Robert: Hi and welcome to Beyond the Arches. We’re going to switch things up a little bit today. I’m Robert. I’m going to be your host. And in the hot seat, we’re going to have Dr. Noorthoek answering some user-submitted questions and imparting his wisdom upon us. So welcome to the podcast, Dr. Noorthoek. Dr. Dan: Thanks for having me. Robert: Yeah, absolutely. So we put out the call to our followers and asked what some of the burning questions are that they’d want you to share your opinion on. And I think it always bears repeating: this is your opinion. Other opinions may differ, but these are yours. I think we got a few really good questions put together here. You want to kick it off? Dr. Dan: Go for it. Robert: Okay. Lay it on me. What do we got? Dr. Dan: We have some good ones. Robert: We do have some good ones. I always say any of these could be their own episode because there’s so much to talk about with each of them. But I think these sum up the biggest questions a lot of people have. And if we get through all of them, I’ve got a couple extras as well. Dr. Dan: Okay. Robert: One I wanted to kick off with—because I know you have a pretty cool story that goes along with this—we had a gentleman named Brian ask about bone grafting. Of all the mysteries in dentistry, bone grafting feels like a big one. Not a lot of people understand that there are different materials involved. His question was: is there an end-all be-all superior material? Is it case-by-case? Do different people do better with different materials? And is there one to avoid? Dr. Dan: Yes. That’s a complex question. A lot of these are going to be. And again, this is my opinion, so we’re going to go against what some people think. We all try to acknowledge the research and use it to improve our practice. The first thing to understand is that bone grafting is essentially about holding space. It’s like putting a bookmark in a spot you want to use in the future and telling the body, “Hey, we want this to become bone.” Gum tissue grows somewhere on the order of 10 to 25 times faster than bone. So if you take a tooth out and leave a hole, you’ll get some bone formation, but you’ll also get gum tissue invading that space. Gum tissue is always trying to meet in the middle. The best analogy I ever heard was the Dixie cup analogy. If you have a perfect paper cup, it can hold water. If you cut a side off, it can only hold water up to that level. That’s how tooth sockets work. Sometimes you don’t get a perfect cup. Bone grafting materials are mostly osteoconductive, meaning they’re hospitable to bone growth but don’t necessarily stimulate it. Some cadaver grafts expose proteins that help with stimulation, but for the most part, grafts hold space. Bovine bone—cow bone—is very dense. It holds space extremely well but turns over very slowly. It can look like bone without functioning like bone. I use it in sinuses, but I don’t want my entire implant surrounded by it. On the other end is DFDBA—demineralized freeze-dried bone allograft. It’s very soft and doesn’t maintain space well, but it’s good as a delivery vehicle for growth factors. The sweet spot for me is a cadaver bone mix—about 70% cortical and 30% trabecular. It holds space and reliably turns into the patient’s own bone in about six months. A lot of confusion comes from people creating problems by placing implants poorly and then needing grafts later. In hybrid dentistry, once the implants and prosthesis are in place, that structure itself acts like an umbrella and helps with space maintenance. That’s why hybrids often need less grafting than patients are told. Overprescribing grafting can come from lack of experience or financial incentives. We don’t charge extra for grafting. If I need it, I use it. If I don’t, I don’t. There are categories of grafts: DFDBA at the weakest end, then trabecular bone, then cortical mixes, then fully cortical bone, then bovine bone, and beta-TCP on the synthetic side. You choose based on the defect and implant position. Where the graft comes from also matters. During my residency at Virginia Commonwealth University, we toured LifeNet’s processing facility in Virginia Beach. Seeing how tissue is handled, documented, and processed eliminated concerns. They do everything from organ transplants to cranial grafts. Dental is almost an afterthought to them. They had letters on the wall from transplant recipients to donor families. That experience stuck with me and is why I trust that source. Beyond grafting, you also have to protect the site with collagen membranes to prevent gum invasion. Cross-linked membranes last longer and are used in larger defects. In hybrid dentistry, we generally use simpler membranes because we can