Ep. 19: Q&A With Dr. Dan - Part 1

Part 10:00

This is Beyond the Arches, where full-arch dentistry meets real talk. Let's get into it. 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. Thanks for having me. Yeah, absolutely. So, yeah, 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 some, you know, a few good questions put together here. And you want to... You want to just kick it off? Go for it. Okay. Lay it on me. What do we got? We have some good ones? ▶We got some good ones. I always say, I feel like any of these could be their own episode, because there's so much to talk about with each of them. But yeah, I think these are... I think these kind of sum up the biggest questions that a lot of people have. And if not, and we get through all of them, I got a couple I could throw in there as well.

Okay. Let's do it. The one I wanted to kick off with, because I know you have a pretty cool story that goes along with this, is we had a gentleman named Brian ask about bone grafting. And of all the mysteries and dentistry and things that are kind of difficult for the average person to figure out, I feel like the bone grafting is a big one. Not a lot of people understand that there are different materials involved in that. I know you have a pretty cool backstory. So, what his question was is, is there an end-all, be-all superior material? Is it a case-by-case thing? Different people do better with different materials? What's your outlook on that? And is there especially one to avoid? Yes. So, that is complex.

A lot of these are going to be... Yeah. And this is going to... Again, this is my opinion. So, we're going to be going against what some people think, right? And I have different opinions than others. And we all try to filter and acknowledge the research as much as we can and use that to help interpret and improve that, improve our practice. So, I guess the first question is, what... To me, to you, back to you, is what question are you... Or what story are you referring to? Back when I was in residence...

And we went to the... Correct. Bank? Yes. Okay, cool. I've always been fascinated by that story. Yeah. So, all right. So, when it comes to bone grafting, the first thing a person should know is that bone grafting is essentially kind of holding a space or a bookmark for a place to be used in the future. And you're trying to tell the bone and communicate it in a way that says, hey, later on, we want to... We want to use this as bone. Or we want to use it now, but you could kind of hurry up and just become bone, please, right? And so, all of your goals and aspirations and materials that you use are fought from a position of, I want to make this bone in the future. I want to tell the body that this needs to be that, right? Sure.

And gum tissue grows... I'm going to screw this up, but it's somewhere in the order of 10 to 25 times faster than bone tissue. And so, what you get, if you just take a tooth out and you leave a hole, you will get a portion of that that becomes saved by the clot and becomes bone eventually. But you'll also get what's called an invagination of the gum tissue, an ingrowth of gum tissue. Why does it invade there? Well, because it grows a lot faster and it's trying to find the other side. Gum tissue is very cool in that it's always trying to find a partner or a place to meet in the middle. Also, a reason why, if you have stitches, the stitches are trying to get those wounds close together. So, they say, oh, it's my buddy's right here. I can seal it up. If you don't put the stitch in, it's got to do a lot of work to find it. And that's where you get extra scarring, et cetera.

So, when you're doing bone grafting, when you're trying to determine how you're going to communicate this message, generally, you're looking at the hole that is there, okay? And the best way it was ever described to me is when... Let's say you had a paper Dixie,

▶right? And you need to fill that with water. Well, obviously, a full intact cup can fill all the way with water, right? Perfect scenario for filling with water. But if you cut a side or a corner of that off, right, like a strip out of it, it's only going to be able to hold water up until that point, right? Likewise, if you cut two sides, it's even worse at holding water because there's a lot more patching and repairing you have to do.

Well, that's very similar to a bone socket. That's very similar to a tooth socket, rather. When you take a tooth out, it's not necessarily just this perfect hole. Sometimes the bone is a little bit weak and it breaks out, et cetera. And so, sometimes you don't get that perfect Dixie cup. And so, a lot of our processes to bone graft or seal that up are made with the intention of getting sort of that Dixie cup full of water, okay? Bone grafting specifically doesn't have osteoinductive properties, okay? So, osteoinductive means that bone forming, bone stimulating, okay? I'm blanking on the term, but there's osteoconductive, right? And that just means that it's hospitable to the growth. It's just not spurring it on. That's what bone has, bone grafting, any type of grafting material is mostly going to be osteoconductive, right?

The one that spurs it on, we don't have a lot of... Research on yet. And there is a little bit that comes along with grafting with cadaver bone and the way it's treated to expose certain proteins that give signals to help stimulate this bone growth. But it's mostly just there as a space maintainer, as a boxing out. Think of it like a basketball player. You heard the term boxing out. It's just saying like, hey, that's my space, right? And so, when you put bone graft in, it has to be really good at holding the space open for the blood to flow in and turn into bone. It also needs to be really good at breaking down and becoming what you want it to be. Otherwise, it's going to stay that long term. So, when you look at selecting bone graft and you're going to put it in this hole to build up the space, the less substance that your Dixie cup has, the more substance you have to provide, the stronger the material that you have to provide. So, let's just take a bovine bone, bovine bone is from a cow. It's processed in a very similar way as a human bone.

And when bone graft is processed, it's generally going to sort of just be reduced to its mineral content, right? And cow bone is very, very, very dense. It's very hard to flip over, okay? So, you're going to put that in there and it will, by and large, stay and be that bovine bone for a really, really, really long time. Well, that may sound awesome, because when you put an implant in, it's going to look like it's perfect.

But it's not really functioning like bone. It just kind of looks like there's bone there, right? And so, we can use it almost as like a deceptive technique to be like, oh, yeah, there's bone there, right? There is use for it, right? It provides structure, it provides that maintenance, that boxing out of the space. And it is important. And I use it in a lot of my sinuses. It's such a great material. But it's not perfect. It's perfect for everything. We want to stimulate bone in that area. I don't want my whole entire implant to be surrounded by that, because we can't verify until we see a big problem that that ever turned into bone. It just looks like it did, okay?

