Ep. 36: Ask Us Anything: Patient Submitted Q&A!

Part 10:00

This is Beyond the Arches, where full-arch dentistry meets real talk. Let's get into it. Hello, everyone. Welcome to Beyond the Arches. I'm your host, Dr. Daniel Noorthoek. And today, we're going to be going over patient questions. Could be as random or as poignant as possible. We'll see what people have in store for us. But to ask those questions and discuss, I have a panel with me of Robert Odom. Hello. Lilia and Erica. Hi. Hi, guys. Hi. I have to like say his last name no matter what. I think he's like Madonna, like it's just one. Yeah, exactly. All right. So who wants to kick this off? So we've asked questions to or asked four questions to Facebook. And they have heard our message and replied with their inquiries.

And so I guess, Erica, if you want to ask the first one. Absolutely. So from our Facebook page. The Kelly Fellows one. Let's save that one for last. Just in case you were going to lead with that one. I need a moment. Do you guys remember in SNL? I'm Brian Fellows. You don't remember Brian Fellows? It was supposed to be like Steve Irwin, kind of like the animal person on Talk. Show. Yeah, of course. And he would just he was like it was Tracy Morgan. He was kind of like playing an idiot. And he'd just respond. I'm Brian Fellows. That's great. Any. OK, sorry.

So if a patient can only afford one arch as opposed to like doing a double arch, which means upper and lower for anybody who doesn't know. So if they could only afford to do one or the other, what would your normal suggestion be for like how they should go ▶about that?

Of doing the top versus the bottom. Yeah. First. OK, sure. So let's dive into that. I'll kind of go in further than they may have asked. One. Yes, it's very possible to do a single arch. The way that we do our designs, you know, will will easily handle doing a single arch. If you are going to have to pick one or the other and it was a money. And it's very possible to do a single arch. So I'm just going to have to pick one. I'm just going to Um, you could make an argument that my favorite argument would be for the upper first. It's what allows us to sort of set the the look and establish sort of the mode of where things are going to head and also going to get sort of your biggest pop for your for your buck to begin with.

The lower is a lot easier to kind of manipulate and use what's there. Um, sometimes. It can vary a lot with what we do with it. Sometimes if we know for 100% fact that a person needs this done in the future, we might take some of the bad teeth out on the bottom just that are in the way or are going to cause them future problems. And we also may make the decision to cut their teeth down to make it better in preparation for the lowers when they come in so it's not so much of a roller coaster.

If you look at the pricing on the website and you were to add two single arches together, you would get a higher fee than what it is to do the two at the same time. That's a very specific thing, and it isn't to lull or manipulate people into getting it all done up front. It's that, generally speaking, doing a single arch versus a double arch case almost takes the same amount of manpower and the same amount of time to do it.

And so just to kind of cover us a little bit for that extra time, that's what that extra fee comes in. It has nothing to do with whether or not we're trying to manipulate somebody into making a tough decision. ▶And that's something we've done a few times on our end, actually, is that when someone comes in for an upper, they know they're going to be getting the lower done within the next couple of years. We'll kind of go in there, help them with anything that's concerning any active infection that they're having.

We'll kind of go in there and say,

Part 24:28

Generally, when we run into a single arch scenario, there are unique circumstances that we have to address. Let's say it's five teeth on the lower absolutely have to come out. We've done it before where we just take them out for free and put them in. We've done it where we charge them, and then in the future we give it back to them in the arch in their future fee. Generally, we're really easy to do that. We're really easy to negotiate and work with because it's all about us setting ourselves up also for success and not putting the patient in a worse scenario than when they came.

And so sometimes that means even though they have to wait on the big, on the fancy and brand new car on the bottom, we'll get them to a point that's reasonable financially and gives them the vision of where they want to go in the future as well. Do you see like a more common area in someone's mouth, like the upper right? It is always susceptible to like the most infection that you typically see, or is that like just random, just wherever the patient's dental health has taken them is kind of really, really, really good question actually.

So your upper teeth, your upper jawbone and your lower jawbone are very different in terms of the consistency. It's not all the same wood. If you will, the upper is a lot softer. The lower is a lot firmer. So generally just generalizing, you're going to see patient tooth loss on the upper first before the lower. ▶So if you see somebody that's edentulated, meaning not have any teeth or have to have their teeth taken out at a different time, they'll come in with an edentulous or no teeth on the top with teeth on the bottom.

That's because the bottom teeth, they're not necessarily stronger, but they are in better bone in a better scenario. Another thing that they think also can kind of be protective for the lower arch is that when you drink or eat you, a lot of times have your tongue covering the lower teeth. And so it's a little bit protective. It's not as immersive in the experience of sugary aesthetic bad foods, which total random side note, since we're going down this path, it's also something that we can if a patient has bulimia or anorexia, worth reporting or talking to recommending getting like medical attention for, you'll see because of the act of vomiting that your tongue goes forward and protects those lower teeth.

And so if somebody has like a really like, let's say they eat lemons all day, you're going to see erosion and smoothing of like almost like it's sandblasted on the top and the bottom equally. If it's like a diet thing, right? But in a person that has, has a disorder like bulimia or anorexia, who is forcing that or having that exposure all the time, you're going to see that smoothing on the top way more than the lower because they're forcing that sort of that's, that's what is eroding their teeth.

I know that was like totally off topic, but random pieces of that's the thing to think about. I always assumed bottom teeth would be the most prone to decay. This might sound so stupid. I'm sorry. But because of gravity, right? So you have food, you have everything settles kind of towards the bottom. So you're, you're brushing your teeth, the uppers. It's a little bit easier to jiggle everything loose and maybe it falls down to the bottom. So don't know why I thought that, but always thought the lower might be more prone to you could, you could study this for like three months and still be figuring things out.