manipulate implant position. Robert: That is wild. Very interesting. Okay. Yeah, I’ve always found that grafting—and that whole aspect of it—for the average patient like myself, it’s just kind of this afterthought. But you really have to know your stuff, know what you have to choose from, and what’s going to work best for each scenario. It’s always impressive when you have that arsenal of tools and you understand it and can use what’s right for each situation. Dr. Dan: Yeah, that was like—of course you pick up a lot of stuff in practice—but that’s the number one reason why a person really should live a residency: oral surgery, periodontics, or ortho, for what they’re going to do and specialize in. Because you live, eat, sleep, breathe it for three years. It’s not that you can’t learn it on your own. It’s not that you can’t learn it as a general dentist. But knowing exactly how to break it down and look at it, and all the exposure that you have, can be very difficult if you don’t know what you’re looking for. That is the number one defining thing to me. A general dentist can do the surgery—it’s not rocket science. You can teach them to do it. It’ll be safe enough, no problem. But knowing the little tiny nuances—like I would almost say I’m fine with a general dentist running the procedure from start to finish, as long as they have resources available to them that are a good, strong surgical team that can give them feedback and insight. Maybe they don’t understand all of the reasons and the nuances, but that’s why. If I had a general dentist doing surgery for me, there’s certain things I wouldn’t be allowing them to really weigh in on because they just don’t have that training. But otherwise they’d be an equal colleague—besides those little nuance things. Robert: Absolutely. Could go on. I mean, that’s a topic you spent three years trying to learn. Dr. Dan: Right. Robert: Let’s move on to another. Hopefully you explained it in a simple enough way. Dr. Dan: Sounded good to me. Robert: Okay. And I’m the king of layman’s, so that’s a good sign. Let me see which one of these… I really like this one just because I don’t think it’s talked about enough and it kind of ties into another one. We have another question about dental insurance and why teeth are treated as cosmetic as opposed to health insurance companies covering other health factors. But even before we get into that one, another gentleman here, Evan, asked: “What are some potential health risks that are associated with bad teeth—waiting too long to address certain problems?” And I think this is not talked about enough because we’re seeing studies now that bad teeth can directly affect heart disease, which is—if I’m not mistaken—like the number one killer in America is heart disease. But even beyond that, it can lead to a host of problems that I’m not smart enough to rattle off. But there is definitely a link between bad oral health and overall bad health. So anything you want to say on that? Dr. Dan: Yes. For starters, I did just look that up and epithelial migration happens at 0.5 millimeters a day—0.25 to 0.5 millimeters per day. I was about right. Robert: That’s wild. Dr. Dan: Yeah, it’s a lot. It doesn’t seem like much, but when you’re in the mouth and you’re only two millimeters separated, that’s four days. Robert: Exactly. Dr. Dan: Okay, so back to the question. It’s definitely not talked about enough. And it’s new enough research that I can understand that. I’ve also made it a point in my career to not profit or capitalize on fear tactics and fear-mongering, so I don’t spend a lot of time talking about it in the consult very often. Even though I know it’s going to improve things like sugar regulation for diabetics and wound healing, it’s going to help with heart disease patients—and periodontitis can end up systemically all over, sort of bringing the body’s systems down. Any system that flows with blood can be susceptible to it. So it definitely has a big role. And we know it’s not just a link—we know there are causation effects, there are correlative effects—and that’s important for patients to know. There are two aspects to that question. There’s an acute aspect—meaning what can happen to me immediately with this infection here—and then there’s the systemic chronic disease regulation type question. So the easiest is to start with acute. If you have an active infection—meaning bacteria caused a cavity that led to your nerve, that caused an infection at the bottom of your tooth, and then you get a toothache—you have an active infection living inside your body. Antibiotics are not going to fully remove that. They’re not going to remove all the parts of the infection. They calm them down so it’s not