Ep. 27: The Patient's Guide to Full-Arch Maintenance (Part 2)

Part 10:00

This is Beyond the Arches, where full-arch dentistry meets real talk. Let's get into it. Hello and welcome to another episode of Beyond the Arches. I'm your host, Dr. Daniel Noorthoek. Today, we are honored to have Erica with us and Dr. Hauer. So, welcome guys. Appreciate you being on here. This is going to be a part two of a series or a couple episodes on maintenance of a hybrid, both in the day-to-day and in the long-term residual care in terms of routine scheduled maintenance. And so, we're going to try to cover what we're looking at and all of the different aspects that go into sort of our position and sort of the industry's position on how often things should be cleaned. But we're going to do the part two today is going to be revolving around frequently asked questions. And so, Erica here has compiled a list. And so, we're going to go through different questions that may come out through things that she's exposed to. And of course, we'll have conversations in between, but we're going to keep it to mostly how does maintenance work. We'll probably touch a little bit, I would imagine, into warranty and how we see the world and the system and why we've set things up that way. Right. They kind of go hand in hand, I would say.

Yeah. You can't separate the two. No. Warranty and how long things last and how well we're taking care of it, both daily and on scheduled maintenance is definitely a huge integrally connected piece. I would say so. Basically, just kind of give everybody a general idea of what to expect when they come in for a hygiene. Because these are some common questions that I see. We would get asked on a daily basis as far as consultations

▶go, patients in the office, what is hygiene going to look like? How long is this appointment going to take? How long do I have to stay in? Et cetera. So the first thing that I want to ask you guys is kind of what does a regular routine maintenance look like in our office? Time frame, what exactly is done? Are any parts and pieces replaced? Yeah. So our philosophy is that patients are always going to be with us. So we're not just placing these implants and then the patients are off on their own way. So patients will come in at a year and that's when we first remove the prosthetic. There's many reasons for that. Well, first of all, we want to make sure that the implants are in place. So we want to make sure that the implants are in place. So we want to make sure that the implants are in place. So when we take x-rays, we take it about once a year and this is our hygiene appointment. And we look at things. We look at the teeth, look at the gums, and we look at the implants and the screws. You can't really get the whole story just looking at an x-ray. So you want to be able to see clinically and understand what's going on. And we want to be able to see clinically and understand what's going on. So you can best diagnose health or disease and just provide the right maintenance protocols for our patients. What would you say you look for in the tissue levels? Do you remove the arch? Yes. So once a year, we actually remove the arch. So all we have to do is access the four screw holes. It could be more, but usually we place four implants. We want to see healthy pink, almost coral pink like tissue. We don't want to see red, angry tissue. We don't want to see anything that's separating.

That's angry. And sometimes we can't tell what the tissue looks like. We need to remove the teeth, which is why we need to see underneath. Sometimes tissues are great and healthy. Sometimes they can have problems maybe because screws are loose or maybe because a component is not in the right place. Whatever it is, we have to be able to see to diagnose. And that's critical. And in addition to that, once we have the teeth in hand, there's parts of the teeth that you can clean well and parts that you can't clean well. That's just the reality of full arch. So if we can provide that then that's just a true cooperative relationship. You know, we put in our part, you put in yours at home and we can give you the best hygienic set of teeth so you can maintain everything.

Yeah. And we try, one of the reasons why we kind of do it once a year is many people that end up losing in their teeth isn't for overly taking care of them. And that's not to be in a dismissive or a rude way, but generally speaking, if you exhaust them and say, Hey, I need to see you every three months, which would be bad for the teeth. And then you can maintain everything. And that's just teeth. But if you said, Hey, I need to see you every three months, that's going to be too exhausting of an interval for them. And so once a year kind of comes to a nice balance where it's not going to overload their system and overload their schedule, but allow us all the safety of knowing that things are being taken care of well, that there isn't anything broken or warping or any type of negative thing happening biologically in their, in their mouth, right. And in terms of their gum tissue.

So that gives us a nice checkpoint is it's the key is sort of to not exhaust the patient with a ton of visits and a ton of work, but it's also to, to get some sort of physical interval and some sort of checkpoint, which even discussing this. Yeah. And I would say just as the industry as a whole kind of develops in, in hybrid dentistry, a big change that I've seen over the last 10 to 15 years is that when we first started doing these, the offices that I was exposed to, we never even talked about taking care of them afterwards. And many patients would show up two or three years later after not being seen and then maybe have an issue and would be sort of shocked that we even needed to see them. And I, so I think that that's a big step that the industry is taking forward. Maybe it's through competition and people bringing it out to light, but you know, these do need to be maintained. Implants still function in the human body.

In a way that needs to be looked at and taken care of. And so providing that message and getting that out, that's something that we discuss with every patient and something that I'm proud of with the way that our system works. But just as an industry as a whole, I think people are coming out of their consultations, regardless of where they go, they're coming out with a better knowledge of how frequently they need to be looked at and, and sort of a knowledge that these aren't fail proof. Right. I think we make it very apparent.

At least during the consultation, we definitely discussed the coming back for one once a year for cleanings. But it does seem like maybe some prior pasts or patients who, you know, didn't really pay attention in their consultation. Sometimes they are shocked that they have to come back and actually have like cleanings done. They're like, well, I think I thought this was the end all be all place. You know, you kind of come here, you get your dental implant work done and then you leave or you go out of town. But as you're mentioning, you know, just the regular daily brushing, daily water picking. Sometimes that's not enough because that's kind of surface level. There's more going on underneath than you can even see.

