed in their twenties, and they had to manage with, you know, your jaws, that bone resorbs over the course of a lifetime, and your, the dentures become more and more challenging and difficult to function over the course of the lifetime. So oftentimes, what I say as a periodontist, that's my specialty, I look to do whatever is possible to rebuild structures, to keep the teeth as long as possible. And so if we can get another 5, 10, 15 years out of those teeth, now we've preserved that bone for a longer period of time. And then just like other medical innovations, if we can extend function over longer periods of time, new therapies will emerge where they'll be much more predictable to save teeth.

Dr. Giannobile (33:03):

And so you know, another specialty I have not mentioned so much endodontics, these are the specialists that do the root canal therapies. It's been remarkable what they've been able to do. They take three dimensional imaging to look at the quality of the tooth itself to rule out if there's a fracture, if there's a need for a root canal due to the dental caries. And the success rates of endodontic therapy have greatly improved. And many endodontists too, patients will come in, and I saw my endodontist about a year ago, and I was certain that I needed a root canal. And I went to him and he said, no, I don't think you need a root canal. I think you're grinding your teeth, which is very common. I had started this job, and and I'm, now, I'm fine, you know, and I didn't need it.

Dr. Giannobile (33:54):

So being more conservative with some of these therapies and endodontic treatment now with either microsurgical approaches, endodontists now are able to have much higher success rates. And so these teeth do not need to be removed. You can work from the inside of the tooth that's with endodontics and then from that outside portion of the foundation with periodontics, and then good restorative dentistry. So I think we're seeing a pendulum shift on tooth preservation, I hope, versus extraction and dental implants, which again, as I mentioned, has been a, a, a major you know, advance in dental care, being able to use dental implants, and it's, it's a, it's a great therapy, but it's not a one size fits all where all patients need to, you know, consider if they have a problem with the tooth, that it should be extracted Many more options today.

Larry (34:56):

You alluded to it. So what do you think the future holds for dentistry?

Dr. Giannobile (35:03):

Yeah, so we've, we've touched on a couple of those areas, and Larry, it's something that I, I get very excited about, especially, you know, when I think about the students, we hear that we have here at the, the Harvard School of Dental Medicine we have a group that's called the, the Harvard Dental Innovation Society. And this is a group of our students who many of them want to be, you know, entrepreneurs start their own companies to develop new technologies. And we've seen in many different areas, advances in dentistry, ranging from, I I met three dimensional imaging. Now we're able to come up with ways to look at in three dimensions the tooth itself, the soft tissues, and there's a technique. One of our faculty members has developed Lorenzo Teve, where he can take basically an ultrasound probe, put it around the tooth to examine the, the soft tissues and the bone surrounding the teeth without any radiation.

Dr. Giannobile (36:07):

It's a non-invasive approach. So we're gonna see a lot in three-dimensional imaging that will be less invasive. That's, that's one big area. In terms of prevention we now are developing and identifying new biomarkers of disease that can be detected in the saliva or just a scraping of the cheek. We can get a genetic analysis of the patients. And there's something you mentioned earlier, you've heard of precision medicine or personalized medicine. And so as we engage our patients, and you've heard of maybe 23 and me or these direct to consumer genetic tests, we can combine genetic information with our traditional clinical measurements and then our patient interview to put that all together to personalize the care for that individual patient. Because genetics always plays a role, and we can do it in a way that helps the patient participate in the process when the patient knows that he or she has had their care customized to them.

Dr. Giannobile (37:18):

Precisely. so I take, for example, we did a very large genomic study where we, we evaluated certain genes associated with tooth loss. And so we could then propose some patients have low risk where maybe they didn't need to see the dentist as frequently for cleanings, for example, something as simple as how frequent is the preventive recall to be needed, and others who need a much more intensive. And so those listeners who may be afflicted with periodontal disease, they might have to get cleanings done every three months versus every six months, or maybe once a year. So you can dial up and dial down based on preventive personalized medicine. Another area that I think is it's affecting everything with across society is artificial intelligence. And artificial intelligence is, is a major disruptor. And we want to really engage in all of the opportunities to leverage how artificial intelligence can advance clinical care.

Dr. Giannobile (38:34):

So the, the big areas where artificial intelligence is already impacting dentistry is in the imaging area. So you can take dental radiographs, identify how much bone loss is there, help identify early stage curious lesions and then using that 3D information, be able to provide that information for the clinician to help in the diagnostic problem list for the patient. Also in the area of dental pathology. So microscope slides that a pathologist would look at them, they can be rapidly evaluated. And then that information process, you know, we'll still need the clinicians to take a look at that in the direct interaction with the patient. But diagnostic problem list will be made available. And being able to very comprehensively look at that. So those are two areas where artificial intelligence, there's something called machine learning we've heard about, like chat, G P T can really customize our letter writing.

Dr. Giannobile (39:43):

But you know, taking this information actually at, at Harvard, we're going to be having a global symposium this fall at the science and engineering complex in Alston, where they have the Keppner Institute for Natural and Artificial Intelligence. And we're bringing together global leaders in dentistry, medicine, and from the regulatory environment. So these new technologies, you know, they're, they're affecting the clinical practice at dentistry. How the food and drug administration, how insurance companies will use this information will be very important to the future. So those are, those are a couple of examples. Larry,

Larry (40:29):

Well, we may have gone over the heads of some of the listeners, but I'm delighted we did, because one of the things I wanted to stress in talking with you is broadening people's perspective of what dentistry is and what services dentistry performs, rather, as I mentioned earlier, than what the public sees and hears from advertisements and an occasional article in the press. This has been terrific, and I really appreciate your participation.

Dr. Giannobile (41:11):

Well, thank you so much, Larry. It's been my pleasure to have this conversation with you and I, you know, as a distinguished alumnus of the Harvard School of Dental Medicine and having you you know, get, providing me with this opportunity to share some of my insights and to help communicate to your your listeners here today has been I've enjoyed it very much.

Larry (41:35):

Thank you again. This has been a joy and a distinct honor as I said.

Dr. Giannobile (41:42):

Okay. Thank you so much.

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