getting worse and it alleviates symptoms, but the splinter is still in the finger. From an acute phase, what we want to try to do is remove that infection. And the best way generally is to remove it physically—remove the splinter, remove the infection, stitch it all up—and it’s going to heal, because our bodies are awesome. So there’s an acute aspect to it. I don’t do this often—again, I don’t like making my wage on fear-mongering—but there was a guy who came in and he wanted to pay all cash. He was approved for financing, but it was going to take him another year. Well, he had so much active infection I actually had to stop him and say, “Listen, you’re going to push this up. I don’t know if you have to give me half now and then pay the other half later and we’ll finish you out in zirconia later, or what we’re going to do—but I would get that out immediately. Let’s not just wait around for money.” It can get to a point where you’re going to hamper my ability to do my job by leaving that infection in there and ruining more bone that’s vital and necessary to us. But you’re also putting yourself at risk of a major acute event. Bacteria putting pressure inside the bone and causing that toothache can erode the bone very quickly. And when it does, especially like a lower molar, it can get into spaces. We don’t just have a body that’s a bunch of muscles and bones smashed together. There are linings and walls and spaces between muscles that allow them to function individually. Those spaces can get invaded by pathogens. When that happens, the infection can travel fast through those spaces. When you see somebody go into the ER, end up in a coma, and die from a toothache, what happened is the bacteria got to an important place and created enough swelling to close off the airway—or it gets into the bloodstream. One of the biggest critical ones is a lower molar infection closing off the airway. It’s called Ludwig’s angina, and it can close off your airway very quickly. So we do everything we can—even if a person can’t afford surgery now—we do everything we can to take those really bad teeth out as soon as possible. Maybe wait. Maybe let the space heal. Maybe we collect on the extractions, but generally we credit them back toward the full procedure because we did it as prep and for safety. In an acute phase, the best thing is to see a practitioner and get it resolved. Then for long-term effects—its contribution to chronic disease—our systems are connected. Think of an accident on the interstate: traffic jams up, rubbernecking happens, and there’s concern about secondary accidents. The same idea applies in the bloodstream. Your bloodstream is like a highway. If you have micro-injuries—like cholesterol invading into the wall—that creates a constriction, and blood flow changes. Now you’ve got a problem point where further issues can happen. Periodontitis is an accumulation of bacteria—a hotel—staying right on the tooth. Blood flows along the inside of gum tissue, so it’s like an Uber pickup. It can hitch a ride into the bloodstream. Bacteria in the bloodstream is not good. Bacteria in a bloodstream with an “accident” is really not good. So that’s where you get its contribution to cardiovascular health. Cholesterol is the accident on the side of the road, and bacteria comes along and parks there. You get accumulation over time. You get this turbulence—turbidity—where flow is messed up. It’s like a river where you see stagnant pools and swirlies. Stagnant blood isn’t good in the bloodstream. So you get injury, stagnation, and bacteria hitchhiking—and that’s where you get effects on cardiovascular health and stroke and all of those interconnected things. It’s not hard for bacteria to get into the bloodstream once established. That’s why cardiothoracic surgeons—heart valve replacements—when they send samples to a lab, they often find dental antigens and dental pathogens. When I was in residency at VCU, I had a dental student whose father was a cardiothoracic surgeon. We were talking one day and he told me a story that in the last year of his practice—this would have been 2011—he hadn’t sent one valve replacement out for bacterial/pathologic testing that hadn’t come back with dental antigens and dental signs that dental pathogens were in there. That always stuck with me because he didn’t need to tell me that. He wasn’t on stage. He was just saying, “By the way, this is what I’m seeing.” So it definitely has an effect. Keeping your mouth healthy and getting that out is important. And parlaying that into hybrid dentistry—as we always do—you kind of get a reset button. You’re disrupting every single hotel in the city. If you took every hotel in Boca and put them out of business—no more