Okay. Interesting. On the other spectrum, it's called DFDBA, which is demineralized freeze-dried bone allograft, okay? And that's essentially, they wipe out almost all the minerals, okay? It's basically just a matrix of collagen. And it's very squishable. If you put it in a box and you squished it, it would give you a lot of space that you could squish it. And this is just like synthetic bone graft? I'm sorry. Yes, this is a cadaver bone. This is cadaver bone.

Oh, okay. Yeah, sorry. So, cadaver bone in the DFDBA doesn't have a lot of the space maintenance. So, it's not boxing out, right? And so, if you put a lot of pressure on, you're going to get a lot of dieback off of it because it's not really holding its own presence. An example of where you would want to use that would be maybe a perfect socket that is already its own perfect Dixie cup, and you want it to heal maybe a little bit faster.

Maybe you're using something as an additive, like a growth hormone or some sort of growth stimulating material. That would be a good host, like a sponge, to deliver that product into your body. So, that would be a good host, like a sponge, to deliver that product into your bone area, into that blood clot. Okay. So, where's the sweet spot? Well, the sweet spot and what I use is not demineralized. So, it's not the bone missing its mineral content. It's actually cadaver bone. And it's sort of 70% of the outer shell of a cadaver bone and then 30% of the inner shell. And it's sort of this nice mix where we get some good space maintenance and we get some changeover. And then we get some good space maintenance and we get some changeover. And then we just kind of get good results with it, right? And we know it's going to turn into our own bone.

It's usually around six months or so. Okay. All that being said, with bone grafting, when I'm looking at a space, I'm looking at it to say, can I grow bone there? What type of boxing out do I need? And how much of it do I need in that space as well, right? And is this an area that's so bad that I need to wait for it to grow? And I'm looking at it to say, can I grow bone there?

And let that bone grow and heal in there before putting that implant in, right? That answer obviously is very tricky. It's hard for me to even explain on that level, right? Or try to simplify it. But the take home is if I come to a spot and I say, whoa, that needs that much work, right? Then I'm going to have to wait. Generally, I'll find another spot. The goal, the goal is to find another spot. And I'm going to have to wait. And I'm going to have to The goal that you're after that you're trying to dig out of this person's jaw is finding spots that are held by the bone that's already present and already healthy. You want this as an additive measure. Now, when it comes to bone grafting, because I'm looking for those natural spaces and because I've done a bazillion of them, I can kind of see where I need to be putting them rather than finding out later and going, oh, crap, I need to put a bone graft.

Right. This is where some of the confusion comes, because if you don't have somebody that's doing that, they might say, well, I have, you know, I see hole I need to put here, right? When you put it in there, then you're going to create a bunch of problems where you need grafting, et cetera. ▶So I'm trying to avoid that day one or minute one. But one added benefit that we have in full arch is that once that structure is there with the implants seated in the jaw and the, and the structure, the superstructure, the denture is screwed in on top of that.

Right. We now have a nice, perfectly secured umbrella, right? And that umbrella also does part of the job of boxing out. Right. So in hybrid dentistry, you're a little bit cheating for bone grafting, which to go another layer further, a lot of patients that come in and have been pitched on a lot of bone grafting. It's not that it wouldn't ever need to be done. But you're, you're showing your, you're showing your experience by over prescribing bone grafting because you don't know how much you can rely on with that hybrid denture. And you don't know how to readjust where to put those positions, those implant positions. Right. So you're kind of saying, well, I don't really know. So I'm just going to blanket fill all these holes and hope that it comes out with enough. Right. Right. And so that's a, that's sort of an uphill battle.

That I, that I face every day because a lot of times I'll say, well, you don't need any bone grafting and we'll come in on a patient who's already seen someone and been told they need extensive work and 20 grand worth of bone grafting. Right. Well, yeah, there's a little bit of practitioner difference there, but there's also some experience different difference there. And, um, you know, price transparency is a big thing for us. We don't really care if we end up putting bone grafter in anything and we don't really ever charge extra for it.

Um, but for a lot of places that's like the add on, you know, that's the, that's the tire service that you can sell the patient on when once they've already committed to the car. Sure. And so you'll see it over prescribed one from lack of experience and you'll see it over prescribed from a financial position as well. Yeah. My approach has always been, look, I don't really care if this costs me $500 in materials. If it costs me $0 in materials, we're going to, we're going to find the space that is most appropriate for this patient. That's the most host natural bone to them. And if there's holes that I'm concerned about not being able to hold the space, then we're going to put it in there. Okay. So all that being said, I'll break down very quickly, the different sort of categories that you have of different bone grafting available to you. Yeah. So on the top, in terms of weakest and leading, I'm going to put it in there. I'm going to put it in there. I'm going to put it in there.

The least amount, uh, least able to box out the space, um, is that DFDBA it's very, very weak, uh, and serves a purpose for almost like medication delivery. You can kind of think of it as it's more stimulating. It's it's for growing bone really around directly around teeth. Okay. Next one down is you can get bone graft. That's made of all the insides of a cadaver bone. The it's usually out of a long bone. It's called trabecular bone, right?

Trabecular is that sort of fine stuff on the inside of our bones, like kind of the sponge. They crush that up. That's second down in terms of hardness, right? Third down would be the cortical mix that I use, right? I use 70% the hard bone and 30% the weaker bone. Right. Uh, you can get it all in the outside shell, the cortical bone. Okay. This is all cadaver. Okay. Uh, and then, um, lastly you would have, uh, what's classified as, um, you know, your bovine bone, your cow bone, right? And that's very, very hard, very, very slow to turn over and grow.

