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How Can I Boost My Perio Department? My Soft Tissue Management Program Is Non-Existent!

By May 31, 2019 September 2nd, 2019 Podcast Episodes

How does a dental practice know if they have a true periodontal therapy program or if they are just a “prophy palace?” In this episode, The Dental Practice Fixers, Dr. Richard Madow and Dr. David Madow discuss ways to provide better patient treatment AND boost revenue by correctly diagnosing and treating periodontal disease. Most adults in the United States have some form of perio disease – so let’s learn how to treat it correctly – and how to answer the question “Why didn’t my last dentist tell me this?”

And then of course there is the “Call Of The Week.” We continue the theme by asking an office manager if they have a soft tissue management program. It’s a weird question, but one word really tripped her up. Most importantly, did she schedule the patient? Listen and find out.

How does a dental practice know if they have a true periodontal therapy program or if they are just a “prophy palace?” In this episode, The Dental Practice Fixers, Dr. Richard Madow and Dr. David Madow discuss ways to provide better patient treatment AND boost revenue by correctly diagnosing and treating periodontal disease. Most adults in the United States have some form of perio disease – so let’s learn how to treat it correctly – and how to answer the question “Why didn’t my last dentist tell me this?”

And then of course there is the “Call Of The Week.” We continue the theme by asking an office manager if they have a soft tissue management program. It’s a weird question, but one word really tripped her up. Most importantly, did she schedule the patient? Listen and find out.

If you have a question that you would like answered on our podcast, please send it in to podcast@madow.com. We will do our best to get yours answered!

If you have a question that you would like answered on our podcast, please send it in to podcast@madow.com. We will do our best to get yours answered!

Related article: Top Five Reasons You Have A Lackluster Perio Department


How Can I Boost My Perio Department? My Soft Tissue Management Program Is Non-Existent!

(Dental  Practice Fixers Podcast is brought to you by the Madow Center for Dental  Practice Success. To find out how we can help to increase the success of your  practice check out madow.com or call us at 1-800-258-0060). 
    
  [Music playing]  
    
  Dr. Richard Madow:  Hey there I'm Doctor Richard Madow; welcome to episode  fifteen, season two of the Dental Practice Fixers Podcast. We've got a great  question from a listener today, without giving away too much of the question,  I'm just going to say that this is something we've encountered in a huge  percentage of the dental practices that we work with over the years. When Dave  and I visit a practice, when our coaches do, it's something that many of the  people don’t realize is an issue, or they realize it’s an issue but they don’t  know how to tackle it. I'll just it enough said there, this is something you  absolutely need to listen to and we know that it will help your practice. So  again, I'm Doctor Richard Madow, I'm here with my partner, friend, co-host  I'll leave it up to you to now introduce yourself. 
    
  Dr. David Madow:    Doctor Dave, Doctor  David Madow, how are you all doing? Thanks so much for being a part of the  Dental Practice Fixers, we really appreciate that you’re here joining us,  watching or listening, whatever you’re doing, we appreciate you. 
    
  Dr. Richard Madow:   All right let’s go  and do the questions. 
    
  Dr. David Madow:        I'm just going to  read the question Rich- 
    
  Dr. Richard Madow:   Please. 
    
  Dr. David Madow:    It’s a great topic. 
    
  Dr. Richard Madow:   It’s a short one but  a good one. 
    
  Dr. David Madow:    It’s something that we encounter all the time even in our  coaching, going into offices, seeing what they're doing, the question is 'I  don’t think my soft tissue management program is as good as it could be. Any  suggestions to boosting it?' And it comes with thanks, he says thanks from Dr.  Silvertan in Michigan. I don’t know where in Michigan but somewhere in  Michigan. 
    
  Dr. Richard Madow:   Dr. Silvertan or Dr.  Silverton 
    
  Dr. David Madow:         It says Dr. Silvertan 
   
 
  Dr. Richard Madow:  Ah man, I hope its Dr. Silverton; I want to call him Dr.  Silverton. I have an old Silverton guitar from the early seventies. 
    
  Dr. David Madow:        Oh is it from Michigan? 
    
  Dr. Richard Madow:   Its actually from New Jersey, it was made in Neptune New  Jersey by Danelectro Guitars. [Crosstalk], anyway who cares about that, let’s  get to Dr. Silvertan or Dr. Silverton’s question. Wants to boost soft tissue  management program. 
    