bacteria stay here—there are still people that live here. You can still have issues, but you’re taking down the main structures that these bad characters live in by removing the teeth or removing the gum tissue that’s the Uber pickup. So you’re getting essentially a reset. That doesn’t mean you’ll never have problems down the road. We always say hybrids don’t get cavities, but they can get bone loss. There’s no way to eliminate the bad characters completely. But you can reset and start fresh. Physically removing a source of bacteria is the number one best way to protect yourself from these issues. Robert: Sure. Yeah. We see those conversations a lot online. People want to save their teeth naturally, but once it’s progressed to a certain point, really your best course of action is to remove that tooth or those teeth as soon as possible because it’s not going to get better, it’s only going to get worse. So if you need to get your teeth removed and wear dentures until you can save up for implants, that’s probably the best course of action because if you leave it alone, not only are you going to lose bone, but you run the risk of major health complications. It’s just—if your plan is to have your teeth removed anyway and they’re doing you harm—try to get that done as soon as possible. Dr. Dan: The take-home is inflammation is bad of any sort. Bad bacteria being next to your blood is bad of any sort. It has fallout all the way down the chain in the system. None of us are impervious to inflammation. We all have an immune system geared up to fight it, and sometimes the fights end up losing. That’s how periodontitis works. It’s your body inflamed, trying to fight an invader, and losing the fight. It’s there to protect you, but eventually, given enough time, it will lose the battle. And inflammation is a source and start of a lot of different diseases. Robert: Right. There you go. Interesting stuff. Timewise—think you got time for one more? Dr. Dan: Yeah, let’s do it. Robert: Oh man—this could be a long one. We could really get into this, but it’s about sedation and general anesthesia. The differences between them, why some people choose general, the levels of sedation, IV sedation… there’s a lot of passion around, “When I have dental work done, I want to be out of it. I want to be put under.” And I get it, because it’s a scary thought. And then there are procedures that can take all day. I saw somebody just a couple days ago over the weekend—they went in at 7:00 a.m. to have a full-mouth procedure done and got out at 8:00 p.m. Thirteen hours, which just blows my mind. I don’t know if you’re supposed to be sedated for that long. I don’t really understand how that works, but that’s a big topic of discussion. We did have Alicia ask if you could go into some of those aspects—your opinion on not being put fully under. Obviously, we all see the articles about complications when somebody’s put under, and they lose their life, or brain damage can happen. So there’s a lot of scary stuff on both sides. But yeah—getting your thoughts on that, I think, is a good one. Dr. Dan: So, there are a couple things that we’ll go very quickly and lightly over. I’m not here to dissuade anyone who wants general anesthesia that they shouldn’t get it. Everyone has a different life and a different story and different trauma. So if you can’t handle the idea of it, I understand that. But for me as a practitioner, there are several reasons why—and we’re going to push general anesthesia and IV sedation both together. They’re different. General anesthesia, you’re totally gone. IV sedation is supposed to be a twilight, happy time IV. Robert: Yeah. Dr. Dan: From my understanding, IV sedation and conscious sedation can really bring you to the same level of sedation depending on what you’re prescribing. So, we’re going to push those into the same category—anything to do with an IV. There are several big dental reasons why I don’t use it. Most people that want sedation and are very hardcore on “I want IV sedation” or general anesthesia are generally saying that because they haven’t had a good dental experience. When you put them completely out, they still haven’t had a good dental experience—because they don’t even know what they were there for. My mission has always been to some degree give patients the understanding that it doesn’t have to be horrible—give them a good experience—and then you don’t have to rely on the tool of anesthesia. Certainly anesthesia brings unnecessary risks—health risks and concerns—as scary as death—that don’t necessarily need to be taken on when you’re doing a big procedure as simple as something for dentistry. If you break your hip and fracture your femur, yeah—please get knocked