Um, and then on the other side, uh, you've got, um, beta TCP, beta tricalcium phosphate, which is generally just coral reef, essentially, you know, chewed up or ground up. Right. It works, you know, the it's amenable to the body, but it's got that same problem of the cow bone where it doesn't really turn over into its own bone. Right. So you kind of have this like stratum of things that you're trying to decide. Okay. So that's first part. How do you decide what to use? Well, you got to know what the use is and what the hole is going to look like and where you put that implant. And that's why you get a lot of different opinions. You know, um, the second part of it would be though, and that goes to the story that you're talking about is why specifically do I use, not only do I use what category I use, but also where I use it from. So there's a lot of the, I did you watch the mortician that the HBO documentary you did, right? Yeah. So there's lots of videos and content involved that talks about documentaries on, you know, um, grave robbers and different sources of where we get things just like you get with kidneys and hearts and all of that kind of thing. Right. There's certainly a gray market, black market, whatever you want to call it for, um, different bone banks. Right. And not all tissue banks are created equal.

Sure. Um, when I was in, at Virginia Commonwealth, we were able to take a field trip. It was the only trip that we were allowed to take that I can remember while I was there. It was, we didn't get to take many, but we got to take one and it was at the processing facility. Uh, it's called life net. It's based out of Virginia beach, I believe somewhere in that area, Virginia beach. And, um, I was just very impressed with that facility. Seeing that bone get processed, alleviated any of my concerns. And life net is one of the only ones that, has never really been in trouble. And again, I haven't looked at this recently, so maybe they have been, but as, as of when I chose it, there were really no tissue banks out there that hadn't been in trouble for some sort of not being able to source, not having their paperwork, et cetera, et cetera. And this place does all the way from double lung transplants and kidney transplants, et cetera, to long bone and, and, uh, they'll do, they'll do, um, sections of a skull, you know, craniotomy and, and they'll do block graphs for people that have, um, neurosurgery and things. So they do some really high level, big stuff. Dental's like the afterthought, you know, it's the, it's the straw that comes with the extra value meal. Um, but just their attention to detail and their level of record keeping and the professionals and the staff and the cleanliness of the, of the location, uh, really overwhelmed me with, um, just sort of impressed on me. Like this is the, this is the spot that I want to go with. And it's not an incredibly expensive bone as bone goes. There's other places that have different processes for cleaning it that are more expensive, certainly.

But I use the particular brand that I use because I've been there. I, you know, went in the building, I met the people, I saw the paperwork, I saw the, the freezers, refrigerators, the treatment facility. So, um, that was a really cool experience. So one of the coolest experiences that I had in dental school for sure, or all of my education. Um, it's really cool to see on the walls. They had a lot of different letters that had been written from you. You can in dental patients, don't do that. They can't, they're not going to fill out a paper that says, thanks to your husband, I have a tooth.

Right. Um, but you can, if you wanted to, um, but if you got a double lung transplant, specifically the one I'm thinking of was on their wall, they had a letter that was written from the recipient of the double lung transplant to the donor family, uh, of the double lung transplant. It's very, it was very moving, obviously. And I think it's really cool that they can put those people in touch and you can get that message to say, Hey, your grandfather did XYZ and, um, just a really cool, unique setup, um, that I haven't really been exposed to elsewise.

So, or otherwise. So that's,

Part 220:29

the very long answer to, um, bone grafting above beyond bone grafting. You also have, how do we, now we've kept the space open. How do we make sure that that gum tissue doesn't invade into the bone graft? And that's where you start getting into what kind of collagen goes over top of the site as well. And so sometimes you can get this really fancy. It's almost like a collagen leather that you can put on. It's called a membrane. Um, that further helps delineate the bone. Okay. Um, most of those techniques are when you're dealing with absolutely nothing to start, but still have a chance to grow it, or you have one tooth missing in that spot and you really need to get it back. So the stuff that, that we do in hybrid dentistry is sort of, I'd even call it kind of low level compared to what a regular periodontist would see or, or an oral surgeon, who's going to do some really big bone grafting to save that one place. And they have to, um, bust out the kitchen sink to make it happen. Whereas in hybrid dentistry, we have rules and regulations of how we want to put the implants. But within that, there's a lot of fudge factor that we can manipulate what is available to us and can use a majority of host bone.

Interesting. And then the membranes, there's different layers of that too. There's different options for that too. So yeah, different qualities you can get. Um, it's called um, non-cross-linked is generally just used to sort of help with the clot to form and sort of be there as like an artificial clot. Maybe it's somebody that you have that's, uh, been on aspirin for a long time and couldn't come off of it for your surgery or something. You're generally going to put that into that site so that it somewhat can develop enough of a clot to turn into bone and heal properly all the way to like cross-linking, which is essentially like a webbing, a leather.

If you will, of those collagen fibers, which can, can be really, really stiff or really, really wet. They have different handling properties. They can be really, um, loose and they can be really stiff. Um, and the, the difference in them and the thickness of them is variant depending on the manufacturer and the intention of use. And, um, what you're trying to do in that case is sort of protect the area, um, from the gum tissue growing in. So if it's a really big, really big, really big, really big, really big, really big, really big, really big, really big area, and it's very, very vital, you might want to use something that's a little bit thicker. So you get really good, healthy gum tissue on top and you get really good, healthy bone underneath. We don't use super fancy cross-linked membranes. We use a pretty simple cross-linked membrane in ours if we ever, um, need it because we're, again, we're generally being able to manipulate where that implant goes and alter where, where that exact position is.