  Dr. David Madow:         It’s a great question and then  congratulations for realizing that your soft tissue management program is not  as good as it could be, and realizing that maybe you should boost it. Rich  what percentage of the offices that we have dealt with over many, many years  would you say had a really good robust, if I can use that word, soft tissue  management program in place? 
    
  Dr. Richard Madow:    Fewer than 20%. 
    
  Dr. David Madow:        Absolutely, most  do not. 
    
  Dr. Richard Madow:    So let’s say  congratulations Dr. Silverton for realizing because that’s where it starts  right, for realizing that this is an issue and that you could be doing  better because many practices, you know  what’s funny we've heard this from dentists, from coaching clients  that they understand that they should have a  good soft tissue management program but nobody in their area has perio  disease. 
    
  Dr. David Madow:   Wow I'd like to move  to that area. Wow that’s incredible. 
    
  Dr. Richard Madow:    I want to move to an  area where nobody has any diseases at all. 
    
  Dr. David Madow:         That would be great, let me know where that  is. 
    
  Dr. Richard Madow:    Isn’t where that all  starts? 
    
  Dr. David Madow:        Thinking that their dental population does  not really have- 
    
  Dr. Richard Madow:    Well it starts with  realizing that you need to be diagnosing more perio. 
    
  Dr. David Madow:        Yeah and the good news about this and this  question is that, I mean we don’t have, somebody is not writing saying 'how  can I do crowns in one day?' Yeah you can do crowns in one day but you can be  spending a hundred thousand dollars upfront to do that. The good thing about  this is you really don’t need to be investing in any expensive equipment, any  systems, you just have to do things a little differently, diagnosing and  treatment planning, that’s all and when you do that you’re going to see a  tremendous difference in your practice, in your production, in your  collections, in your revenue. 
    
  Dr. Richard Madow:    Invest in a couple  perio probes. 
    
  Dr. David Madow:        That’s all you  need. 
    
  Dr. Richard Madow:    Okay I'm going to  give a suggestion to him. 
    
  Dr. David Madow:        Yeah sure. 
    
  Dr. Richard Madow:   I'll just be very brief, I think it starts with a team  meeting, doctor, hygienist, assistant for an office team meeting to talk about  why you feel like the soft tissue management program or perio [inaudible  04:09] lacking, present the statistics that what it is you can find a million  different stats but let’s just say 70% of adults in US have some form of perio  disease and you want to really become a place where this is diagnosed and  treated, because if you’re not doing it you’re just letting your patients  lapse into worse and worse perio disease. So let’s start with the altruistic  nature of a soft tissue management program. The US population has periodontal  disease and it's our job to find it, to diagnose it and to treat it, it all  starts there. 
    
  Dr. David Madow:        And if you’re not doing it, forget about  the revenue for right now, more altruistic and well you’re doing the right  thing covering yourself, because if you’re not diagnosing perio, you’re  setting yourself up for some serious malpractice suits, and it's a disease  that people walking around with and coming in your office and if you’re  ignoring it and especially doing other work on top of that it is a disaster,  it's a mess and now these days especially knowing the periodontal disease is  linked to cardiovascular disease and other things, it’s something that has to  be dealt with. It's not an option; you have to do it. 
    
  Dr. Richard Madow:     You know it’s funny we know and we've heard it  and we know for a fact that one of the top categories of dental practice  lawsuits is failure to diagnosis periodontal infection. I just wonder when  some lawyer, because you know these lawyers right, they're pretty sharp,  somebody dies of a heart attack and then they're going to, the dentist will be  sued for not diagnosing perio disease, we’re supposed to say if this dentist  would have diagnosed perio disease they could have said well what’s meant to  cardiovascular disease you need to see your physician, that theoretically  could happen and that could be crazy. 
    
  Dr. David Madow:        I'll tell you what else is happening right  now, I guarantee this is happening, doctors watching us right now, they're  watching us or listening to us and they're saying to themselves 'ah I know all  about that,' but I bet you that they don’t have a really good soft tissue  management. They might even think they do but I bet they don’t because most  don’t. 
    
  Dr. Richard Madow:    I agree. 
    
  Dr. David Madow:        Most don’t. 
    