out. But the other side of it too is: if you do IV sedation… I used to do IV sedation all the time and did it for a lot of single implants. It’s fine. You give the patient what you want, and because they generally have two sets of teeth opposing each other, you can put some sort of piece in there—we call them bite blocks—but a piece of rubber they can relax and fall asleep on top of those blocks on a solid set of teeth. Because you can do that, you have a space to work in that is stress-free for the dentist involved. It’s a space where you can accomplish what you want, and you don’t need the patient’s help. When you’re doing removal of all teeth on just one arch, you’re removing that stable base. Robert: Yeah. Dr. Dan: So when you try to put a block in there, it slips and slides and it smashes gum tissue you don’t want to heal negatively. It’s a lot of extra work and extra steps to get it stable. And even at the very best, it blocks half of your field of where you’re trying to work. So you end up working more segmented than I like. I like to work globally and see where my positions are. We’ll talk about that in the next upcoming episode—where the screw channels go and how we decide with surgeon and general dentist. But that gives me a global look so I can see. So one: I’m trying to give the patient a good experience. And my guarantee is I’ll always give you a good experience. No one has ever walked out of my chair after oral sedation and said, “Wow, that was horrible. I really wish I had IV sedation.” Not one. Robert: Absolutely. Dr. Dan: Not even down the road when you look in our groups—there’s no one saying, “Man, I wish I would have paid that extra four grand for an anesthesiologist” once they’re on the other side of it. They’re happy. To me it’s a crutch. That’s just for me—that’s the way I practice. I want to give patients a good experience and I want them to walk away and say, “That guy’s a good dude and I trust him,” because that alters everything else—our other interactions down the road. If you never meet me, you never see me, and you wake up with implants and something went wrong—you hold it against me. So I try to develop that bond together right away. The second thing is: once the patient trusts me and we get started, they can understand it’s not that serious and not that scary. That creates a launching platform to take us through the next steps—“Oh, they know what they’re doing.” So once we get the patient past the negative connotation of dentistry and we say, “Look, we’re going to be your friends and help you along this process,” the rest becomes easier. And it’s not about my job being easy—because you want my job to be easy. You want your implants in the perfect position. Nobody would say, “We’re going to hang this picture up on the wall, and in the meantime, we’re going to have 15 people poking your back.” Nobody works well in stressful environments. So I set the tone: calm, relaxed, easygoing, simple. What I get out of that patient is an unencumbered look on where things need to go. I get the implant in a better position because they’re able to open the space and get me the location I need. Then my job is made easier, which gets their results better. If I can get them over that barrier and get them to trust and understand I’m not a bad guy, not giving them a bad scenario—once I win that battle, the rest is automated. The rest is easy. I never felt like not fighting that fight—or just giving in to IV sedation—was of benefit to the patient. It’s always worth the fight to get them on board: “This is why I don’t do IV sedation—your results will be better, you’ll be safer, you’ll be in and out quicker.” Surgical time—the length of surgical experience—is related to infection results. So why would you want an eight-hour surgery? Why would you want your dentist fumbling around in your mouth when you’re not conscious? Why would you want a potentially life-threatening episode when you’re not aware? My goal is zero life-threatening episodes. Give you a smooth process, but involve you enough that you can feel comfortable and have peace. I know that doesn’t answer the question for people sold on general anesthesia. The frustrating thing is me saying I’m a good guy and I do really good work—that doesn’t convince someone unless they’re open to thinking about it that way. The take-home is: I don’t want to put you in unnecessary risk just because you asked for it. I don’t want to put you through something longer with higher infection risk. I don’t want to compromise your implants long-term. And I know I can get you through this process with no problems. I know you’re going to have a good experience. I know you’re going to leave feeling good about me, the