But the upper, another example of why the upper is a little bit, more prone, let's say that you're prone to getting periodontal disease, bone loss, the upper teeth, the back teeth, the molars have three roots. Well, that may seem great for it being stronger, but if you think about three roots, there are where, where a root comes together and starts to form the top of the tooth, that little space in between the two roots is called the furcation.

And when you have bone loss from periodontal disease or whatnot, um, you have, you have exposure to that furcation over time. And that furcation gets infected with harbors bacteria and stuff in it. And so if you think about it, an upper tooth is way more prone to having an issue. Once it's had an issue, it's going to get, it's going to go downhill faster because there's three vacations versus on the lower molar roots have two. And so you only have two for case.

I did not know that either. So there's lots of anatomical factors that go into it. You know, some, some people are prone to bone loss, and cavities, um, in general, but they, you can also have anatomic factors that go into play. So, um, let's say premolars, which is, uh, behind your canine tooth, your eye tooth, you have, um, four, two on each side on the top and two each on each side on the bottom. Um, the upper, you can have the first premolar.

I think that the, oh, I've can't remember the exact research. I'm pretty sure it's 97% of them are two rooted. Teeth. Um, but where that splits into the two roots can be further down on some people or further up. It can be deep. It can be very prominent. So when you take it out, you see these, like this big, like kind of Ridge that falls into like a, a storage corner, if you will, which is exactly what happens, or it can be really shallow and not really even show up.

So people that have those anatomy factors, anatomical factors are going to be more prone to those issues. And then those issues will, will come be more, become more complex and, and an issue also on the full arch. Uh, so full arch, uh, being any sort of restoration on implants, um,

Part 310:36

has about a 90 or implant dentistry is about a 97% 10 year success rate on the lower. Okay. Because of the bone is hard and strong, et cetera. Um, on the upper, that same 10 year timeframe is about 87%. So if we're going to see an upper end and we see that with, with our failures, when we need to replace an implant, it's generally going to be the upper, um, because that bone just isn't that great. Okay.

So there you go. Uh, let me add on to that really quick. So single arch, I think you said your upper would be your preferred. And that makes sense because it's more noticeable, right? A lot of people smiles. You don't even see their lower teeth. So it definitely has the most dramatic effect. ▶I think the argument against that would be if somebody was completely without teeth, right? No teeth on the top or bottom, maybe they're in indentures.

Your lower point is very difficult to keep in. And anybody that wears dentures out there knows this, it kind of just flops around inside there because you don't have that palette. Like you do on your upper for your denture, glued suction too. So a lot of people I've seen say, say they like to start with the lower, just because that upper denture is working for them for the meantime, because they're able to keep it in. Whereas that lower it's just.

And to further add to that complexity. So yes, you would want to do the lower first before the upper in that scenario, if it's going to be like a medium term solution, like of, we'll say just off the top of my head, a two to five year solution. If it's going to be a 10 year solution, you've got a really, really push hard to try and get both sets of teeth in because you can get what's called common.

A combination syndrome, because this all goes to the quality of the bone, the, because the bone is so much softer on the upper, what we see over time with a denture, where is the upper denture will kind of get the, the bone on the top will become compressed and smashed over time. You lose it over time. And that is sort of directly correlated to the strength with which the teeth that are opposing and are. So if you keep them in a denture and they're say they're happy, but you can keep them in a denture, then they're not going to be smashing that as much.

So maybe if the window is in the next two years, maybe that's a scenario where you just kind of wait in general. Yeah. If it's a one year, then go ahead and put it in, you know, with it, with an upper denture, if it's 10 years, think outside the box and try to find a solution. So even though I'm not answering any of these questions directly, hopefully anyone that's asking this question, and listening to this can understand that by working together, there are many, many ways to, to cut this apple.

There are many, many ways to find that solution. And they're not like, they're all sort of nuanced for that person's pocketbook and timeline and their anatomy. So sometimes things can be like obscure, like how much is the sinus lift? Well, it depends, you know, asking, answering a question with a question. This isn't like that. This isn't like, oh, you know, for this it's two grand, but you're probably that special seven grand, you know, here's the bad news.

It's more about fitting the, the chest pieces on the board so that you're going to play the appropriate games. Right? The, the, the end game will end up being the same. It's just figuring out the, the chest pieces that are going to work best for each patient. Is it true that a dental or a tooth infection will never go away? Like, even if you took like a, a, do you have to take it out for it to go away?

Or more or less? Yes. The, um, so you have root canals that can sort of, uh, allow for murdering the bacteria. Um, probably can't say murder on YouTube, pewing. Um,

Part 414:39

but the, so we're going to get really into anatomy today, apparently. So teeth, when they're formed, uh, they have the nerve on the inside, right? That's where the blood vessel, but, but blood and the nerve lives in that nerve. And that blood is vital to sort of giving you sensation to your teeth, et cetera. If you get a cavity or it's broken into that, that gets infected, then you have the infection that goes down the route down that sort of shoot, if you will, the canal, and then sets up and harbors bacteria inside of it.

Well, it isn't the reason why you can't just take a systemic antibiotic and have it go away is not that it won't kill. That bacteria, but the structure with which that canal works, um, the way that there is blood supply, et cetera, and the way that you get sensation to feeling pressure and hot and cold is there are little tiny holes, essentially all through your tooth that go to the outside. And those little holes on the outside or on the inside, wherever the bacteria ends up, you can end up getting layered deposits of bacteria.

That's sort of set in and entrenched themselves. So it can be very hard to eradicate. Um, and, and while we're on the topic of infections, some infections can hurt and go away. And generally when you have a, an infection that was hurting and went away is because you had temporary reduction of the bacteria or some relief of the pressure that's built up on the bone. ▶So I always tell people it's like a water balloon. If it's on the inside of this confined space, it's putting pressure on and that's where you get the pain.