Right. The gum tissue from growing in and, and depending on the thickness is what creates its longevity and its strength, right? So the, the more cross-linked and the more stacked layers you have, the longer it's going to last. Therefore, the longer your bone has to heal. Okay. That's interesting. Yeah. I always, I always found it fascinating. You know, you use tissue formers or what else do they call them? We use them. Yeah. We, we were just called healing caps.

You know, whatever. And if you don't place those, that gum tissue can literally overnight fill, fill back in. Like that's how fast. It's shocking. It grows again. I don't know the number exactly off the top of my head. It's like a quarter millimeter every half day or something. It's insane. That is wild. Yeah. Very interesting. Okay. Yeah. I've always found that, uh, I'm gonna look it up actually. Yeah, there you go. Always found the, the grafting and the, you know, that whole aspect of it. It's just, it's, it's for the average patient like myself, it's just kind of this afterthought, but you really got to know your stuff and know what you have to choose from and what's going to work best for each scenario. And it's just, it always, again, from layman perspective, it always, it's always impressive when you have that arsenal of tools and you understand it and can use what's right for each situation.

Yeah. That was like, of course you pick up a lot of stuff in practice,

Part 324:57

but that's the number one. These type of conversations are the number one reason why a person really should live a residency oral surgery or periodontics or ortho for what they're going to do and specialize on. Cause you live, eat, sleep, breathe it for three years. It's not that you can't learn it on your own. You can't, 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, um, can be very difficult if you don't know what you're looking for.

Right. And that I, that is the number one defining to me, you know, a general dentist can do the surgery. It's not rocket science can teach them to do it to 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, 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 that sort of feedback and insight. Maybe they don't understand all of the reasons and the nuances, but that's, that's why, you know, if I had a general dentist doing surgery for me, there are certain things that wouldn't be allowing them to really weigh in on because they just don't have that training. Um, but otherwise would be just an equal colleague, you know, besides those little nuance things.

Absolutely. Could, could go on. I mean, that's a topic that I spent three years trying to learn. Right, right. Let's move on to another one. Hopefully, hopefully I explained it in a simple enough way. Sounded good to me. Okay. Um, and I'm the king of layman's, so that's a good sign. Um, let me see which one of these. I really liked this one just because I don't think it's talked about enough and it kind of ties into another one. You know, we have another question, um, about dental insurance and, and why teeth are treated as cosmetic as opposed to.

You know, health insurance companies covering other health factors. But even before we get into that one, uh, another gentleman here, Evan asked, what are some potential health risks that are associated with, um, bad teeth with 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 the heart disease, but even beyond that, it can lead to just a host of problems that I'm not smart enough to rattle off. But, um, there is definitely a link between bad oral health and overall bad health. So any, anything you want to say on that?

Yes. For starters, um, I did just look that up and it is epithelial migration happens at point of death. So it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, 0.5 millimeters a day, 0.25 to 0.5 millimeters per day. I was about right. That's wild. Yeah. It's a lot. It is. It doesn't seem like much, but when you're in the mouth and you're only two, two millimeters separated, that's four days.

Um, okay. So back to the question. So the, um, it's, it's, it's definitely a, a very, it's not talked about enough, no doubt. And it's, 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 right even though I know it's going to improve things like sugar regulation for diabetics and wound healing uh it's going to help with heart disease um patients and with you know periodontitis can can end up systemically all over the fact all over sort of bringing the body systems down any system that flows with blood can can be susceptible to it so it definitely has a big big role and we we know it's not just a link we know it's uh there's some causation effects there's some correlative effects and that's you know important for the patients to know there's sort of two aspects to that question there's an acute aspect meaning like what can happen to me immediately with this infection here and then there's the systemic chronic disease type regulation type question right so the easiest would be to start with acute so you know if you have an active infection meaning bacteria caused the cavity that led to your nerve that then caused an infection at the bottom of the body and then you have a disease that caused an infection at bottom of your tooth and then you get a toothache, you have an active infection that's living inside of your body, right? Antibiotics are not going to fully remove that, right? They're not going to remove all the parts of the infection. They're just going to calm them down to the point that it's not getting any worse and it really, you know, alleviates the symptoms. But the splinter is still in the finger, if you will, right? So, from an acute phase, what we want to try to do is remove that infection. And the best way generally to do it, if it gets to that point, is to remove it physically, right? Remove the splinter, remove the infection, stitch it all up, and it's going to heal okay because our bodies are awesome. And so, there's an acute aspect to it. Just as an example, I don't do this often. Again, I don't like making my splinter. I don't like making my splinter. I don't like making my splinter. I don't like making my splinter. I don't like making my splinter. I don't like making my splinter. I don't like 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 he wanted to pay all cash. But it was going to take him another year.

Well, he had so much active infection, I had to stop him and say, listen, like, well, you're going to push this up. Like, I don't know if you have to just give me half now and then you can pay me the other half later and we'll finish you out in zirconia later or what we're going to have to figure out. But I would get that out immediately. Let's not just wait around for money, right? Right. It's to the point, 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 is vital and very, very important

Part 431:27

and necessary to us. But you're also putting yourself at risk of some major acute event, right? And acute events that can happen is that bacteria that's putting pressure on the inside of your bone and causing that toothache can essentially... It can actually erode the bone at a very high rate of speed. Sure. And when it does that, let's say, especially, let's say, a lower molar, when it does that, it can get into spaces. And spaces are, you know, it's not like we just have a body that's made up of just a bunch of muscles and the esophagus and all kinds of, you know, connective tissue and bones, like, all just smashed into one little space. There's sort of linings that sort of protect, there's walls, there's spaces that go in between every different sort of muscle.