I think one of the things that's misunderstood by the dental community is that implants are a lot different than teeth. And, you know, the cornerstone of maintaining teeth when you're a patient who has your teeth is maintenance. You know, people that have periodontal disease are being maintained usually in a minimum every three months. Now, implants are different for many reasons. But I think it's important to understand that there's a lot of difference between implants and prosthetics. You know, there's a lot of different reasons, but they're actually harder to clean. They're a foreign object and they have a different tissue attachment that's not as firm. So the cornerstone of keeping teeth is maintenance and so is implants and even at a higher level. And when you have a prosthetic that's very difficult to clean, that's just the reality of Full Arch. We have to be on the same team and it's just of utmost importance.

Yeah, there's a touch and a communication aspect to it that's a little bit intangible as well. And that's why we highly recommend our patients, even if they're from out of state, that they come in to see us is that you get that touch point, you get that continued relationship build, because this is a long-term relationship and a friendship in many ways. And one of those aspects is in terms of getting that relationship to stay established. You kind of mentioned, and I'm sure we'll talk about to some level, the decision of adding gum tissue and relining the zirconia prosthesis. Part of that is a, is a relationship. So there are patients who are insistent on, they need that, that gum tissue to invade and push really hard into the, into the, their existing gum tissue, because they want absolutely no gap and that's fine, but they need to know the risks that come, come in along with it and what they're putting their system at risk for and finding that balance and striking that balance. You know, Blake and I, as periodontists, we really want, I always tell patients, we want that space to be there. We want that space to be there. We want that space to be as wide open as possible because it's going to allow you to more effectively clean. When you hide that away, it's harder to get to that, those areas. And so finding that balance of what is going to be the appropriate amount of gum tissue is a very personal experience, whether it's three months after your surgery and you did it the traditional way, or did it on a more accelerated protocol like our, our own, regardless of what your professional's belief is, it's very important that you work together to find that and strike that balance.

Like that was actually going to be my next question is that, do you guys have a preference where it comes to where the zirconia prosthesis kind of meets the natural gums? Because that seems like it sometimes is more in the patient's hands. Sometimes it's more in our hands. We kind of come together, I think most of the times and, you know, come to an agreement. But some patients just can't get over that feeling. Yeah. And that's, that's a real, the reality is we don't want this to be a procedure that the patient goes through.

At an expense of the patient goes through to be an encumbrance on their life. We don't want that to be something that they constantly, constantly obsess about. And so, you know, even if it's little bite things, this is another reason why a maintenance is a great, because if they've got something that's just a little nuance that they want adjusted, that may not be worth making a special trip for it gives them something to kind of get to where you can then say, sit down and adjust the bite. Some, some, in some ways that they may have discovered going home, that's different or whatnot. Maybe like in a particular area or a particular space, that's specifically giving them some trouble. Yeah. So maybe the bite is adjusted on paper very nicely. And at the first glance, it was fine, but working together to get that better adjusted so that they're more comfortable and having that touch point is very important.

Same thing with deciding where the gum tissue goes. We want it to be as healthy as possible. So you mentioned, where is that mark? So as a periodontist, like I already mentioned, we want that to be as big of a gap as possible. Big enough that you could drive a semi through it. And there actually was a,

Part 211:08

there was a prosthetic known as a Montreal bridge, Montreal high water. Have you ever heard of it? It was essentially a hybrid. It was a big bridge that was on implants that they did for a while. And it essentially, it had a belly to it instead of an entirely, it had an underside that called the belly. And it would, they would separate three, four, five. I forget exactly how far it was. It's a very old school technique, but they would separate on, and it was on the lower arch. So it didn't affect the speech, but there was essentially nothing coming even close to touching the gum tissue for hygiene. And so we want to obviously strike a balance. We want some, some comfort level of comfort to be there. And obviously the comfort to, to some degree was still there on a Montreal bridge because there wasn't any food.

It wasn't stuck in it, but we want that comfort to be there. So it's all about striking the balance with the patient and informing them of the risk of if we do this, you're going to invade and cause some inflammation. And so just to explain to patients what that differing level could, could alter. It's a lot like if you were to just stick your finger on top of your fingernail for, for five days, right? It's not going to be pissed off because it's just sitting there on the fingernail. But if I was to push inside up, up into your cuticle for five days, it would only take about three hours before you're pretty good and angry. And you can imagine that there would be some redness and some inflammation around that cuticle. And that's what basically is around the, the implants is essentially a cuticle. And so we can't invade that for too long because eventually that gum tissue will get very irritated.

Yeah. I think one thing to kind of circle back is that that's a key part of our maintenance is when you come in once a year, we'll evaluate how does the teeth, the pink area line up to your actual gums. And for obvious reasons, you want to have space to keep it clean, but we're on the same team. If we see that there's an area that needs to be relined, we'll do it. And, um, it's always a balance between you keeping it clean and how you feel and function. If you feel that there's a space there, that's kind of preventing you from, um, doing the right cleanings, whether it's affecting your skin.

That's something we'll definitely change. But I think Dan really, you know, talked about it well, that you, your ability to clean it is number one. Absolutely. I think it's kind of interesting because it's somewhere along the lines of the surgical procedure itself. And then all the way through restorative for you guys to all kind of work together and figure out what the appropriate space is going to be because the first week the patient's there, they're going to be probably a little bit still swollen, probably still a little bit irritated from the procedure itself. So as they're working through the restorative, they're going to be a little bit irritated from the restorative team. Um, they kind of, you know, try to assess everything and see how, how it would fit the patient the best. But sometimes when the patient is still swollen again, um, it's just kind of tricky to kind of find that happy medium. What's right, what's wrong, what's too much, what's not enough. Um, so sometimes it, it's not really able to be assessed until the one-year hygiene when that patient is fully healed, all of the tissue has settled down. And then from there, we kind of see both sides. We see that sometimes the zirconia needs to be treated.