If it all of a sudden inexplicably goes away, it's because it found a way to drain back into your mouth. It found a way to drain into the sinus, found a way to drain like underneath your tongue, which is this really scary place to have it happen. Uh, and so even though it kind of the symptoms dissipate, you are still living with that active infection. We see that weekly, right? No, I've heard patients say that like even day after surgery, they're like, I feel better than I did yesterday because that infection just got out of my mouth.

I do think a lot of patients think like antibiotics will fix it all and be like a quick fix. And unfortunately maybe it's just like, it's just suppressing it. It's not killing. Yeah. Well, yeah, you're just, you're not eradicating, you know, it's like going to Afghanistan and sort of taking over and saying, I'm the government here, right? Well, there's a whole network of bunkers and, and, and caves and such that, that you can't get to and eradicate.

Right. And that will grow back and fester and come back to, to bite you. So managing that is really tough. I think singing or your cheese. I hate to go all political like that, but that's really essentially what it is. It's really hard to eradicate. You have to go through and, and eradicate every single sort of Avenue.

Part 517:39

I know a lot of patients before surgery. They're very concerned of like, I, I think I have too much app, too much infection. Like, what is your take on, you know, active infection surgeries next week? Like, what would, what would you say to those patients? So you, there are several ways to take care of an infection, or if you look at the triage of how to take care of things, the number one thing that people want to go to is antibiotics.

But the number one thing that you can do to fix anything and eradicate that problem is remove the offender, which is the tooth. That's number one, every single time, anytime you can actually get that tooth out. Number one, best thing to do. Number two thing you can do is animal, or number two thing is to like physically cure at the infection. After that tooth is out, get rid of the, the, we call it infected tissue, but it's really just like inflamed, pissed off.

It does have some bacteria, but generally it'll resolve, but you're going to get that out and eradicate that physically, physical debridement, physical removal. And then the third thing is protection with antibiotics to keep that, that calm inside of the mostly resolved scenario. So for those patients, best case scenario, their surgery is next week. They're going to get that all cleaned out by you. Yeah. And that's, I think a lot of patients feel relief when they know like, oh my gosh, I'm not worst case scenario.

It's going to be handled in surgery, you know, that's an area, but isn't there a factor of like active infection can block the numbing agent from circulating. So it's active infection can create an aesthetic environment. And an acidic environment sort of blocks the action of the anesthetic. It doesn't allow it to like penetrate into the nerve properly because of the environment that it's in. So you can get what's called a hot tooth. So sometimes treating with antibiotics ahead of time, which we do on occasion.

The other side of it is that you can get if that infection has been going on too long. Sometimes that bone can be really weak. ▶Really like Swiss cheesy, if you will, and really hard to anchor an implant. We don't see that like preventing implant placement, but at the time of surgery, we'll make an assessment for what that is. And we'll usually fill up that Swiss cheese that hole with with bone graft, but that isn't just like set it and forget it, you know, in orthopedics.

They have a big advantage, which is they can they can hammer in something physically inside of your femur or whatnot. And it will take up that space and you don't have to worry about whether or not it's going to heal. They also have different cements and things to hold their pins in dentistry. We don't have that. And on top of that, we're also like immerse immersing it inside the nastiness, which is our all of our saliva. And no matter how good of a job we do, that's always going to have a connection to it.

So the name of the game is to keep it clean and eradicate as much as possible. When that does happen when that bone isn't the greatest quality for putting, implants in, we will generally fill it with bone. We'll say cross our fingers, but we'll put it in a way where that and discuss with the patient.

Part 620:56

Hey, this is what I found. So if we have a problem, it'll probably be this one. I need you to be super careful with this. Also, we may have to replace this, but you're going to have teeth. We're going to move forward as if it's going to heal fine, but we may end up having to, you know, if I had to identify something, it would be this and that's, I've found that that's working that way with a patient and just being transparent and honest and communicating that with them is a whole lot better than trying to make the decision ahead of time, whether or not it's going to work because I don't know.

Yeah. And so my belief has always been get the implants in, make it as good of an environment for healing as possible, but also let's set ourselves for success by setting that patient's mindset and leaving us a space for the implant that we would want to heal. I want to replace, you know, I kind of leave a, in that scenario, I may, may not put that implant in the absolute ideal position because maybe I feel like that ideal position in the future will be a better backup.

If there is an issue, there's a lot of decisions that make that are made game time that you may be able to get an ideal from on those on the CT scan and doing all the prep work, but you honestly don't ever really know until you get in there. And I just, ▶I've always, I've always had a piece of mind of things have always gone smoother when I have that conversation with a patient and say, this is what I'm going to try my best.

And this is what I'm going to figure out. And this is how we're going to go forward. Then making sure that all my teas and eyes work, you know, dotted and crossed before hand, because then you're just setting somebody up for failure. Yeah. I think my mom was actually a good example of that because she had one that was very, very iffy. Okay. And I don't remember that exactly. We told her, like, here's the implant that we're most concerned about other ones.

Good to go, but this is the one. So because you can be honest and transparent, and especially when it's my mom and not a random person said, look, that's the one that's in trouble. You have to do everything you can to take care of that one, chew on the other side of your mouth and, and giving those instructions that give them the best chance chances excess at success requires that conversation. And sometimes, you know, people want to avoid tough conversations, but it's those conversations that are giving the people the best, best chance to, and she didn't have any issues, correct?

No. Yeah. So lately, that's an example. Like most of the time, it works out fine. Yeah, but I like to always give a little, like, wave the flag, like, hey, you know, this might be an issue. And then when it happens, or if it happens, then they go, he told me, and this, here I am. Yeah, I like it when we do that. It usually works out. Oh, that's the way. Yeah, communication. Yeah, absolutely. So I actually have a question for Lilia.

This is something that we got on our Facebook page as well. And this patient States. I had my procedure two years ago and loving my teeth.