That allow them to function individually, et cetera. And those spaces can get invaded by the pathogens, by the bacteria. And when that happens, it can grow sort of out of control and can travel very fast through those spaces. So when you see somebody that went into the ER and they ended up in a coma and they ended up dying from a toothache, you know, what happened there is the bacteria got to a specific place and generally what happens and got to a, an important enough place that it created enough bacterial growth to sort of swell and cause them to not be able to get any more air or gets into the bloodstream, et cetera. But one of the biggest critical ones would be like a lower molar creating an infection in a space that then closes off your airway. It's called blood wings angina. And it will close off your airway very quickly. And so we do everything we can, if a person can't afford to do the surgery. Now we do everything we can to essentially take those really bad teeth out as soon as possible. Maybe wait, right? Maybe let them have the, the, the, that space heal for a while. Maybe we did collect on the extractions, but generally speaking, we're going to credit them back towards the full procedure because we really just did it as a prep and for a safety for them. So on an acute phase, the best thing to do is to see us, to see somebody, to see a practitioner, to get it resolved. And then when you're talking about long-term effects, which I think is where more of the intention of this question is, when you're talking about long-term effects and its contribution to chronic diseases, you know, all of our systems are connected, obviously.

I'm going to make a blanket statement because I think it's what sort of exemplifies, gives the best example of what I'm trying to say here. So we've all seen an accident on the interstate, right? And what happens when you have an accident on the interstate? Traffic jams up, rubbernecking, right? And when that rubbernecking starts, you have a, a, a concern or the, or the, the emergency department has a concern that you're going to cause additional accidents, right? There can be an additional bad fallout solely because of this one bad thing that happened. Right. Well, um, the same thing happens in our bloodstream. Our bloodstream is like, a highway okay when we have little micro injuries like uh let's say cholesterol and invading into the walls and you have that stuck there on the side of the road okay if you will um that creates a point in which there's a constriction and then there's a flow of water you know not water but blood that's different than normal it's supposed to flow free and clear just like a freeway now we've got an accident on the side of the road it flows differently there's potential for further problems okay well periodontist or periodontitis rather specifically is an accumulation of bacteria it's like a bacteria hotel staying right on your your tooth right and you have um blood that flows along the inside of your gum tissue and so it's essentially just a an uber carpool pickup you know just comes right by and like hey you want to ride comes by and it goes to the big it ends up making its way to the full interstate right and bacteria in your bloodstream is not a good thing right bacteria in a bloodstream with an accident is really not a good thing so that's where you get your contribution to say like cardiovascular health right right because you've got the cholesterol that's sitting there on the on the wall that's the accident and you've got this bad guy coming along and he's like oh there's nobody after here so i'll just park here and so you've got this bad guy coming along and he's like oh there's nobody you get this sort of accumulation in this it's called turbidity it's where the the blood flow is kind of messed up afterwards after the cholesterol it's kind of like if you're looking at a river and you see sort of like this stagnant pool on the side you know stagnant blood is not good on the inside of the bloodstream right but you can also see the little swirlies that happen along the stagnant water in the moving water yeah that's turbidity and it's not the way that a river really needs to flow down a pipe or whatnot right and so you get that uh injury and you get that stagnation you get that accident on the side of the road and when you get that and your bacteria decided to hitch a ride on the uber blood flow stream you then can get attachment into those places and it gets worse and worse over time and that's where you get its effect on cardiovascular health and stroke and all of those things that are interrelated and so it is very very important and and it's not very hard for the bacteria to get into your bloodstream once it's established in that way periodontitis or uh an infection from a cavity that then goes down into underneath the tooth and so because it's so intimately involved in the bloodstream there are a lot of cardiothoracic surgeons doing heart valve replacements etc when they do that they send it out to a lab i when i was in residency at vcu i had a dental student whose father was a cardiothoracic surgeon and just off the record off the cuff we were just talking one day his his son was visiting me and he was visiting so we were just the three of us were hanging out and he told me a story that in the last year this would have been 2012 in the last year of his practice 2011 in the last year of his practice he hadn't set sent one sample out for i don't remember what it was probably a valve replacement but he hadn't sent one valve replacement out for bacterial and urologic testing that hadn't come back with dental antigens and dental signs that dental pathogens were in there yeah and that's telling right that's uh that that's really kind of like when a lot of that research was sort of emerging is whoa this is serious and that always stuck with me because that was he didn't need to tell me that that wasn't he wasn't on stage telling me