It needs to be taken back a little bit, but then we also see when relines need to happen when some material needs to be added. Yeah. And that isn't, that adjustment is always just very minor tweaks for quality of life. It's not major tweaks to the prosthesis. So do you have a question in there about, um, did you come up with a question at all about relining the prosthesis or should we address it now? I don't have one specifically. We can address it now. Well, we can address it now. So when, when we used to have a prosthesis, we used to have a prosthesis, we used to have a prosthesis, glue the gum tissue into the surgery. You would see drastic gum tissue changes over that three months. One, because the acrylic is porous and would hold bacteria. So it didn't heal quite as nicely or as, or as smoothly. The second reason is that we weren't putting a lot of foresight and thought into the design of it. And so you would generally see this massive difference between the temporary to the finals. And one of the biggest benefits of going into a final after three months of a patient dealing with a temporary was improved soft tissue adaptation.

And so you could think of that as the difference of a centimeter, right? We'll just throw a number out there for a measurement. And so you see these wild changes, we'll say up to a centimeter, which it wasn't. But by comparison, when we're talking about tweaking and finding and striking a balance, we're talking about probably a difference of two millimeters, 20% of that centimeter, right? So. So we're not talking about these big, massive sweeping changes that we used to see when we're doing our digital design. One, one thing that's been a huge benefit is we're incorporating our, our book of knowledge and our experience with our designers into how we want that to heal. And so we're manipulating and adjusting that healing in the way that we want, almost like a cast, like I always say. And so our gum tissue is going to heal in a, in a healthier position. It's going to heal in a, in a better position, and it's going to be more likely to be exactly adapted to where we want.

The nitty gritty is that long-term, how do things finish? How do, how does it actually finish healing? How did the gum tissue actually get along with the ideal position versus well, how they ended up healing and working that nuance out is what we generally will address in that year. And that's where that relationship comes to strike that balance. And, and to, to add to that, when, when we used to, do different materials, adding and stacking material on top of it was not as much of a chemical bond. It was more of a mechanical retention. So you would have to cut essentially grooves in to add material to it. You would have to treat it in certain ways. And a lot of times it didn't, didn't stay long-term. So when we first started doing these and it was an acrylic based on top of a, of a bar 10, 12 years ago, the old way, you're going to get a problem with relining or adding material because that's really just kind of locked in there in position. And when you get any sort of flex, it's going to break that mechanical bond and cause that to separate. So when we talk about adding and changing gum tissue, what we do is we're adding the pink porcelain in the same way that we would add it to the gum tissue when we're doing the original processing. And it doesn't really hurt or change any of the factors or the integrity.

The strength, the look or anything of it. And so we're just literally just filling in that space. And so adding material, adjusting that gum tissue, one is a very quick and easy procedure, but it's no longer a mechanical thing. It's really an integrated, it becomes an integrated part of that arch, an integrated part of that person's prosthesis. So there really isn't any compromise to adding. It's just a matter of will these gum, will these gums in this implant complex stay healthy?

Mm-hmm. I would say a real line. It's probably one of my favorite things that we have to offer just because it's so routine. It's so simple. It makes the patient feel 10 times of a difference, whether, you know, we're taking away, adding whatever it is. But it's so quick. It takes like two to three days typically at the lab. The patient's still wearing the temps, so they're comfortable. They're not going toothless or anything like that. We give the teeth back. They look exactly the same way as they did before we took them and sent them out. But the patient's not having, these same issues.

I have a question. So on read lines, is there a limitation to as many times you could, I guess, treat a prosthesis? Yes. Generally, it's one or two. Then you have to remake the prosthesis. But in that scenario, we would just scan the gum tissue, incorporate it into the digital file and remake the whole prosthesis. So that's why you don't want, you want to make sure that the patient and you are on the same team in terms of which direction you're going to go. Because if you do it after, do it more than once, you're going to end up having to remake it. Pretty much, we just work that out with the patient. If it's something that's really, generally, if you're on your second read line, you're talking about really splitting some hairs. And so most of the time that kind of goes to the patient in a just, hey, this is a little bit over the top. But sometimes it can happen where we just end up remaking it. And that's kind of goes into the warranty, which we'll talk about.

Or what we did talk about in part one. So that doesn't need to be covered too much. But yeah, you generally have one or two. I've only seen it in super severe cases where anybody's needed over to like when they maybe have a medical condition that has to do with like bone loss. And they're like actually suffering from that, unfortunately. So we try to help out there as much as we can. I would say the average patient usually just needs the one itself. If they need it at all, it's typically just one unless it's another.

That's a good point. Yeah, we have seen that a couple of times. And just like we always pitch and tout, et cetera, it comes to a relationship. You know, if a patient's been very pleasant to work with and they have a medical condition or something, we just remake it.

▶I think so. So as far as cleaning and everything else like that goes, do you guys have preference? What would you advise a patient? Do you like an electronic toothbrush? Do you like a handheld toothbrush? Do you prefer? A water pick over super floss? I'll start. You can finish it. So for teeth themselves, just as an FYI, electric always trumps mechanical. For a hybrid, I'm kind of indifferent to mechanical versus electric as long as it's effective. The reason why is when you're brushing teeth, you're actually brushing. We'll go back to the cuticle example. You're actually brushing.

That cuticle to keep it clean. The connection between your hard tissue, which is your nail and your soft tissue, which is your cuticle. And so that is important that it gets thoroughly brushed and taken care of and mechanically debrided. When you're using a toothbrush in the mouth for a hybrid patient, you're more or less surface cleaning that. So it doesn't really become stained. You're kind of helping disinfect the area. You're not doing anything to help rebuild or connect, reconnect any of that soft tissue to hard tissue. And in general, the soft bristles, even if it's a super soft bristle or whatever toothbrush you're going to use is really hard to get to where the implants are located.