Part 723:56

I also signed up for the lifetime warranty. I'd like to know how they're sorry. I'd like to know if there's any way to get the annual cleaning covered by my insurance. I just turned 65 and I have Medicare and Baycare plus supplement. So this person is just, I'm just kind of questioning. Do they have do they need, you know, do they need dental insurance is kind of what I'm getting out of it. If they also have the lifetime warranty program.

Yeah, I hate to say like cancel your insurance. I feel like that is definitely a personal is what she does a personal. I don't want to ever get on the record saying like I said to do it. I do know that we're a specialty office. I do know we're out of network. So it all depends on the plan. You have how strict they are, you know, what what they cover. In office. We always say we're more than happy to submit a claim for you and we'll show, you know, document the codes that we use for that cleaning.

So I think it's really case-by-case. I would probably think that they're not going to cover as much honestly with especially the cleanings. It's one thing for the procedure extractions, maybe dental implants, but cleaning I would probably say I'm leaning towards they're not going to cover. But again, I'm very optimistic and we can try and we can hope for the best. And you can reach out to your dental insurance and see what kind of coverage they have. I think if you have our lifetime warranty, that's essentially like the best thing you have as far as like quote insurance.

It's not insurance, but insurance covers your cleaning anything that happens with your implants. Your prosthesis is all covered. So correct me if I'm wrong, but I really don't know. There's probably coverage. I was going to say it's I've never told anybody to cancel their dental insurance, but I have highly encouraged. Yeah, just because usually, after the procedure like after we submit for the procedure itself. So surgical extractions dental implants usually any reimbursement you get on that like then great.

I'm glad we were able to help you get that back into your pocket. But other than that our lifetime warranty kind of has you covered as far as like, you know, just in case if you got into it, ▶I don't want to say the worst thing ever but if you got into like a car wreck and you broke your teeth or you broke, you know, just like a normal human would and your zirconia broke, we'd replace it because it'd be covered you would have no out-of-pocket costs for us.

But I could definitely see that being kind of controversial, especially if someone has like a I would never tell somebody to cancel it. They had like a family plan or yeah, you know, obviously other people who like relied on that insurance program that they're on. Yeah. Yeah, unless you have Dependence. I would be so bold as to say if you have the lifetime warranty cancel your dental insurance reason for it. And then we had a question in the group the other day.

Someone was asking can we go to a local dentist? Do we have to come back to Florida? And I think that gets asked a lot. The responses were all I go back. I love it. We make a trip out of it. Most people do for sure. And just to touch on that really quick. I've had this conversation with a few people before but no one is as motivated to to make sure that you are in the best position possible because and I think we talked about it the last time I was I was on the show.

We don't want to come out of. A rough pocket for all of you know, anything that you may need. So we want you to do your part to keep everything looking good, but we're also going to do our part. And if that involves nipping something in the bud and catching something early, we'll do that. Whereas somebody that doesn't really have any skin in the game is just going to say keep an eye on that and you know, check it out next year.

I yeah, we're more inclined to catch those things to to prevent. Either side from having to go beyond what needs to be done. Yeah, the this question is essentially exemplifies why we felt the need to come out with a subscription-based lifetime warranty because it's an answer to hey insurance won't give me anything. I just had $30,000 put in my mouth or 50, you know at the local big box chain. Now, what do I do? Yeah. And The world doesn't have a very good answer, right?

And so we were trying to fit the niche or give that person the peace of mind that even though we're not technically insurance. It's a replacement or an alternative to your insurance and gives you that same or a similar peace of mind. Until like you're saying we're so aligned in in that that everything is successful and goes well because we don't want to come out of pocket any more than we have to but that being said we also.

Wanted people to be able to live that life. So that's where we late made the exception that you can go somewhere else. Would I if I had it done and I lived in Missouri, maybe maybe every other year at the most probably I would just take advantage of the free and make it into a trip. I can't say because I don't live in Missouri and don't have to make that follow-up but we tried to make it so that it was amenable to somebody in Missouri.

We're not trying to pin anybody into a space. We're just trying to align goals and align interests and align financial fiduciary type responsibility on both sides. Ever since I saw Nick with the hundred and eighteen dollar round-trip ticket to Texas. I did not know it blew my mind. I'm like so for a hundred my parents go direct from my hometown to West Palm. It only flies on Thursdays and Sundays. And it's with a lesion but it's they can get it for forty eight dollars one way you'll be shocked.

There's forty eight dollars. Yeah, we have hotel the hope and we're in an area where there's an abundant amount of hotels Airbnb. So I feel like coming to see us directly is maybe more cost-efficient than going to a local office with who knows what they're going to charge. Another aspect is we have no control over what your local dentist is going to charge. And if you're not a full-time patient there and spending money and you know, you're never going to have.

Have root canals and you're never going to have crowns and bridges. You're just coming there for cleanings. They're probably going to bust your head that and but we will also support them and let them know what we used and where we use. I mean we see people percent. ▶We do the refresh program which is building new teeth on top of old implants if they're compatible Etc. And we see people with horrible records and but we we try our best if we do have somebody that needs to stay in Boston and doesn't want to leave for work.

And Etc. They have somebody that will take care of them. Yeah, we'll support them as much as we can possibly support them and to the to the point of sending them the screws and the teeth. So we try very hard to be accessible. Even if you are in that scenario. Yeah, and as far as like sometimes patients and constantly like what do you mean? I have to pay an additional like fee for your warranty and you know, it's I explained as best as I can but when I think about my husband and I are done.

Dental insurance for example at let's say my general dentist office that I've been going to for a while, but I'm paying more than $59 a month. I know that because it's a you know, family plan and I know that they don't cover the cleanings. I pay out-of-pocket for like the whole you know, there's so many things like a night guard if I need it if I need a filling it's I'm paying so much money and I'm paying more than $59 a month.