Part 538:30

anything he was just hey you know by the way this is what i'm seeing so it definitely has an effect you know keeping your mouth healthy and getting all of that out is important which is you know parlaying that into hybrid dentistry as we always do you kind of get a reset button on those you're disrupting every single hotel in the city so if you went and you put every business or every hotel business in boca out of if you took every hotel in boca and you put them out of business you said no more bacteria stay here there's still people that live here right so so you're still going to have issues that can pervade people that are staying in hotels become homeless and they live on the streets and they you know you're still going to have the potential for this to happen again but you're taking down the main structures that these bad characters live in by removing by removing the teeth or by removing the gum tissue that is the uber pickup at the airport right so you're getting essentially like a reset that doesn't you'll never have that problem way long down the road you always say you know hybrids don't get cavities but they can't get bone loss that's why there's no way to eliminate the bad characters in your town right but you can reset it and say hey we're going to start building this fresh and new we're going to get rid of all the hotels here we're going to build them all brand new none of the people that were living here can anymore we're going to start fresh that's what your hybrid is so you are removing the bad characters that live in your town and you're going to get rid of all the bad characters that live in your town and you're going to get rid of all the bad characters that live in your town physically removing a source of bacteria is sort of the number one and best way to to protect yourself from these big issues sure yeah we see those conversations a lot online um you know people want to save their teeth naturally their natural teeth but always correct me if i'm wrong but once it's progressed to a certain point really your best course of action is to remove that tooth or those teeth and as soon as possible because it's not going to get better it's only going to get worse so you know we see a lot of people that are like you said saving up look in the meantime if you if you need to go in and get your teeth removed and and wear a set of dentures until you can save up for implants like that's probably the best course of action because if you leave what's going on alone and let it progress not only are you going to lose bone but you run the risk of those major health complications it's just if if you're going to lose your teeth you're going to lose your if you're if your plan is to have your teeth removed anyway and and they're they're doing you harm try to get that done as soon as possible is my my my thought on it inflame the take-home is inflammation is bad of any sort right bad bacteria being next to your blood is bad of any sort and it has fallout all the way down the chain in the system where none of us are impervious to inflammation and we all have an immune system that's not going to work that's geared up and ready to fight it and sometimes the fights end up losing and that's you know how periodontitis works right it's your body and inflamed trying to fight an invader and sort of losing the fight it's there to protect you but eventually given enough time it will lose the battle to inflammation and inflammation is a store source and start of a lot of different diseases right right there you go interesting stuff um time wise think you've got time for one yeah let's do it okay let me uh i always got time okay oh man this is this is this could this could be a good this could be a long one we could really get into this but it's it's about uh sedation and and general anesthesia uh the differences between them why some people choose to you know do general or or the levels of different levels of sedation um iv sedation um there's a lot of um passionate um there's a lot of passion about look when i have dental work done i want to be out of it i want to be put under i want to um and and i get it right because it's a scary thought um and then there's uh some procedures that can take all day i saw somebody just a couple days ago over the week and i was like oh my god i'm gonna have to do this and i'm gonna have to do this and i'm gonna um they went in at 7 a.m to have a full mouth procedure done and they got out at 8 p.m it's 13

▶hours which just blows my mind and i don't know if you're supposed to be sedated for that long at a time i don't really understand how that works but that is like a big topic of discussion we did have alicia ask um if you could go into kind of some of those aspects um what your opinion is on that um and and and and and and and and and and and and and and and and and and and and and not being put fully under obviously we all see the articles of complications when somebody's put under and you know they lose their life or brain damage can happen so there's a lot of scary stuff you know on both sides but yeah uh getting getting your thoughts on that i think is uh is a good one so there's a couple things that we'll go very quickly and lightly over so i don't i'm not here to dissuade anyone that wants general anesthesia that they shouldn't get it you are you 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 right but for me as a practitioner there are several reasons why and and we're going to push general anesthesia and iv sedation both together okay they're different general anesthesia you're totally gone and iv sedation is supposed to be a twilight and i'm not here to dissuade anyone that wants general anesthesia that they shouldn't get happy time iv yeah from my understanding iv sedation and conscious sedation can really bring you to the same level of sedation depending on very similar prescribing yeah right so um so but we're going to push those off into two the same category anything to do with an iv there's several reasons big dental reasons why i don't use it i've often uh most people that want sedation and are very hardcore on i want to get iv sedation or general anesthesia are generally saying that because they haven't had a good dental experience right when you put them completely out they still haven't had a good dental experience right because they don't even know what they were there for right my my mission has always been to some degree give patients the understanding that it doesn't have to be horrible for one so give them a good experience and then you don't have to rely on the anesthesia certainly anesthesia brings on 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 right you if you break your hip and fracture your you know femur yeah please get knocked out but the 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 different 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 a we call them bite blocks but doesn't matter what it is but a nice piece of rubber that they can essentially relax and fall asleep on top of those two blocks on a solid set of teeth and because you can do that you then have a space to work in that is stress-free for the dentist involved right it's a space that you can actually accomplish what you want and so you don't need the patient's help right when you're doing a removal of all teeth on just one arch right you're removing that stable base yeah and so you have no placement that when you put to try to put a block in there it slips and it slides and it smashes gum and that's the issue that you don't want to heal negatively sure and so it's a lot of extra work and a lot of extra steps involved to get that into a stable position but then at the very best it's going to block half of your field of where you're trying to work right and so you end up working very segmented much more segmented that than i like to work i like to work globally and see where my positions are and we'll talk about that i think in the next upcoming episode is about where the screw channels go and how we decide with surgeon and general dentist but that gives me a global look that i can see so one i'm trying to give the patient a good experience and that's my guarantee to them is that 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 absolutely not even down the road when you when you look in our groups there's no one that's saying man i wish i would have paid that extra for that i don't know i don't know i don't know i don't know i don't know i don't know i don't know i don't know i don't know i don't know i don't know i've been in that situation you've ever thought dude really don't you've tried you might really need to get the job done in the공 but i didn't realize you were still trying knowing that told you i can't wait five months i got started going to tons and tons of patients n all of a sudden i'm back up in there you be like that doesn't rain on my car man you won't hear from boys i'm gonna go get my sick friend to go we've been in that situation if i'm not that kind of situation i just i'm going to get my too old을 and something went wrong, you hold it against me.

▶And so I always try to develop that bond together right away. The second thing is that once that patient trusts me and we get started on things, they can then understand it's not that serious and not that scary. And that creates a pedestal or a launching platform, if you will, to then take us through the next steps is, oh, they know what they're doing, et cetera. So it's a lot of, once we get the patient past the negative connotation of dentistry and we say, look, we're going to be your friends and we're going to help you along this process, the rest of it becomes easier for me.