And so for me, I don't make a big delineation versus electric versus manual, except for if a patient wants to ask, I'm going to recommend electric over, but a mechanical, is totally fine. If a patient goes on a vacation to Europe for two weeks and they end up using a manual toothbrush, it's not going to put anything at compromise. The one thing that you can have an issue with is long, long, long term. This surface is like glass. The zirconia we'll say is like glass. You can scratch it. If you use say a wire brush, you know, use a hard toothbrush. You can scratch it and cause an area that will be more prone to staining.

So it's important that you still use a softer toothbrush, but it's not in terribly or as terribly important as it is for brushing regular teeth, electric versus manual as it is for a hybrid. So with that being said too, do you also have a preference on toothpaste? Because during the consultation, we do sometimes speak about the abrasiveness kind of tested toothpaste between your finger test. See, you know, if you feel any little grit, try to stay away. Is that the same kind of example?

I would say, you know, on teeth, toothpaste is actually, you know, meant to promote remineralization of teeth and has fluoride components really for full arch. None of that exists. So I would say if you want to use toothpaste to have that fresh minty feel and to have something that, you know, tastes like you're brushing your teeth, a very, very small amount is okay, but you don't want to be grinding it very hard because the reality is any toothpaste can be abrasive, whereas the brush isn't.

I think the key there is just like Dan said, you know, keeping everything clean, avoiding staining. ▶And for me, I think the number one is using any type of water irrigator to clean the intaglio, which is the undersurface of the teeth to the gum tissue. We used to talk a lot about abrasiveness, which, so I'm glad you brought that up because I've kind of gotten away from it. The surface of the zirconia is such that abrasiveness really isn't going to come into play, but there are toothpastes that are unnecessarily abrasive.

When you get a whitening toothpaste as a general rule, when you get a whitening toothpaste, what they've done is taken their toothpaste formula and they've essentially added different particles of sand. And that pumice that's in there is abrasive enough to take the surface stain off of your teeth. Well, in zirconia, we're not going to have that issue. So getting anything that's 3D white, super oxide white, et cetera. Is going to have that pumice is going to cause more abrasiveness for absolutely no reason. So to Blake's point, you want to select if you're, if you're in the toothpaste aisle selecting, you want something as a general rule, being more of a sensitivity toothpaste, a sensitivity toothpaste, isn't going to necessarily have that abrasiveness to it. So in an ideal, perfect world, we don't need that abrasiveness to make it white. You already chose your color. You just need to keep it from being stained. And so we want to use something that's really streamy. So we're not going to have to use something that's very, very, very, very, very, very, in the hand. So if you were to test two different piece, uh, two different like piece of, of toothpaste in your fingers, and you would be able to feel one is going to be more abrasive than the other, right? We would ideally want you to use something that's more slimy because the practice of using a toothbrush is just to kind of disinfect and clean the mouth, but it's not to scrub really anything off of the surface in a hardcore way. We want to just keep it clean. Um, you're not adding any sort of abrasiveness to make it more white. It's already that white. You just need to keep it clean. Is there anything that patients can potentially put inside of their water pick tank, um, to help with any of the underneath kind of buildup, anything that helps on that end? Some patients like to put some peroxide. I've also heard some like non-alcoholic mouth rinse. What is your perspective on that? So as it comes to water,

Part 326:25

picks and super floss to touch on the super floss thing, I super floss works fine. And it's a great way to get underneath any sort of bridge. If you have a regular bridge, it's a great way to get underneath it. Great way to get it sort of mechanically to bride and get the stuff away. That's loose and kind of in the way is certainly is a, an effective way to loosen things in a hybrid. I don't necessarily push super floss as a daily because it, at some level, it's going to become so inconvenient.

That's what I was going to ask if you had a preference on, because some patients do say it's kind of just, it's, it's one other extra step that you have to do that they probably did not do at all before the procedure. Um, it can tend to be kind of a pain because you do sometimes, sometimes the prosthesis is really tight. So it is difficult to kind of get that super floss through it. So I know we typically don't touch on it too, too much in our office. We do like it.

It's not that we don't. Um, but we, I think, for water picking, right? Yeah. If, if I'm asked what the, and obviously that's the point of this conversation, but if I'm asked what the absolute preference is, sure, use it. But, but it's not something that I'm going to push on you to add to your routine, because I don't want to push anything that's going to encumber you and cause you to do something else that I consider to be of more value less often or less thoroughly. So that's kind of how I see super floss is use it for big stuff, maybe have it on hand, try it. If you want to include that in your daily routine, that's totally fine. It would certainly not dissuade it, but some people are going to have some tough spots. It might be a little bit touchy to, to do it. Uh, it might be even difficult dexterity wise to get it done. So it's not anything that I really, really heavily push on patients, but then as a substitute, we will use water pick and a water pick is really your, in my opinion, your number one go-to option.

Our tool to, to keep things clean. Why? Because it's going to be able to irrigate and get into places that you can't get to. And you want to prevent, we call it biofilm. When you want to prevent bacteria and food for, from collecting on the underside of this area that you can't really brush and get into. And so water pick is going to gently irrigate and rid yourself of all of that stuff. Is there something that goes into a water pick?

Not necessarily. Other than the recommendation is add whatever you would like. You know, you could, you could add a mouth rinse into it. You can add salt water into it. If you're feeling like your gums are sort of irritated and swollen, you can add as, uh, um, an additional step, anything that you want into the reservoir. And while I'm on the topic of, of reservoirs and water picks, I like my patients to always be on a sort of desktop version, if you will, of the water pick or something that is in line with the water pick. So if you're feeling like your gums are sort of irritated and swollen, line with the, uh, shower, because you're going to get the volume of water, the volume of lavage, if you will, through that space versus the more portable ones. I don't really like those. I know it's a big popular thing with Facebook because you can take it with you, et cetera. I'm okay with that as an add on as well, but I'm not, I don't want that to be the number one quarterback of, of what you're using to keep that irrigated because it's smaller amounts of water. And so it's smaller bursts. It's not as strong. And, um, you can use it when you travel.