So I think patients get a little hung up on that, but there's so much good that comes if you ever need it cleanings are covered. Again implants are covered the prosthesis is covered. There's so much good that is covered on. Yeah, everything's sorry. Everything's covered. I mean that's a big point of like there's a lot of lifetime warranty talk these days and just from you know, on course there is we came out with it. They're listening to this podcast whatever we have there.

They're going to implement they're going to start being okay with the people going outside and in my department as I see I see a lot of that and it's always fun to go into the small print. And see exactly what they mean and I will tell you I haven't found one that's as encompassing as ours yet and I doubt we will we do not have any restrictions if you are abiding by the terms of this warranty

Part 832:23

and you're coming in or seeing another dentist once a year and you're doing your part. There's nothing we won't take care of so, you know, we all know how expensive it can get to replace implants to replace prosthesis. When you think about dental insurance, like you said, there's often a cap as well. Fifteen hundred two thousand five hundred and that's the most you can spend in a year. If you need to get a prosthesis replaced at, you know, minimum seven grand you go somewhere else.

You you could pay double that. Yeah, you're talking about a lot of money. So and we already have your file. We already know the teeth. There's two last bullet points. I want to make on insurance is one. We all make decisions on insurance daily again. We're not insurance technically. But we'll call it insurance for the sake of example. We all make decisions every day. You buy a house you get homeowners insurance. When do you not have homeowners insurance when you paid for your cash and you don't really care if it blows over.

All right. All right. Well, not many of us are in that scenario. We buy that as an example of the other extreme yesterday. I was buying a light bulb for a car. Okay, ten dollars and I was offered for eleven dollars. The protection the two-year protection plan. I clearly made the decision to not insure that because I can pay to replace a ten dollar bulb. If it ever goes out, it's led. It's never going to go out, right?

But the example is that we make decisions on insuring stuff from ten dollars to a million dollars every day. 50,000 20,000 40,000 car whatnot. So this is 35. Why would you not want to insure it? Why would you not expect it that the that there's some additional stuff that comes in to take care of it for sure? Yeah, the other thing I was going to mention is that we see this discussion very frequently. Yeah, the nuances of sorts and I'm not going to come down.

So what are my options and rightfully so they're doing their research. They're trying to figure out what the best policy is. Sure, but I would say as a general rule or a general guess that. That decision and discussion kind of goes by the wayside once they're done with their teeth and they met our team and they experienced it and they got to be here for a week and they saw where we live and they saw where they could vacation generally that just goes boop gone.

I agree completely. There's a couple but not many at all usually what ends up happening usually by the end of it. They've either, you know, change their mind or they've decided they are going to follow through with what Robert said and do every other year and just at least touch base with us every once in a while. Yeah. Mm-hmm. I thought I saw a good question on here from a patient. The patient said, how do you handle patients who have high blood pressure as far as surgery goes?

Good question. The first hundred percent step is medical consult medical discussion with a primary care physician, even a dock-in-the-box MD. Now kind of clinic will see a patient and put them on blood pressure meds. If the if the blood pressure is high. If we can't get if we know it's an issue and they generally if we have an issue with blood pressure and it happened last week, generally that blood pressure is above what the ADA recommendations for elective surgery are sometimes that's still nerves.

So we'll generally give them more nitrous and calm and like let them kind of settle down some because in the heat of the moment it can be kind of exciting and scary of sorts. So generally those people will let fall into their sedation a little bit better and nitrous will have sort of an effect on that. But like in the example last week, that person hadn't taken their medication properly, even though we told them to. So we had to reschedule them to the next day.

So and was that maybe the second or third time we've had to cancel? Second. Second. The first time was so high. I was nervous to have him in the chair and we ended up sending him to the ER because it was completely uncontrolled and they were able to get it totally under control for the next day. They just didn't they discharge him and then sent him and cleared him for surgery the next day. I want to say that he did spend the night in the ER.

I think I feel like a lot of patients have blood pressure medications. You know, we see the same. Few different things that's like, you know, patients have but I feel like like you said that's extreme cases for the most part patients, you know, take their meds and you would say surgery goes goes well. It's probably the most medical. It's probably the most common medical condition that we see and have to make a decision on every single not every single surgery, but on the highest proportion relative to any other medical condition, etc.

The only ones that really are a problem, you know, generally if a person's on blood pressure med and they've taken it properly and they still come in and it's high generally were able to get it down with just being calm letting sedation set in nitrous, etc. If we can't get that down in every scenario, even if we've still done the surgery, it's always because they didn't take it like they were prescribed. They left the bottle at home.

They. Are on to light of a Medicaid version of it and they went to their physician the next day or week later and got it fixed. So it's very prevalent in our day to day. But in terms of altering surgical approach and our path and timeline, it generally doesn't affect things too much. And I think if anyone has any fear, like we would always will, of course, will drill console and narrow down if they need clearances or whatnot.

But just being in contact with your primary doctor and making sure. You're taking the proper steps before this procedure to that. You're clear to go. So that's what I was going to say. The only people that have ever had a consistent problem with getting them into surgery and being okay with it, etc. Like getting them across the finish line have been the ones that don't have a primary care physician are unwilling to go get one are unwilling to go to an M.D.

Now are unwilling, unwilling, unwilling. Those are the people that we've ultimately had to just say no to and send them back. To the local cowboy and high blood pressure. Isn't it? It's literally called the silent killer like this. So people sometimes, even if they are aware that they have it, they might not realize how high of a level they actually have it at. Yeah. People will just take the medication and think that it's taken care of. So it's always a good idea to get it pre-op before you leave for surgery.

Make sure it's all good to go. Remember your prescription. Don't leave it at the airport. Those kind of things. I don't think we've ever actually had that. People are pretty good with it. But those are the weird things that happen. Yeah. I saw a few other ones. You want to say? Yeah. I have another one that I read off earlier and it has to do with TMJ and it kind of goes both ways. So I want to ask.