  Dr. Richard Madow:  [Inaudible 06:08] time and time as supervised neglect and  some people will challenge saying 'well the legal definition of that is not  what you were about to talk about but screw the legal definition let’s just  talk about kind of maybe layman, not layman’s but lay-dentists’ definition of  supervised neglect, and that is you see a patient, they're a great patient,  they're coming every six months, they've got maybe a little five millimeter  pocket here, a little four millimeter pocket there, a little inflammation, and  you're just giving them a regular cleaning, you bill them for exam & profy  and you say 'okay so let’s just pay attention to flossing and see if it will  get a little better,' and you’re not treating them as a perio patient. You’re  neglecting it and you’re in charge and they're coming in and you’re kind of  patting them on the back and you're kind of saying everything is going to be  fine, meanwhile they have active disease, it may not be a high level but they  have active disease and we're just letting it slide. 
    
  Dr. David Madow:         And God forbid they go to another dentist  down the road, they move, they change dentists for some reason and they go to  a dentist who is on top of things and they’ve got periodontal disease, guess  who is going to be trouble? You’re going to be in tremendous trouble, so stop  right now thinking that you’re doing everything right, because according to  our stats going into offices over many decades, chances are you are not, now  if you are, congratulations but chances are you’re not. Okay where does this  start, set a team meeting, educating the team, I say make sure the team  totally understands what periodontal disease is, the prevalence, how it's  treated, what can happen if it's not treated. Again in lay terms, they don’t  have to take a periodontal course in dental school. 
    
  Dr. Richard Madow:    They don’t have to  become board certified periodontists. 
    
  Dr. David Madow:        But in lay terms  make sure your team understands exactly, exactly what periodontal disease is.  I was in a restaurant a couple of weeks ago and the waitress she was taking my  orders smiling and you could just, I could see clearly that she had [perio].  She had [crosstalk] but I'm thinking does she go to some dentist who like pats  her ‘Betty you’re doing fine, everything is good,’ a lot of people do that and  it’s supervised neglect. 
    
  Dr. Richard Madow:  But her name wasn’t Betty either [inaudible 08:15] and then  of course then where do we go? Every patient whether it’s a new patient or a  recall patient oh we care whatever term you want to use, gets a full exam and  a full exam includes full periodontal probing, charting, pocket depths,  bleeding points, necessary x-rays. 
    
  Dr. David Madow:        Fremitus, you’ve  got to do it 
    
  Dr. Richard Madow:    If someone is not in  perfect periodontal condition they are a perio patient and we treat them that  way, and it may involve very simple treatment, maybe some limited periodontal  therapy, maybe full blown, scaling and root planing with the idea that you may  have to refer them to a periodontal specialist, whatever it is, treat the  disease even if it's low level; they are a patient with periodontal disease. 
    
  Dr. David Madow:         And the best news is that when you do it  right, we're never going to say here 'do unnecessary treatment, treat things  that don’t need to be done,’ you're never going to hear that from us. We went  through phase without dental practices but we actually hired coaches and  consultants that tried to do things like that. We're on to that, we would never  ethically ask you to do something that's not necessary but if you said 70% of  the American public 70-80% I've heard has some form of periodontal disease,  don’t let it go, treat them, treat them right and it will be more revenue for  your practice which is kind of a good thing as well.  
    
  Dr. Richard Madow:    It's a great thing  but I think when you have the initial team meeting, again if you remember from  the last podcast episode, there was an office manager who thought that fees  were too high, you know that kind of stuff happens. So let’s not start with  the idea 'hey we're going to make more money by treating soft tissue  management program, or by having a better periodontal program or strategy and  practice,’ we're going to do this and it’s true, it’s for the good of the  patients and the good of the practice and we want to do our best to be ethical  and have a high standard of care, not get sued and worry about things like  that and that’s why we're instituting this great perio program. 
    
  Dr. David Madow:         You know what we found over the years that  when you’re doing things totally for the money and when you examine a patient  and you basically have dollar bills in your eyes, and that’s all your thinking  and that's all your team is thinking, you've got gold charts on the wall, and  you've got a [inaudible 10:32] - 
    
  Dr. Richard Madow:    Gold charts in the  treatment room. 
    
  Dr. David Madow:        You know look,  Rich and I both understand that dentistry is a profession but it’s also a  business and we realize that you need income, you need to make a good living  and that’s fine. 
    