And it's not about me having an easier job. It's about you want my job to be easy because 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. Like we don't, nobody works well in stressful environments. So I try to set the tone and it's calm. It's relaxed. It's easy going and it's simple. But what that get, 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 up the space and get me the location that I need. And then my job is made easier. Which gets their results better, which makes them better in the long run. Sure. And so if I can just get them over that barrier and get them to trust and understand that I'm not here as a bad guy, I'm not here to give them a bad scenario. Once I've won that battle, then the rest of it is, is automated to the rest of it is easy.

And so I never felt like not fighting that fight or, or just giving in to the IV sedation was anything of benefit to the patient. ▶It was always worth, it's always worth the fight to get them on board, to understand where I'm coming from. It's always worth that extra conversation to say, this is why I don't do IV sedation because your results are going to be better because you're going to be safer because you'll be in and out quicker.

Right. Surgical time, length of surgical experience is related to infection results. Sure.

Part 651:08

So why would you want to sit around for an eight hour surgery? Why would you want your, your dentist to be fumbling around in your mouth when you're not conscious? Why would you want to have a potentially life threatening episode happen when you're not aware? Right. My goal is to give you the least amount of life threatening episodes, which is zero, give you a good solution, give you a good smooth process, but also involve you to the point that you can start to feel comfortable so that you can start to have that sort of peace, et cetera.

Yeah. And I know that doesn't answer the question for the people, the frustrating thing is me saying I'm a good guy and I do really good work and I pick really easygoing people that also hold those truths to be their own identity doesn't alleviate the person that's sold on the general anesthesia, but the take home, I hope what can sell people on it 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 anything that's longer and has a higher infection risk because of it. You don't want to compromise your implants longterm. And I know for a fact I can get you through this process with no problems. I know I can get you through it mentally. I know that you're going to have a good experience. I know you're going to leave here feeling good about myself and my brand and the employees that we have and the other dentists that we work with and know that that's going to be fine.

You have to sort of leave that out and say, okay, now public decides. And that's where you get a lot, a lot of debate because none of that argument, is going to convince people unless they're a little bit open to the idea of thinking about it that way. 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. Sure. Absolutely. And to hear them tell it, um, twilight sedation is very, you know, there's always some, what, wait, you're awake through the, well, awake with, with air quotes around it.

You're awake. You're, you're, you're not unconscious, but you're also so relaxed and, um, kind of not even caring what's going on. You're really not even, no, I don't, it's very difficult to explain, but you're not really there until somebody says, Hey, how you doing? Uh, or, or Hey, open up for me. And then you kind of snap back to reality and you perform whatever action is being requested of you. And then you just go back to reality.

And then you just go back into this Lala land and it's, uh, it's most, most people are very, very satisfied with it. And, um, it's, it's worked out well for us. When you go under any type of IV based sedation, generally you're saying I'm okay with you doing whatever I, whatever you need to do to get this done. And so the environment just from you not being aware and not being there will become more viable. You're going to have to be more violent inherently because the job needs to get done.

And they need, they're going to be fighting you because you're gonna be fighting to sleep and they're going to be fighting to do work. Yeah. And because of that fight, you're going to end up with more trauma. You're going to end up with a longer phase of healing. You're going to end up with more bruising, more swelling, more things that your body is going to have to fight versus if, if we're working all in sync together, not to be all Kumbaya, but if we're all working in sync together, towards an end goal, I don't have to be traumatic.

I don't have to beat you up. There's going to be minimal bruising, swelling, and infection risk. Okay. Who doesn't want that? So again, once you get them over that hurdle,

Part 754:52

then you, then you get oral sedation warriors for life because they understand they've been through it and they understand that it's not as bad and it is what we said it is and all of that. So it's a tough battle. Um, but I think that, like you said, trust, but verify, look at the, look at the other people and their experience and what they're saying. Yeah. I mean, for me personally, I wouldn't, I wouldn't ever be willing to go under this and full anesthesia. I need, I might need some pretty heavy sedative medication and maybe I would need IV sedation because I know exactly what every sound is and everything. And I'd probably be so, particular about it. I'd be freaking out, but, um, I wouldn't want it. I wouldn't want to have to do that for myself at all. The, the, the other thing too is, uh, I was just thinking of it.

I lost it. I'll come back. I'm always real quick. I'm always, I'm sure you've seen like videos of liposuction surgery and they're just like random, violent. And I'm, I'm watching that. I'm like, I can't. I guess you have to be out for that, you know, for them to be that rough, but, and maybe that's required for them to be that rough. But then, you know, I just went under IV sedation for a second time in my life, like a week ago for a colonoscopy. And all I'm thinking is like, man, is that how they're going to be in there? Right. Probably. So I, I personally, I don't like going under, I don't like just the, the not being in control, um, you know, personal, personal preference, but I don't know. It's, uh, and then I'll be honest, you know, I, I wake up out of it and the nurse is like, Oh, everything looks good. A plus. Nope. Nothing to be concerned about. I'm like, okay, well, I'll talk to the doctor in a week when we do the follow-up and, you know, for sure. But, and I'm like, did they even, did they even do any, how do I know that doctor didn't just walk next door and go on to the next patient when I just spent this money and nothing actually happened. And I guess the pictures will confirm that. And I'm probably being ridiculous, but I don't know. I just don't like being unconscious while things are happening to me.