I want to kind of twist it into my own words and ask kind of like, do you see people who initially have TMJ come in? Do you feel like that can ever like having full arch? Can that resolve a TMJ issue and then vice versa? Have you ever seen it? Where a patient has come in with no TMJ, had full arch completed and then kind of is having some effects of that afterwards? Really, really good question. That could also be studied for three months and you still couldn't get an answer.

So. TMJ is the actual joint. TMD is the disorder of the joint. So generally you're talking about a dysfunction in the TMJ. So you're talking about TMD. There are many, many. Different ways and philosophies that you can subscribe to as a dentist. I tend to really align with there are people with genuine disorders and placing the teeth in the exact right place where the joint can be happy is can be difficult on them. But generally they're going to have had worn a splint and had those issues their whole life, etc.

And these are people that we're talking about, like maybe have a full regular set of teeth. The other side of people are more confused and maybe a dentist has told them they've had TMD and they need a night guard, etc. Those those scenarios most of the time come from the teeth being in the wrong position. In my experience, that's what I subscribe to. Occlusion in the bite being correct. Really fixes a lot of that stuff. There's if you think about the teeth, the way that they come together, there's the height.

Right. Like how how tall your teeth come out of your head. Essentially, there's a happy place that you and I go. There is a position forward and back. And then there's also the positioning of the individual teeth and how those come together. All three of those things is what makes up your joint being happy or not. When you're. Let's say. Let's say that for you, I wanted to do you wanted to do full crowns or you needed full crowns and I wanted to do all of them.

You basically it's it's considered or my training was considered bad practice to enhance and build those up taller without taking your time and doing it in a temporary like you couldn't do it in an all one experience because you're shifting that length. Right. So. So if you parlay that logic into full arch, you go, well, we're definitely going to be changing the height. Some people have lost back teeth and it's not as tall as it used to be.

Those teeth got pushed out of the way and they're not where they're supposed to be at all. What I've found in what we're trained to do is to essentially put that patient back to exactly what they were when they came in. But what I've found is I put them. I like to put them where they feel comfortable. And there's a big difference there. So where you we would need to take a lot of time if I wanted to build up height and change your height because it takes time for your joint to accommodate it.

See if Erica can adjust to it and not do anything permanent. But with a full arch, by putting you in this functional, comfortable position, we generally are going to be seating the the jaw joint where it's supposed to go. And then also by getting back. Teeth back. And by getting a bite that we're in control of, if anything, people that grind and grinding comes, by the way, for a lot from a tooth being malpositioned. And it's like that obsessive thing.

You know, you have a little tag on your on your thumb, a little skin tag. You cannot let it go, even though it's like one micron big. It's a cuticle. It's the same thing in your mouth. So if you have one tooth that's a little bit off, you're going to be messing with it. That's where grinding kind of comes from. So we see a lot of redness. We see the resolution afterwards in resolving those type of they call them pair of functional habits or any type of that disorder.

In fact, I can't think of anyone that we struggled to be comfortable. We used to. I used to struggle with it when we I was following the prescription of they come in with this height. They leave with this height no matter what, because that's what they came in with. Then you're fighting anatomy and you're fighting uphill. pill. In my opinion, hybrids totally knock everything out, allow you a full fresh, like workspace, allow you to start from scratch. And therefore, since we're in control can put you into that position that is going to be ideal. So if, if a regular dentist saw how I get my position, generally their first view is, well, that ain't going to work because they only know getting it back to original. But after 10 of these working perfectly and getting rid of grinding, et cetera, they go, Oh, makes sense. I like that. So for something like this, we'd probably suggest that if a patient ever had like those funky, like TM, like felt like she kind of felt like they kind of, um, adapted to like TMJ after getting the zirconia arch, you would say probably just like come back in and let us take a look and just kind of see what we can do. Cause it's not unreversible. Correct. From what I've seen just from over hearing Dr. Laks and restorative team, if, if a cusp of a tooth is ever so slightly high, it can make like a world of difference just for her to like chair side, make an adjustment or do a quick bite adjustment. Um, is that something you think Alex had some kind of issue that was completely fixed, like very quickly and easily. Yeah. It's just, it's like the, the P under the mattress, the princess and the P they can throw your whole night of sleep off. And, and, um, it's, it's usually pretty quick.

Fix. Sometimes it can be a little bit more involved. Maybe, you know, there were two disheveled in the surgery to like really make a decision. Um, that's not to say that going faster is, uh, a bad alternative, but the, that, that is, that does speak to why more further, why we do a five and a seven day or however long that patient needs to actually do all those try-ins it's to get that bite correctly. Because if you're going to be grinding in that bite after you insert it, and it's a little bit off on a zirconia one, it's hard and it's, you are compromising the material, but the chance that you're going to recarve the right anatomy and the right bite in is really low. So our adjustment is getting that really close so that the adjustment doesn't ruin the anatomy. So it keeps that intact, but you know, you can get adjustments. It's not bad to get adjustments, but those adjustments are going to just kind of perfect it rather than slaughter what was there.

Right. So in a case like this, it might be best to kind of like go slow, take our time, let this person's anatomy kind of like adjust, see where they feel comfortable at maybe rather than even though we can do the five day process of the Monday through Friday, this may actually be like one of the only scenarios where that might not be ideal. Yeah. Those, those scenarios are so minor. It's more like just fix it once they identify that it's an issue. Um, because you could, we could, they could be here for three weeks and we wouldn't be able to identify some, some things require time and figuring it out.

Right. I have a nice question from a patient. What was it like for you witnessing your patients for you to witness your patients seeing their smiles for the first time? New smiles. Well, the, I think social media has sort of ruined it to some degree. Everyone sort of knows and can see that experience now and know that this is a procedure to come in. Well educated. And this is not to negatively, you know, to say people don't, don't watch videos, but we used to get just waterworks, waterfalls, crazy, bring the family, the mom in the, just the reveal was incredible. Uh, and that was, those were just temporaries because these are people that didn't think it was possible. You would get it done in a day that has really worn off.