  Dr. Richard Madow:    And we want to help  you make that. 
    
  Dr. David Madow:        That’s a good thing but when you totally  base your practice on money and on income and that’s a problem, but when  you’re truly treating disease and helping patients, the money is going to come  to you, you’re going to be fine, do it the right way. 
    
  Dr. Richard Madow:    Let’s cover  something that I know many people are thinking that actually is one of the  reasons that people are a little hesitant, it’s a hurdle, a good one, a hurdle  and that is they're afraid that the patients are going to say 'well doc, or  Jane or whoever,' you know my hygienist is Farida, she's fantastic. 
    
  Dr. David Madow:        Farida. 
    
  Dr. Richard Madow:    ‘Farida. I was in  here last time and you didn’t tell me I have this, what happened?’ I think  people are afraid of that question or with the new patient, ‘well my last  dentist never told me anything about this, what’s going on here?' And they  kind of take the defensive and they think the patients are accusing them of  wanting to make more money. How do we handle that? It’s a great question. 
    
  Dr. David Madow:         We always start with being honest, I mean  when you’re honest about something you rarely can go wrong, well so there's  nothing wrong in saying 'well Betty, or whatever your name is Mrs. Jones, Mrs.  there's new research out there, we're always learning, we're always taking new  courses, and although you looked pretty good at your last cleaning, we're  realizing now we're seeing some gum inflammation and we have now learned that  the evidence, the science is out there that if you have gum disease it could  be linked to more things going on your body, such as heart disease and such  things as well. We want to make sure we treat this, catch it in an early stage  and take care of it very conservatively, very easily which will hopefully take  care of your problem and that will be, if we let it go, if we ignore it, if we  let it go then you could have not problems not only in your mouth, infection  could move to other parts- 
    
  Dr. Richard Madow:    I love the word  infection. 
    
  Dr. David Madow:        Nobody wants an infection. 
    
  Dr. Richard Madow:    Nobody wants an infection  and that’s a fantastic strategy for the patients who are already in your  practice and for a new patient my favorite strategy is something like 'well I  can’t tell you what your last dentist saw because I wasn’t there, all I can do  is tell you what we see today and this is what we see today and we really take  a lot of time and as you can tell and care to diagnose every issue that you  may have so that we can help you get better before it’s too late.’ 
    
  Dr. David Madow:        Agree, never blame another dentist even if  the work coming in doesn’t look good, we've gone over that just it’s never a  good thing to say something bad about a previous dentist, it's just not good. 
    
  Dr. Richard Madow:    I think we pretty  much nailed this, everybody in the office has to be on board. Kind of last  episode I think we talked about Max the office manager who was not on board  with the fees that the dentist was charging the patients. So, it’s not a good  thing, so every single person in the office, not only the hygiene department  but the assistants who are going to be coming in contact with these people and  the front desk. Everybody needs to understand periodontal disease to a certain  point and they feel that we're doing the right thing. If you let anybody on  the team  feel that this is just another  profit center, we shouldn’t be doing this, we're over treating, that’s a big  problem and if you can’t straighten that out, that person is not right for  your practice. 
    
  Dr. David Madow:         Did I tell you I was in a plane one time? 
    
  Dr. Richard Madow:    No you never told me  that. 
    
  Dr. Richard Madow:    And they made the  announcement if there's a doctor on board ring your bell and like this guy  opposite row I could see rung his bell and the flight attendant came over and  said ‘sir can you help out,’ and he said 'I'm a board-certified periodontist.' 
    
  Dr. David Madow:         Did that really happen? 
    
  Dr. Richard Madow:    Yes. 
    
  Dr. David Madow:        What did the  flight attendant say to him? 
    
  Dr. Richard Madow:    Next. 
    
  Dr. David Madow:        Exactly. 
    
  Dr. Richard Madow:   First of all does he  have to say he's a periodontist and then a board certified, oh you know what  this patient is having a heart attack they're about to die, if he was regular  periodontist he [inaudible 14:24] to help but the fact that you’re a board- 
    
  Dr. David Madow:        So you think he should have just said a  dentist. 
    
  Dr. Richard Madow:    Yeah. 
    
  Dr. David Madow:        I'm a dentist I  can help out, trained in medical procedures, I can help this. 
    
  Dr. Richard Madow:   A board certified periodontist. 
    