brand, the employees, the dentists we work with. Then you leave it out and say, “Okay, the public decides.” That’s where you get debate. I hope what sells people on it is: I don’t want to put you at unnecessary risk. This is going to be smooth and easy. Robert: Yeah. I think if you’re open-minded enough to ask and listen to the people who’ve had it done, that’s your best course of action. Dr. Dan: Sure. Robert: To hear them tell it—twilight sedation is very… there’s always some, “What? Wait, you’re awake through the—” with air quotes. You’re awake. You’re not unconscious, but you’re so relaxed and kind of not even caring what’s going on. You’re not really there until somebody says, “Hey, how you doing?” or “Open up for me.” Dr. Dan: What? Robert: And then you snap back and perform whatever action is requested, then go back into la-la land. It’s difficult to explain, but most people are very satisfied with it, and it’s worked out well for us. When you go under any IV-based sedation, you’re saying, “I’m okay with you doing whatever you need to do to get this done.” So the environment—from you not being aware—becomes more violent inherently because the job needs to get done. They’re fighting you because you’re fighting to sleep and they’re fighting to do work. Because of that fight, you end up with more trauma, longer healing, more bruising, more swelling—more things your body has to fight. Versus if we’re working in sync—kumbaya or not—toward the end goal, I don’t have to be traumatic. Minimal bruising, swelling, infection risk. Who doesn’t want that? So once you get them over that hurdle, you get oral sedation warriors for life. They’ve been through it and understand it’s what we said it is. It’s a tough battle. But trust but verify—look at other people’s experiences, what they’re saying. Take a poll. Robert: Yeah. For me personally, I wouldn’t ever be willing to go under full anesthesia. I might need heavy sedative medication, maybe IV sedation, because I know what every sound is and I’d be particular. I’d be freaking out. But I wouldn’t want to be unconscious while things are happening to me. Personal preference. And I’ll be honest—I wake up out of it and the nurse is like, “Everything looks good. A+. Nothing to be concerned about.” I’m like, “Okay, I’ll talk to the doctor in a week.” But then I’m like—did they even do any… how do I know the doctor didn’t just walk next door and go on to the next patient when I spent this money and nothing happened? I guess the pictures confirm it. I’m probably being ridiculous. I just don’t like being unconscious. Dr. Dan: Trust but verify. And the easy grab is, “I want to be totally out.” But the answer is you’ll probably have better peace of mind and a better experience if you go with what we feel is best—which is conscious sedation. It’s going to go smooth and it’s going to be easy. And I remembered what I was going to say: because we run as we do, and because it’s efficient and smooth and predictable timewise—because they all pretty much flow the exact same—we have a very cushy timeline in terms of when we need to start before we run into the next appointments. We want to afford that patient time and length of sedative effects such that they feel comfort. We’re never on a tight enough timeline where we say, “Okay, you need to stop and sit down and we’re starting right now.” Slam the needle—boop boop boop. Right? Because of the way we flow our schedule. That’s only made possible because it’s not commanded by IV sedation. IV sedation takes more time. You have to show up earlier. The doctor has to be there. The doctor has to get you fully out. They have to do the full surgery. It’s much more dependent on things and timelines and fitting into those timelines. With oral sedation, we’re never in a rush. So when the patient shows up and says, “Oh, I’m not ready,” we’re not starting. We’re on a team. We’re friends. I’m on their team as much as they’re on mine. If they don’t feel comfortable walking into the stadium, we’re not walking into the stadium until they’re ready. We have a floating beginning time of our game, versus “It has to start here.” Robert: Yeah. Dr. Dan: And so for us, it’s nice because we can get them to a level—but we have the time to put them to that level—that gets them comfortable, which allows things to go smooth, which allows the timeline to be kept, which allows us to keep on time with everybody. Robert: Right. Dr. Dan: And another thing I think it’s worth pointing out is, in our office at least, this procedure is done pretty quickly. And always in comparison with IV sedation—again, I’ve only had it twice—but my experience was you come in, you start the process of getting an IV set, and then there’s a whole