I don't know. Trust, but verify. And the easy grab is I want to be totally out. But the answer is you'll probably have a better peace of mind and a better experience. If you go with what we feel is the best, which is conscious sedation, it's, it's going to go smooth and it's going to be easy. And that's, I remembered what I was going to say is because we run as we do. And because it's a, it's a, it's a, it's a, it's a, it's a, it's a, it's a, it's a, it's a, it's a, it's efficient and it's smooth and it's predictable time-wise 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 get, start running into the next appointments. Right. Because we want to afford that patient time and, and length of sedation, sedative effects such that they feel that comfort. So we're, we're never on a tight enough timeline that we say, okay, you need to stop, and you need to sit down and we're going to get started right now. Slam the needle, boop, boop, boop, boop. Right. Because of the way that we flow our schedule, that's only made possible because it's not commanded by IV sedation. Right. 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 sort of fitting into those timelines, the way that they get scheduled, because they are longer because they do require more work with the oral sedation. We're never in a rush. So when that patient shows up and they say, oh, I'm not ready, we're not starting. We're, we're on a team. We're friends. Right. You know, I'm on their team just as much as they're on mine.

And so if they don't feel comfortable walking into the stadium, we're not walking into the stadium until they're ready. Um, and that's a nice thing. You know, we have a floating beginning time of our game, right. Versus it has to be a little bit longer. So we're not to start here. You're not ready. Okay. Well, let's go shove you out in the Coliseum. Yeah. Uh, and so for us, it's nice because we can get them to a level. 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 is allows us to keep on time with everybody. Right. And another thing I think it's worth pointing out is in our office, at least this procedure is done.

Pretty, pretty quickly. Um, and always in comparison with IV sedation. So you, and again, I've only had it twice, but my experience was you come in, you start the process of, of getting an IV set. And then there's, uh, it's a whole, it's a whole thing, right? It, it takes a little bit of time. Then they finally knock you out and you count down from 10 and then you're waking up and you have to recover a little bit. And then you have to go to a recovery room and then you have to go to a recovery room and then you have to go to a recovery room. So it's just like this entire process. It almost feels like to me, you can be completely done with the entire procedure from start to finish. And the time it would take in 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. Absolutely. So that that's always, in my opinion, worth pointing out is, yeah, if this was a 13 hour procedure, like, this lady had over the weekend, like maybe it's a, you know, you weigh your options, but if you're in and out in a couple hours, there's really no, no option.

Absolutely. That's why I'm, that's why I tried 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 a general anesthesia. General anesthesia is the easiest funds to get out of people. It's going to be this much. Great. Would you like to be fully out? Would you like to not have any worries? Would you like to blah, blah, blah, blah, blah? Yeah. Because you can sell it. Of course. Yeah. That's the easiest money you get out of their credit card. That's not why we do, why we sort of champion this fight, if you will. Right. We champion this fight because we believe that this is your best path. This is your smoothest, easiest, least psychologically overwhelming, best case results, everything.

▶And so I'm willing to lose a few patients over that because I, that's how much I, I believe in it. I don't, 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, et cetera. Right. And so that's why we champion that. And if a patient, like we say all the time, if a patient feels comfortable with a message from a doctor, with their experience and for the patients and the reviews that they've talked to, and they want to do general anesthesia and they want to do it the old way or whatever way that they're going to get, have it done. That's absolutely where they're going to be. And so I'm willing to lose a few patients over that.

This is not a, we're the only way that's right. Right. This is just my opinion and why we fight this fight. This is why I tell every periodontal periodontist that I interview to put your IV sedation certification on pause when it comes to stepping in my office, because I don't want that to be part of our culture because of the things that we just listed. Yeah. I'll say for every patient that that's a deal breaker for, there is literally hundreds who have had it done that say it was a breeze. Glad I went that direction. Glad I took their advice or listened to their instructions because like you said.

Of interesting note, I have never, I've interacted with a lot of dentists over the years of between being a lab, offering our services as a lab and all the different varying speaking engagements and things that we've done. I've interacted with a lot of dentists. I've never had one that does this surgery that heard that we do conscious sedation only go, you can't do that. They all go, yeah, I think that's better. I think that's the better way. And then they go, but your patient base doesn't fight for it. Man, you're lucky. You're lucky you get to do it on oral sedation.

I would much rather do it on oral sedation. Yeah. You can, you just say you don't offer it for these

Part 863:28

types of procedures. Right. Point being is behind closed doors. They kind of all agree with me. I'm seeing more and more come around to that, to that same idea. They'll always copy. I definitely, I definitely felt like we were the odd man out there for a while, but I'm seeing, I'm seeing more and more doctors come around to that mindset. One thing I can say for us at Dun & One is right or wrong. We try to vet out everything that 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 a gimmicky intention and purpose. We're here to provide results that give all of us a peace of mind so that you can market for it and go home and sleep so that the front desk can answer a couple of phone calls and go home and sleep. And we all feel good about the way that we treat people, the way that we work, the job that we did, the quality of the results.

▶And so every little aspect isn't just because we picked it out of a hat or because we're lazy. There's a very specific intention of everything that we do from the lines and the logo and the colors to the sedation methods. And, um, you know, I would encourage anybody that's a, that's a practitioner out there starting their own hybrid dental business or any dental business for that matter. Pick what, pick what you believe in and fight for it. Fight for it till the end. Don't just give in to it. Don't just give in to it. Don't just give in to it. Don't just give in to it.

Don't just give in to anesthesia because everyone else is doing it. You're going to lose that race every single time. Right. Amen. Uh, I think that's a great point to, to, to leave off here. I will say this might require a part two Q and a part one here with Dr. Dan Noorthoek. Uh, I foresee, uh, uh, a part two coming up. So appreciate your time. Thank you for, for being here. Thanks for having me. Yeah, absolutely.

▶We appreciate you joining in to be on the arches and we will see you next time. We'll see you soon.