Right. And, um, now people expect, to be incredible and to the point that your first set can be a little bit disappointing if it's a little bit off, cause they're not just that like instant gratification, but the, the appreciation for it has grown for me because no longer is that fun reveal that fun experience of showing them in the temporary and knowing it was a temporary knowing you had a battle coming. Now the experience that is rewarding is in the, they, they get their final. And now that weight has been lifted from their life and seeing, you know, we just did a patient interview with crystal and she very clearly is wearing her emotions on her sleeve. Just, just lights up a room instantly. It's unbelievable. It's like plugging in, you know, plugging, plugging, plugging a battery in so that it has shifted. And I think for the better. Um, but that first initial reveal has kind of like diminished or it's not as bright of a light bulb as it used to be in a good way. Um, but I can sear it into my memory are definitely the reveals from those first teeth when it was a long day and you got it done and just changed that person who didn't think it was possible. There's lots of those stories.

Speaker 2 Yeah. Speaker 3 Yeah. And to add to that, I think that, that, that feeling of, I didn't think this was possible and I'm overwhelmed and amazed at how the light bulb worked. this turned out has kind of been replaced because I feel like at the time of the initial delivery, there's still a lot of uncertainty. Is this going to work out? You're not fully comfortable saying this worked out. There's still, are these implants going to fail? Am I going to do something wrong?

I really feel like that level of contentment with your decision has moved further down the line and you see people coming back in a year being happier than they were during that final delivery and two years. And it's like a progressive thing where people are just happier and happier as time goes on. It's almost like we've all been at a restaurant and had a meal and it comes and the first bite you have is just like stunning and unbelievable. Maybe it's your mashed potatoes and then you go on the steak and it's like this huge letdown, right? But you've already bragged about it. So you kind of.

I have to like stay in the moment and be like, this is really good, but you're really like disappointed. That's kind of the way it used to be. People were eating their mashed potatoes and like, yeah, you're the best chef ever. Well, they haven't tasted the steak yet. And the steak used to be four months of follow-up visits and anointings. And they're not as pretty as the temporaries because there had to be more material. So now we're getting people to like taste everything and actually write a review of the full restaurant experience, which is a really cool.

Yeah. Yeah. We see a lot of people that, um, you know, of course we collect Google reviews. We, we appreciate Google reviews. It helps a lot of people make their decisions. Uh, we don't had, I saw somebody, uh, ask the other day, um, why in the Facebook group, what, why are so many people like sharing their experience? Did you guys see that comment? Oh, wait, I did. It's done in one, like paying these people to comment. Yeah. Are these people real? You know, she was genuinely asking and understandably. So there's a lot of happy patients in that Facebook. We have on record, we have two patients that have ever been fine financially comp, uh, compensated for, from done in one. And they are both employees, Robert and Alex. And, uh, but going back to, you know, we, we appreciate Google reviews. Um, I feel like people are hesitant to leave Google reviews.

Right. Cause again, they're uncertain. They don't know how this is going to work out. You don't want to leave a glowing review. And then three months later, these fall out and you realize you had the worst treatment done ever. And then now you can't take it back. You can, but, uh, I think people wait and we often see these people coming back at their one year that are again, the happiest they've been and they're excited to leave the review. And that, and that's a great review.

Cause I feel like you have a lot more insight to share with other people after you've been through this a year and gone through the whole process and acclimated, uh, is we always get some, some really good reviews then. Yeah, I agree. I totally agree. I think sometimes even when it comes back for like the, the one year review, I mean, I love all of our reviews. We share all of our Google reviews in our done in one group chat. It's like the best thing. It's like someone's birthday. Yeah. It's like a million likes a million hearts. We love it. It's amazing to see. Cause it's kind of just, you know, we, we get to view whatever the patient viewed on our end. So we're glad that we did a good job.

Um, but sometimes even that one year or two year review is even more interesting. Cause like you said, they just have a little bit more experience and insight to what it actually is like to live their life with the full hybrid. Yeah, absolutely. I would say that we may not have the most reviews of anybody, but we have the most real raw, awesome reviews and we do share it to the group texts. Just throw it out there. There's what, 20 people on it or something like that. It's a celebration.

I can't tell you how many times I've had a tough day and you know, something isn't working out or my mortgage bill just came out or, you know, just something a little frustrating and just kind of picks us up. Yeah. It helps. It really. Yeah. I'm a, I'm a big review guy. I read reviews on everything like Amazon products have gotten impossible now. Cause you can't tell which ones are real ones. I don't even read them. Yeah. It's pointless now, but a word of wisdom to all listeners out there.

Read reviews for the dental offices that you are looking into. If you go on our reviews and you read a thousand word testimonial that, you know, is coming from someone's heart and is genuine and authentic. And then you go to other place and you say, you see a plus would recommend know that that is not a real review. No one has their life changed and comes in and writes a review like that. So be wary of that. We earn genuine, real reviews. Doesn't matter the amount of time. We don't buy your review with a crumble cookie. I love crumble. Everyone loves it. I'll buy you one. I know how to get her point. Yeah. I love crumble. He'd win me over the story. We don't bribe. No, there's no bribe. We let our patients bribe us. So let's wrap this episode up. Um, this is going to be the question from Kelly fellows that we wanted to save for the next episode. So if you have any and this is a question for Dr. Noorthoek. These are always my favorite questions, by the way, answers. Absolutely. What is one of your most memorable surgeries that you performed? So it's not really a question. It's kind of an experience or a story. He's got the best stories. I have a lot. I'm trying to like go through my role of memories to see if like, I can even think of, I've, I've heard patients like laughing in the back. And actually we had someone come on the Facebook group. And I was like, I'm going to do this. I'm going to do this. I'm going to do this.