That's fine. That's great. But I don't want that to be the number one water pick. That's always your, your convertible. If you will, I want your daily driver to be something that sits on the desktop that has a relatively big reservoir that has the difference in the pressure that you can change, et cetera, versus being relied on like short little bursts that may not get to where we want. And we're not pressure washing with a water pick. We're, we're not cleaning the water pick and we're not cleaning the side of a house. Like I always say, it's, it's, we're just irrigating it.

You're just trying to flush that area of soft particles. When it gets to a point that you've left it long enough that it becomes hard. That's where the maintenance comes in. That's where we have to come in and get that off and fix you as a habit person, you know, as, as you fix your habit and make it so that you're getting it better. We want to be able to attack this when it's still soft and when it's still there. So daily cleaning, where the water pick is very important in terms of an additive, we're working actually on something to be an additive to water pick, but it's one of my projects. Um, but long-term what we're going to have is essentially, uh, something that will be, uh, a pack that they can add to the water pick as a, as an additional thing that's specifically formulated for, for a hybrid, but what that will exactly be and what that will exactly look like. It'll probably be some sort of subscription as a tack onto the wife.

Time warranty. Um, but that's something that's actively being worked on. Um, but not quite ready to discuss any further. Yeah. I'm excited. It's something that will help peace of mind. And this is, this is such an, we always talk about it, but this is such an intimate personal journey for everyone. The expense, the travel, the who is going to do it and the selection and the, how am I going to take care of this long-term and who's going to be there for me? And what am I going to do? And where do I get this?

All of those answers, you want to try to, to bundle up and be as, as comprehensive as a system as you can such that, you know, let's, let's just take the water pick additive as a, as an example. It's not about the water pick additive doing anything other than making it so that we have less problems. Less problems means that my employees are less encumbered and we can treat more people and people will be happier with it. And so that's really the focus of everything here.

Absolutely. Um, with that being said, so on the contrary, have you ever seen where patients over water pick or over brush or anything of that sort? Um, just like, you know, have, has anybody come in stating my tissues are kind of getting raw? I'm kind of bleeding. Am I doing something wrong? Not to the frequency you may expect. Okay. There are patients that will get obsessive about it. One big thing that can happen, um, is I've seen it quite often in, in patients that have early onset dementia or some sort of dementia, they start to get very obsessive about cleaning something that doesn't exist.

You know, maybe it's that they're feeling their, their implant connection in a certain point. And there is no cleaning that because it is a hard fixed structure. They can get very obsessive about it and start to use instruments that we wouldn't tools that we wouldn't recommend. And so the main take home is that there isn't a lot to worry about in terms of a patient hurting something. So long as they're using the right tools and the right tools are some super floss, a water pick, not at too high of a pressure and a toothbrush with soft dish, or I would say maybe even medium brushes or bristles are kind of okay. They're not in your own teeth, but they're kind of okay. And a hybrid, the, the main thing is that there isn't a lot that they can hurt with those instruments. Um, what, what, what, what, what, what, what, what, what, what, What we normally see as a fallout from, you know, a patient being too aggressive with something is they're using something they shouldn't.

They're getting in there with a toothpick or their sister-in-law had a pick that they got when they had a random bridge from another person in Costa Rica or whatever it is that they may be using. If you go outside of the toolbox that we've given you, that's when we see issues. I will say I've definitely heard a few patients complain about some discomfort from the water picking, but usually it does end up coming from the level of the pressure, which is obviously where our favorite quote came from, is not to pressure wash your gums.

So I do think sometimes it happens. We see it. It's not super, super common. Typically doesn't cause any bleeding or anything, just kind of some tender areas. And most of the time, if they just back off, it'll resolve itself. Yeah. And so if you're going to turn up. Your water pick, it's for that one particular thing. And if you can't get to it and it still is an issue, call us or call your provider. If you if you do get it, great.

Turn that sucker back down because you don't need it like that all the time. Yeah. Yeah. Have you guys ever seen any kind of crazy patients who didn't think they needed their teeth cleaned, kind of had their procedure done, left, you know, out of town, out of state? We haven't seen them for the. Last two to three years, they came back into our office, haven't had a local cleaning done. What would that patient's mouth look like? Yeah, I think, you know, if you want to look all holy hell, if you want to look at anecdotally, look at literature, you know, anything, it's very obvious that with better maintenance, you're going to have better results and we have to be able to recall our patients.

So the patients that are more likely to have problems prosthetically or implant related. Are going to be the ones that we haven't touched base with, you know, diagnosis is everything and you just have to be on board for maintenance. So those patients that are erratic, noncompliant and don't come back are typically the ones that may have issues. And you even mentioned earlier, Dr. Howard, that sometimes the x-ray isn't the end all be all kind of tell all to the story.

So if a patient does go somewhere, sends us a local x-ray to check everything out, looks like it's OK from there. Sometimes it's not. What are some things? That you would find physically going on inside rather than being able to tell it from the x-ray? Yeah. So just to rewind a little bit, I think it's a good segue is, you know, we're sort of in an interesting spot in full arch where no one has a true consensus on when do we remove these things?

And I'm going to quote the 2016 consensus statement that's made by the ACP, which is the American College of Prosthodontics. What they say is that the removal of a fixed screw retain implant prosthetic. For example. Evaluation is not needed, and they only recommend it for signs of peri-implantitis if the patient can't clean or if there's mechanical complications. Well, the problem, as you said, is that peri-implantitis, which means that you have a issue with the implant that affects the bone and the soft tissues.

Sometimes you can't diagnosis on an x-ray. Patients may have symptoms, but the x-rays, a 2D image or even a 3D image with a CT scan, there's a lot of scattering artifacts because of the abutments. And because of the restorations, so for us to be able to see what's going on, it's, it's critical to be able to take these off once a year and look under the hood per se. And I guess your question was, what are you looking at once it's off?