  Dr. David Madow:         What is that? 
    
  Dr. Richard Madow:    Exactly, before we  get the call of the week which cleverly is linked to this question by Dr.  Silverton, I just want to say something that Dave and I talk about from time  to time and we call it lazy expenses and that means money that you’re paying  out every month that you don’t have to be and if you go through your charge  card bill, you'll be amazed you’re still paying for AOL or some kind of web  service that you set up that you don’t use anymore or maybe you just have been  paying for Netflix or some music service that you don’t use anymore, get rid  of that lazy expense. One lazy expense that we've seen is people that are  overpaying for their credit card processing. You don’t know it because some  bank called you two years ago and said 'I can save you money on your credit  card processing and they showed that they could save you money and so you got  that and month after month you’re probably paying a lazy expense. Check out  Fattmerchant, they do it differently, they do not charge an average  percentage, you’re being paid by your credit card, I mean you’re being charged  by your credit card processing company an average percentage every month, an  average percentage every month, Fattmerchant just charges you a really low  monthly fee. You will save money and get rid of that lazy expense, so check  them out. bit.ly/fattmad fat is spelled F-A-T-T-M-A-D. So its bit.ly/fattmad,  that’s a landing page that we've set up just for you and the reason we want  you to go to that page, that website landing page whatever you want to call  it, is because when you do that they'll give your equipment at no charge. 
    
  Dr. David Madow:        Wow. 
    
  Dr. Richard Madow:    We use Fattmerchant  for our credit card processing at the Madow Center and you should use it to. 
    
  Dr. David Madow:         Would you say that lazy expense they kind of  add something on to their typical credit company. That’s similar to a hotel  having a rate of like 139 dollars but then you get there and then they charge  you like resort fees. 
    
  Dr. Richard Madow:    I don’t know because  that’s a flat fee, so it may be more like a tax, because that's a percentage.  Something that doesn’t have to done but hotel man that’s ridiculous. You go  book online The Hilton in Manhattan wow its expensive its 249 dollars a night,  wow I'll book it and you get there and it’s like 350 and by the time you check  out it’s crazy, the city tax, the state tax, the local tax, the amusement tax,  the Javits Center tax they have in New York, all kinds of stuff. 
    
  Dr. David Madow:        If you are  following us and we appreciate that and if you just feel like you’re in your  practice and that you could be doing much better but you just don’t know how  to do it. You know that you’re kind of right here but you want to be here, you  want to be doing better in your practice, we invite you to attend one of our  Madow Masterclass days, here in Baltimore Maryland at the Madow Center For  Dental Practice Success, it’s a full day or almost a full day, it’s a very  limited number of doctors that attend. Each one we keep it small intentionally  and during this day we will show you pretty much from start to finish how we  can help you build your practice and grow your income, increase your revenue,  it’s a great day, we invite you to hang with us, me and Rich and our coaches  for a full day. To find out more we've got some coming up right now and by the  way they do fill up.- 
    
  Dr. Richard Madow:   I think we need to schedule another one. 
    
  Dr. David Madow:        We really  should, you can schedule right now by going to masterclass.maddow.com. We've  got some coming out really soon, check them out, we’d like to see you join us,  hang with us, it will be fun. 
    
  Dr. Richard Madow:   Let’s do a call of the week. 
    
  Dr. David Madow:         Sounds good. 
    
  [Phone  call] 
    
  Terry:   Thank you for calling the office of doctor *, this is Terry how may I  help you? 
    
  Dr. David Madow:   Hi Terry I'm kind of new in the area, and I'm looking for a  dentist and everything I read about now it says make sure you have somebody  that has, I think it's called a soft tissue program. I want to find out if you  all have that? 
    
  Terry: Um- 
    
  Dr. David Madow:    Some type of soft  tissue- 
    
  Terry:     Um well not necessarily a program but we do check the soft tissue and measure  your gums, take gum measurements and everything. 
    
  Dr. David Madow:  Okay but you don’t necessarily have a program in place or  anything like that? 
    
  Terry:     No, never heard of that, a soft tissue program. 
    
  Dr. David Madow:        Soft tissue  management I think, soft tissue management I got written down here.  
    