Like, have you, I know, no question. Just anybody else laugh during their surgery like me. Yeah. He said you had to tell him to stop laughing so you could work. Yeah. That happens more often than you think. That's a great, that's a great compliment to your service. I tell a lot of deadpan worn out jokes, but I can't believe Dina still laughs at him. I can't believe how she does it. Um, I would say that there's probably just off the top of my head. And if you asked me in a month, there's going to be two different ones cause there's so many of them. But, um, the first one would probably be, um, back in Jacksonville. Um, we had a guy that we, um, saw and his teeth were just really, really bad looking from every angle and he didn't know what to do. Um, Reggie, so I'm talking about, you guys have all seen his commercials. Um, and the change that it made in his life was awesome. He, at the time he was taking care of his father, I think his father

[redacted] And the

two years, three years after that, following up with him and watching his life change back to what it was, he was a, he was a chef. He got a food truck and then he got another food truck. And the last time I spoke to him, he made his own barbecue sauce and he was always made a point to bring that particular barbecue sauce, like as much as we wanted to us, which was, you know, as a gift, which was really cool. Anytime there's been like some sort of like residual gift, not that I'm out here doing it for gifts, but like anytime there's a residual gift, um, I myself struggled to think of like, Oh, this person might like that. And anytime somebody has something unique like that and they bring it in, it always sticks to me. Cause the last thing I would think about is my dentist. So that's clearly, yeah, that's clearly a, a sign to me that, that we made like a, a long.

lasting impression. And so for years he brought in barbecue sauce and would update us on his story. His sister ended up coming in. Um, remember his sister? I don't. Do you remember his sister? I think so. She was the bank security agent or not security agent, but she ran like bank security for bank of America. That was here in Boca. Yeah. Lost prevention stuff. Uh, and he came in with her for the surgery. He came in for several years for the cleaning. So that's, that's probably number one in terms of impact and long-term relationship, et cetera.

And then the obvious, obvious, obvious one is Robert. Um, that's been like the best, uh, relationship and like the most rewarding thing to see this smart guy who hadn't been given like a big chance, like really, and not that we're there even like giving him a chance, like a charity, like he comes to work and he works really hard and he has developed a passion for this and spreading it out. And, uh, you know, his, your ability to, um, self-study and your intelligence. I know that you feel a little bit awkward that you don't have a degree, but as a person that has a degree, there's a lot of people that have them that aren't even a third as smart as you. Um, and so I wouldn't feel that bad. Um, but you know, in terms of like payoff and rewarding and like seeing how it's changed your family and your trajectory, uh, you know, 401k, and house now and career like kills me. Yeah. It's pretty awesome. I appreciate that, man. I definitely appreciate it. I am agreeing with you. My favorite cases are always the ones where, um, people look at this as, as a gift and an opportunity and use it to the best of their ability to succeed. When you see people come back a year or two later and, you know, they went from down in the dumps, not at the best point in their life. Now they've got a new job or they've gotten married. They have a love life now. And they didn't before, like, I don't know, there's some element of paying it forward. You with your surgical skills, you're paying it forward to these people. These people are going out and they're paying it forward and it just spreads around and it makes everything very worthwhile. The, um, to some level, I don't, this is going to sound bad, but it's not.

▶To some level, like I don't give a crap what you want as your teeth. Like you can have whatever tea. I don't have to think that they're awesome, but if it allows you to have that feeling and that confidence to go out and do something awesome. And like you said, pay it forward. I'm all for those teeth. As long as they're not medically compromised and going to be an issue. I don't care if they're green. You know, if that makes you do what you want to do and live your life full, that's what it, that's, that's my point being is that.

That's why we're here way more than the color in this, the symmetry of teeth. And that's a lot of why I don't say get along too much with like the dental community is they nerd out and they, they have to follow X, Y, Z rule. Well, if, if Robert doesn't want to follow that rule, why do you have to follow the rule? As long as it's not hurting him. Um, I don't nerd out on that cause I'm going to let Robert pick. And so, um, it's always fun seeing what people pick and see how people change their life. Um, the worst ones are the ones that pay the highest amount and don't care and don't take care of it. The ones that, um, have generally been the most rewarding, the ones that are scrapping it and they change their life and maybe they lose a deadbeat spouse and they finally make their changes that they were supposed to make or whatever it may be.

There's a thousand million stories out there. Um, that's, that's always the most rewarding. Yeah. We, we talk a lot. Giving self-confidence back, which is unimaginable reward for sure. But there's some people that lack self-confidence for other reasons. Maybe it's not just their smile. There's plenty of people where that is the one thing that is keeping them from fulfilling their destiny. And if you can change that one thing for them, they're, they're off to the races and, uh, it's a, it's a really cool thing to see. It's awesome. It's very, it's why we're all here. Absolutely.

That's a great note and a great question from Kelly fellows to follow up with and finish with. Um, if you listen to this and it's spurred on some more questions, maybe you want to hear us do this stuff more, et cetera, send us a line, send us a question. We'll accumulate them and we'll just do this time to time. Like we did. I always think it's really fun. The weird stuff that comes out, like the bulimia acidic scenario. Um, maybe someday in Afghanistan, the war in Afghanistan, I have to bring that up. It's gone. Uh, someday I'll get on my pedestal and we'll talk about saliva because saliva is very, very important. Um, much more important than the genetic makeup of somebody, uh, in terms of the health of their teeth. So maybe we'll talk about that at some point, but yeah. Um, let's keep accumulating questions, keep listening, keep inquiring, and, uh, we'll be here to answer link to the Facebook group that we've been harping on.

The entire show is down in the show notes. Feel free to join, come, hang out and, uh, yeah, we're always here for free questions. All right. Thanks everybody.