So we want to make sure from an implant level that there's no active separation, there's no bone loss, and there's no, you know, excessive gray showing through the implant, no signs of bone loss from a prosthetic level. We want to look at the abutments. ▶Which are basically the connectors from the implants to the teeth, make sure those are healthy, those aren't loose, those are screwed down. And then as we talked about before, we want to catch any prosthetic problems with the actual teeth and make sure that the contours are okay, maybe realized needed, maybe there's too much material.

So all these things come into play, we're going to re-torque screws, we're going to clean, take x-rays. And I think another important thing about this is we're going to talk about oral hygiene at the visit. What are you doing to clean? How can we be on the same team to, you know? You know, guide you to maintain things better. And also if you're in the office, there's an opportunity to talk about medical history. What has changed? Are you taking new medications?

Are you now, you know, maybe you have a new diagnosis like diabetes. That's important for us to know so we can look at you from a different lens.

Part 438:34

Mm-hmm. Yeah. A way I kind of think about it is, you know, I've been, I was a lifeguard when I was really young. And so we went through basic life support, CPR in there. Mm-hmm. And then we went through it all in dental school, and we went through it all, and we have to keep doing it, et cetera. And in theory, I could do it, you know, obviously it makes changes occasionally along the way. But let's say that it's, for the most part, it's kind of stayed the same.

In theory, I could perform CPR from when I was 14 until now. And probably could have retained that information the whole time. And maybe by the research, I didn't need to go to that class. But because of the bulk of everyone, and because we know that things fly out of the window in terms of memory and such, just like truly being on top of it, there's an interval that we're supposed to go get recertification from, regardless of whether or not we know.

Why? Is it because you or the bulk of the public will lose that information? No, it's a refresher. And so this, when we talk about maintenance at the one-year interval, I think it's important to understand that. ▶While I may be able to perform CPR at two years out and five years out from the last time I took the class, it's still important to get that refresher and to get that little touch point because it just makes things better.

And we don't want to touch it too much. We don't want to alter, again, the schedule. And we don't want to alter the materials there. We don't want to put too much pressure in and out on the screws. We don't want to overly financially burden the patient. But we want to find some sort of... We want to find some sort of happy medium that allows us that refresher course, refresh the CPR knowledge, refresh the oral hygiene and things like Blake was talking about.

And so for us, that one-year interval is important because it's sort of very easy and reliable to look at. It's an easy interval to be able to tell if something is going south. And so to touch on your point, have you ever seen patients that come in after not being seen? And I'll tell you that... The attitude was that once you put somebody in a hybrid, they will fail eventually. And when they fail, they're going to fail so catastrophically that they won't have very good options to replace.

And so as a general whole, hybrids weren't really pushed in my education. It wasn't anything that we really learned. And this is just 10 years ago. Well, a little bit more, but around 10. And what I've seen throughout the process is... Kind of where we started this was that I've seen this become a bigger part of the conversation. And so being a bigger part of the conversation and being part of the responsibilities on the patient, they are more responsible and therefore take care of them.

And we have better materials that can last longer. And so I'm seeing when we have a problem, we're able to jump on it, fix it better, fix it more efficiently for them, and also kind of keep them in something long-term. When we... When I used to... When I used to see bigger catastrophic issues, if you will, it came from the group of patients that were getting treated and maybe spent $100,000 on it, but were in two or three different offices.

There really, really wasn't a consensus on how often they should get cleaned. And when that dentist, good or bad intention, was explaining or telling them about the procedure, there was no responsibility put on them for cleaning. It was just pitched as like the most ideal, amazing thing ever. And then they were using materials that had a tendency to pick bacteria up. So where I've seen really big issues is patient disappears for forever. Material isn't that great for guarding it against bacteria.

And so it used to be like a lot of acrylics on top of a bar. And that's when you see like whole prostheses coming out and smelling like a dead person, to be honest. It was... It's horrific when you see it. But things have improved to such a level that if... If you can impart on that patient the responsibility and what their role is and lay that out in the very beginning, and then in tangent use a great material that will perform and be pretty resistant, if you can get those things, two things to hum and go in line, that's why I've committed my career to this is I don't see that as being a big handcuff.

I can always pretty much get us out of it in a very black and white way. Absolutely.

Part 543:14

I would say so. Even when we see patients who sometimes do go local, for a cleaning, which is something that we encourage if you're not able to get back down to Boca, you can go anywhere that's, you know, nearby your house, kind of get it done. We do still recommend that the arch does get removed. We do prefer that rather than it being cleaned like hand scaled or anything inside of your mouth. Just because like Dr. Hauer explained earlier, we can check under all those like gum tissues, check on all the abutments, make sure they're nice and tight.

They're doing what they're supposed to be doing. But do you ever think it makes our job... a little bit more difficult kind of going in after someone goes to get a local cleaning? Would you see any problems when people go get a local cleaning with like maybe a general dentist's office who's kind of doing this patient a favor because they've been going there for 20 years, but now they've had a full arch procedure completed and they kind of go there just because it's convenient?

Sure. Excellent question. For those watching or listening, generally, I don't put anyone that I have on this podcast up to any sort of big schedule and list of things that I want them to say. So Erica was on her own to come up with this list of questions. And that is an amazing question. Thank you. Really, really good. When it comes to... Thanks, guys. That was really good. When it comes to... How do I put this?

Just let it out. Let me think of it first. Let me tell you what made me think of asking you that question. So the other day we saw a patient. She did not have her zirconia done by our office or she did not have her full arch procedure done by our office at all. Totally had upper lowers completely done. I don't know if it was four implants. I want to say it was six on the bottom, six on the top.