thing. It takes a little bit of time. Then they finally knock you out, you count down from ten, then you’re waking up. Then you have to recover a little bit, then you have to go to a recovery room for half an hour or however long they want you to. It’s just this entire process. It almost feels like you can be completely done with the entire procedure from start to finish in the time it would take an anesthesiologist to set up and for you to recover. You’re done and out the door. You’re home. And there’s nowhere you’d rather be than home. Robert: Absolutely. Dr. Dan: So that’s always, in my opinion, worth pointing out. Yeah—if this was a thirteen-hour procedure like the lady had over the weekend, maybe you weigh your options. But if you’re in and out in a couple hours, there’s really no option. That’s why I try to champion this argument. It’s not because I can’t do IV sedation. It’s not because I can’t bring somebody in to do general anesthesia. It’s not because I can’t get the funds for people to pay for general anesthesia. General anesthesia is the easiest funds to get out of people. “Hey, it’s going to be this much. Would you like to be fully out? Would you like to not have any worries?” You can sell it. Of course. That’s not why we champion this fight. We champion it because we believe this is your best path—smoothest, easiest, least psychologically overwhelming, best results, everything. So I’m willing to lose a few patients over that because that’s how much I believe in it. I don’t want anyone to come in and pay for IV sedation. I don’t want an anesthesiologist to come into my office and get in the way and compromise my results. That’s why we champion it. And if a patient feels comfortable with a message from a doctor, with their experience, from patients and reviews they’ve talked to, and they want to do general anesthesia and the old way—that’s absolutely where they should go. This is not a “we’re the only way that’s right.” This is just my opinion and why we fight this fight. This is why I tell every periodontist that I interview to put your IV sedation certification on pause when it comes to stepping into my office—because I don’t want that to be part of our culture for the reasons we just listed. Robert: Yeah. I’ll say for every patient that that’s a deal-breaker for, there are literally hundreds who’ve had it done that say, “It was a breeze. Glad I went that direction. Glad I took their advice.” And of interesting note, I’ve interacted with a lot of dentists over the years—between being a lab, offering services, speaking engagements—I’ve interacted with a lot of dentists. I’ve never had one that does this surgery that heard we do conscious sedation only and said, “You can’t do that.” They all say, “Yeah, I think that’s better. I think that’s the better way.” Then they go, “But your patient base doesn’t fight for it, man. You’re lucky you get to do it on oral sedation. I would much rather do it on oral sedation.” Dr. Dan: Yeah, you can. You just say you don’t offer it for these types of procedures. Behind closed doors, they kind of all agree with me. I’m seeing more and more come around to that mindset. They’ll always copy. Robert: It definitely felt like we were the odd man out for a while, but I’m seeing more and more doctors come around to that mindset. One thing I can say for us at Done in One is—right or wrong—we try to vet out everything we do. Every screw, every piece of plastic, every employee, every method—everything we do, we try to do with intention and purpose, without it being gimmicky. We’re here to provide results that give all of us peace of mind—so you can market for it and go home and sleep, so the front desk can answer a couple phone calls and go home and sleep, and we all feel good about the way we treat people, the way we work, the job we did, the quality of the results. Every little aspect isn’t because we picked it out of a hat or because we’re lazy. There’s a very specific intention behind everything we do—from the lines and the logo and the colors to the sedation methods. And I would encourage any practitioner starting a hybrid dental business—or any dental business—to pick what you believe in and fight for it. Fight for it to the end. Don’t just give in to anesthesia because everyone else is doing it. You’re going to lose that race every time. Dr. Dan: Amen. Robert: I think that’s a great point to leave off here. This might require a Part 2 Q&A—Part 1 here with Dr. Dan Noorthoek. I foresee a Part 2 coming up. So appreciate your time. Thank you for being here. Dr. Dan: Thanks for having me. Robert: Yeah, absolutely. We appreciate you joining us on Beyond the Arches, and we’ll see you next time. Dr. Dan: We’ll see you soon.