  Terry:     No, never heard of that, we do, do things called like if you have like gum  disease, like bone loss we do something called scaling and root planing and  periodontal cleaning which is basically under the gum line and you have to be  numbed for it but as far as an actual program I've personally not heard of  that. 
    
  Dr. David Madow:   Okay. 
    
  Terry:     It sounds like you may want to see like a periodontist. 
    
  Dr. David Madow:   Ah I see. 
    
  Terry:     Yeah it sounds like that, something a periodontist would do. 
    
  Dr. David Madow:   Right, well thank  you very much for your help. 
    
  Terry:     No problem. 
    
  Dr. David Madow:        Okay thank you bye-bye. 
    
  Dr. Richard Madow:   Interesting. 
    
  Dr. David Madow:        These things just keep writing themselves,  you can’t make these things up. 
    
  Dr. Richard Madow:    Well look I mean I'm  going to defend her for a second. 
    
  Dr. David Madow:        No you cannot defend her. 
    
  Dr. Richard Madow:    It was a very odd  question. 
    
  Dr. David Madow:        Okay I’ll give her that. 
    
  Dr. Richard Madow:  You could never have anticipated that question in a team  meeting that someone is going to call and say 'do you have a soft tissue  management program?' She was really thrown by the word program. That threw her  for a loop. 
    
  Dr. David Madow:        Yeah the  [inaudible 20:02] thing she said, I think she said they do soft tissue  management but they don’t really have a program. 
    
  Dr. Richard Madow:    Well I don’t know  what she thought that meant, like a TV program, I'm not sure what she meant.  
    
  Dr. David Madow:         I don’t know but I'm not going to defend her  as much because it was not a difficult question, if she'd been trained even  understanding, look we talked about it the first statement on the show, get  your team to understand, on a fairly simple level what gum disease is and why  so many people have it and why we're treating it. She could have given a  simple explanation, 'oh you called the right office, yes every patient that  comes in here we thoroughly check your gums and we check the gums for  infection and if we see anything, we can mostly likely treat you very easily  here.' That’s all she had to say. 
    
  Dr. Richard Madow:    I agree she could  have just said 'yeah we absolutely, we don’t call it that,' she could have,  just kind of stipe on here, she could have said 'we don’t have soft tissue  program but we absolutely check gum disease here, let’s get you in for a full  examination.' 
    
  Dr. David Madow:         I mean did she have to say that 'sometimes we  numb you up and we clean under your gums.' Nobody knows what that is. 
    
  Dr. Richard Madow:   Absolutely not, nobody wants to hear that. 
    
  Dr. David Madow:        Nobody wants to hear that, that’s right. 
    
  Dr. Richard Madow:    But I love how at  the end she was ready to send me to a periodontist. 
    
  Dr. David Madow:         Doctor Perio dentist.  
    
  Dr. Richard Madow:       That sounds like an Irish guy, Doctor Perio Dentist. 
    
  Dr. David Madow:         [Inaudible  21:17] 
    
  Dr. Richard Madow:    I mean that call  within a minute and ten seconds, she's already referring you and not knowing  anything about you. 
    
  Dr. David Madow:        Yeah a good point, I called to become a  new patient, she’s already diagnosing me- 
    
  Dr. Richard Madow:    And referring. 
    
  Dr. David Madow:   Referring me. 
    
  Dr. Richard Madow:    So the bottom line  is she didn’t really understand the question but she could have easily said  'why don’t you come in, meet the dentist, we’ll do a full examination and if  you do have  gum disease, chances are we  can treat you here.' 
    
  Dr. David Madow:        We are very in-tuned to gum disease,  continued education, we know how to treat it, we do all the time; we see it  and we'd love you to come as a patient. 
    
  Dr. Richard Madow:    We still have a  program. 
    
  Dr. David Madow:        If you want a  program you've got to see a periodontist. 
    
  Dr. Richard Madow:    I hate to say it but  I think the fact that she made no effort to get you in, as a matter of fact  she tried to get you out, and she’s going to get an F. 
    
  Dr. David Madow:        I say she gets  an F-o-dontist. 
        
  Dr. Richard Madow:   Okay, great stuff,  we will see you. That was season two episode fifteen of the Dental Practice  Fixers, I'm Doctor Richard Madow. 
    
  Dr. David Madow:        Doctor David  Madow and we will see you next time, thanks for being with us. 
    
  [Music  playing] 
  
   
David Madow

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