She's coming for us. I'm sorry. She's coming to us for something that we call a refresh, which is actually where we go ahead and remake the zirconia. Kind of freshen everything up. Check on her implants. Something we'll probably talk about in another episode as well. But she is coming to seek treatment with us. She let me know that while she was in the office, she wanted to have one of her access holes filled. ▶If you don't know, an access hole is one of the screw channels where we access the implants and kind of screw in the zirconia or screw in the temporaries.

Just make sure they're nice and secure. I guess that's the correct thing. Okay. Well, she actually stuck a piece of orthodontic, like wax into her access hole. And it just about made it impossible for the girls. I almost felt bad for the clinical team that I grabbed to kind of help this patient out just temporarily while she was in the office for a few minutes. I was like, hey, she lost one of her hole fillings, which if you have a full arch, you know how frustrating and annoying that is.

Cause it's kind of like a little circle hole that your tongue kind of. You can have sharp edges. Yeah. Your tongue kind of bothers with it, finds it. She stuck a piece of orthodontic wax into that little hole. And I was like, Oh my goodness gracious. She's going to spend the next 30 minutes trying to get that out of there. Absolutely. The, the part that I was struggling with, with addressing to begin with was.

Part 646:30

I can understand the preference of major centers or anywhere saying you have to come back here for me to ensure this work that I put in. I want to be the one that has the touch point where, and I understand that. Where we've diverged from that and allowing other offices to touch it. If, if a patient can find said office to address it is in the change of materials and the switch over into zirconia. Zirconia is really, really, really, really resistant to abuse, if you will.

And as such, when you're accessing those access holes, you, when you are going around, in a, with a burr in any other material ever, it can open and widen before you even blink. And that can hurt the processes and the longevity and can really make it intolerable to the patient to wear. So any sort of plastic, any sort of nano ceramic, since we've switched over into zirconia, we kind of think that it's unfair for a patient to be locked into a location.

You know, 90% of, of who, who, and what we see in Boca is from out of state. And while we want them to come back, we realize that there needs to be a system or an avenue or a release valve that they're able to go in a pinch, go local to Washington, somebody in Washington state. And the switch in that material is what has given us that confidence because a person can touch it without really ruining it.

If they're even somewhat competent, they're not going to ruin our prosthesis. And so they're going to get that look in that check. It's, uh, more about, we don't want the work that's in there. If the whole point of taking it out is to make sure that it's intact, you don't want to ruin it in the process of opening it up. And with a nano ceramic, you almost risked that prosthesis every single time, or a, or an acrylic, you almost put that prosthesis at risk because to some degree, anyone that's a dentist that's listening to me will, will understand what I'm saying.

When you would have a hole in the acrylic. Right. And then, um, let's say it was a bar with a denture teeth on it with acrylic, the filling material, the resin that goes in there is almost harder than the outside, the acrylic. So when you would go in with a burr, you would kind of almost accidentally hit a trough because you, it would just run to wherever it was softest. ▶And so you'd write minute one, you don't make this whole like around and hurt the dent, the denture of the teeth.

So Zirconia is not that way. So we can get into it and clean it out. The other negative. That came from those materials being so soft is we wanted an easy way to retrieve without hurting it. And so there was a lot of different methods that we used to use. We used to use temporary, uh, endodontic root canal filling. We used to use impression material here and there. That was a little trend for like a year. Those fell out and didn't really keep the area clean.

Cause you also want it sealed so that it can stay clean, but very long story short is a good question. That's the reason why we don't mind if somebody else sees it, because. They're still, they're going, they're plenty competent to check to see if the implants. Okay. If not more critical than we will be, because they're going to be trying to look for something that we did wrong. Um, but they're going to be more than confident to not hurt our prosthesis and not put things at long-term risk, which is why we're okay with it.

Versus another office that may not be because they haven't taken that leap of faith. But, um, in general, it's very hard to hurt those access fillings and hurt the whole four. And so as such, that's why we're okay with other people saying, I'm kind of fascinated by your answer, because I never thought it had anything to do with the zirconia itself. I always thought it had to do with the implants. Right. And I wouldn't blame you. Right.

And that's why I said it was a really good question because it's not, it's a very, very nitty gritty reason why we're okay with other places touching it. Um, that's just very like accidentally or intentionally insightful because, um, that's generally why. I never. I never would have thought about it in that direction because it's always more so just what kind of implants do I have? Do they, does that office have the proper tools and nine out of 10 times they do.

Yeah. The, the screws that, that hold the prosthesis in, in most offices that are going to be okay with seeing another person from another location of any sort, they're pretty much going to have those instruments. The other thing is if they over tighten a screw, those screws are made to some somewhat be a. ▶Shearing pin, a safety factor to not hurt the implants once they're fully healed. And so even if they, in the worst case scenario, they're going to break a screw and a patient ends up coming to us that they, that a problem that they created, isn't anything that's irreversible.

I don't want to give a patient over to somebody that's irreversible. If you've got a high finesse procedure, you know, if you've, if you go for an orthopedic surgery, that's a knee replacement and you go to a general practitioner. And they could make it so that you end up losing your leg. That person doesn't want you to be seen by them. So it's all about retrievability and reversibility. So we're at a point with our materials and the way that the screws and the implants are built out.

You're not going to cause generally, you're not going to cause any implant problem. What you would cause is a prosthesis problem. And since that's resistant, we don't, we don't find the big need to get real particular. Yeah, that totally makes sense. I just never thought of it in that direction at all. Yeah. It used to be so soft, like scary. Very soft. Wow. I had a, there was a dentist a long time ago that was, um, had all of his assistants remove those screw holes, uh, those access fillings before he would come in.

And I remember there was an assistant that was brand new and she came to me. This was when I worked in Jacksonville. She came to me and she said, um, I can't find the screw hole. And I came back and the whole thing was essentially just cut in half obliterated. Just. Like 18 different holes. Yeah. Should have gotten me like 50, 50 minutes ago. Um, so those are the reasons why you would want to prevent that versus, um, versus the way that we use it now, the materials that we use now.

Part 753:02

I think, you know, to kind of summarize where we're at is the big question is, you know, what is real maintenance look like in the office? And just to kind of break it down, cause we've been talking about a lot of topics. It's coming in once a year, having your prosthetic removed. Yeah. Having an updated x-ray done, looking at the gum tissue, looking at the abutments, making sure everything is torqued down and screwed down properly, um, cleaning that prosthetic as well.

And in addition, this is a great opportunity to diagnose from the doctor's end, any biological implant related or prosthetic tooth, um, or above and related to complications. And I think another thing we should talk about is what are the nitty gritties from our staffs in? And what are we doing for cleaning? Are we using irrigation? Are we brushing? Are we flossing? You know, what goes on in the office? So on our end, um, it's usually pretty quick, pretty simple, pretty easy.

Um, I tell patients it's about a 90 minute appointment, give or take a little bit, you know, maybe an hour if we're really quick that day. Um, but usually about 90 minutes, so it can be pretty thorough. The zirconia does get unscrewed kind of to put it into layman's terms, just because this is the way. I was. Explain the way that I explain it to other people. Um, though we take the zirconia out, we place it into the ultrasonic kind of in this bath, um, kind of get it all shaken off.

Any calculus that has built up over the year, over time, get all that cleaned up. We check on the gum tissues, check on the gum health, make sure everything looks nice and nice and healthy, nice and pink, um, teeth get put back in screws are correct me if I'm wrong, but assess on an as needed basis. We replace them if they need to be. And this is not the implant. This is the screw that goes into that access hole, um, the shearing pin, kind of like we talked about the failsafe, they kind of get replaced on an as needed basis.

Sometimes we do, sometimes we don't. It just depends on the integrity of them. We give you back your teeth. We close everything back up and you're good to go. ▶You're on your way for the next year. Just keep doing what you're doing or take the oral hygiene advice that was given at that time. Um, we do provide a few aids, not many. We actually don't provide our patients with a water pick, um, but we do aid. We do advise on kind of how to go about that.

We always say, you know, Amazon is like our favorite store. There's tons and tons of options. Sometimes it is kind of a trial and error to figure out what you like and what you don't like. Um, we do try to kind of sway everybody in the way of what Dr. Dan was saying earlier, as far as the desktop water pick, but for learning curve and learning purposes, sometimes that travel one is cool because you can kind of take it into the shower.

Um, if you've never used a water pick before, it's the messy. It's the messiest thing ever, especially on the first time when nobody explains to you what the heck to do. Your whole entire bathroom is soaking wet. Um, so just for learning purposes, sometimes we do advise the travel one, take it into the shower, kind of get in there. There's also one that, that plums in line with the shower. What? Yep. There's one that literally goes in line with the shower head and it hangs down as a hose, like almost like a sprayer.

That is crazy. I haven't heard of that one. Um, I do know that a lot of patients. Also. Like we try to advise, but they like that one water pick head. That's kind of curved just because for accessibility reasons, like there's a, there's a few water pick head options that come with the whole pack. Um, but there's one in particular that we really like, and we always advise it kind of is shaped like this. It's shaped like a hook that way you can kind of stick it in there.

And it really gets from like, Uh, from, from the inside out. I don't know how to explain. Yeah, it gets around the corner, kind of around the corner in the best way. That way you can get all angles nice and clean. Um, I don't know if you have any questions or comments, but it's really, really helpful. Um, however long it takes, but. That's pretty much it. Yeah, absolutely. Do you have any other questions on, on your list?

I have one last question and no, I always like to save this question for last or this topic for last, but as far as fees go, what is the fee for a hygiene appointment? And how would you say it's expensive? Would you say it's affordable? Would you want to put this in line? I mean, our lifetime warranty covers it. So I think that's incredible.

Part 857:13

Yeah, we've tried to make it so that for us personally, we've tried to make it so that it's fair and reasonable to the patient. So, of course, over the grand scheme of things, we're going to be making money. So there is a there is a fee involved. It's not ten dollars. But we intentionally have made it not accessible or we've made it accessible so that if you've done this procedure, it shouldn't be an encumbering expense that adds on top.

There's lots of places that one one big sign of whether or not the office wants you around is what their cleaning fee is going to be afterwards and really their interval. And I always tell patients, if you have if you go to a place that tells you more often than once a year, meaning six months. Number one. One, run away from them. We don't talk about on many offices and there really aren't that many that recommend it.

But if you recommend every six month cleaning, the research and the consensus is really clear that we don't even need to take this out. We only do it for touch points and making sure things are OK. ▶More often than once a year is either a cash grab or they don't really know what they're doing and they're just doing it like they would a human, a regular person's teeth. Or they also don't know what they're doing. It's too much pressure on.

The system is too much in and out on the screws is too much fatigue in these materials. And so we want once a year. We don't want it to be financially encumbering or be something that is is too big of a deal. And and to sort of summarize the point, there are locations out there that may be charged seven hundred an arch or a thousand dollars an arch or thirteen hundred an arch. That is not because they do a better cleaning.

It's because they don't. They don't want you to ever come back for cleaning. They made their money on doing the procedure. Now, any problems that you come in with, they want it to be somebody else's. So we've tried to position ourselves where it's fair to ourselves. We're in the market as a very fair, reasonable price and send a clear message that we still want you to come here. Yeah, absolutely. I have some closing remarks. Take care of your arch and Dan will take care of you.

Done in one. Done in one. Done in one. Doesn't end. When you leave the chair. It's really good. Well, we appreciate everybody's attention for part two of our maintenance series, if you will. And we look forward to talking next week. Thanks, everybody. Thank you. Thank you.