Ep. 7: Why Surgery Should Be Boring

Part 10:00

This is Podpopuli, podcasts for the people. Hello and welcome to another episode of Beyond the Arches. I'm Dr. Daniel Noorthoek, your host, and with me today, the pleasure of introducing Nadia Davis. Welcome, Nadia. Thanks, Doc. Nadia is my original surgical assistant from my first job out of school, first day, first interview, first all of that. I pretty much taught him everything he knows.

But we have Nadia today with us, and today we're going to be talking about why surgery should be boring, why it should be straightforward and not be overcomplicated, and how if you make it boring, it'll go well because it's a lot more straightforward, it's simpler, and there are things in it that need to be complicated. It's complicated, obviously, because it is a surgery and should be performed at the highest end possible, but will be sort of, should be straightforward and boring.

And probably, luckily, Nadia's passed here. Well, I'll let you tell it in terms of, yeah, just how you've worked with me in the past and bring it up until we got to work together again last week. Let's see. It started back in 2013. Yep. We started with teeth in a day cases. I think they were converting them same day. That was chaotic. Yep. Absolute chaos. And how long was it? ▶It was about seven years you worked with me?

Seven years, yeah. Six, seven, something like that. And then you went to another office and started to do the teeth there? Correct. So worked with you. Yep. No surgery, strictly surgery. No restorative for seven years. Yep. And then got a little interested in restorative dentistry. I was still interested in surgery, and I did surgery. I started out in surgery. But restorative dentistry with Full Arch had just changed so much. It was so interesting that I started doing that.

Since we're talking about surgery being boring, did you like the idea of the teeth maybe being a little bit more straightforward and a little bit more? Easy of, like, what to expect? Like, as far as what? Just making the teeth look good. And did that seem simpler, or was it just the fascination with the results-driven kind of thing? Yeah, it was because I got to finish the print. So I got to finish the first set of teeth that the patient saw.

So I got to be part of, like, that wow factor for the patient. So that was huge. Yeah. That kind of pulled me in. Surgery doesn't have a lot of wow. It does. Sometimes it does. It has a lot of ow. Yeah. No, sometimes it has some wows. So you worked there. I called and begged you. I tried to recruit you first. And then you're like, give me some time. And then you called me down. ▶But, yeah, worked there for, what was it, two years?

Two years or three years? Two years. Something like that. I've been here now for almost three years. Yeah, which is wild. Yeah. And now you still do teeth. And you're hard. It's like pulling teeth to get you to come do surgery. No, it's not. We had a little window where you were my surgical assistant for a few more minutes. Yeah. In Tampa. A couple more days. Yeah. And so that was really fun for me to be able to work with you again.

Because it was actually just kind of like falling back into normal habit. Yeah, like we didn't skip a beat. Yeah. So that was nice. I was nervous at first. I was like, oh, man, it's been a while. Yeah. So did you feel a big difference? Have you felt a big difference in the change? If you look back at the 12 years or so that we've worked together, did you see a big change in the surgery becoming more straightforward and boring?

In yours? Mm-hmm. Yours has kind of stayed the same. Yours, I haven't seen like a huge change. You don't remember the days where I was sweating? I mean, I remember those days, but it was case by case, right? Like if there was a really difficult extraction. But for the most part, it's... Been very similar steps. Yeah. And those steps are really important for making sort of a complicated workflow that could go anywhere, kind of stay in the middle.

You know, if you're going to make, let's say, bread, and you don't have any instructions in front of you, it can kind of go anywhere. Now, you may know how to make bread, but the timing and the different iterations and the way that things flow in STEM, can be a little bit overwhelming in terms of when you're making this bread. And so it's helpful to have a recipe that you can then veer off of, right? I mean, we've all followed a recipe, and we've all kind of gone off of it a little bit.

But if you have that recipe that's sort of straightforward and sort of stepwise gets you through everything, you can get things a lot more efficient. And that's... I've spent most of my career, I would say, looking at the last... Surgeries. We used to take a lot of pictures. Remember we... Yeah, that was my favorite part of it. Took thousands of pictures. Looking at them, what works, what doesn't work,

Part 25:39

what's a little bit more overwhelming for patients, what's underwhelming for patients. I mean, not to be, like, overtly graphic, but one of the biggest things is when we essentially, as you know, we clip the bone down just a little bit, and it's really... It's been vilified in the world, but it's really... Essentially just clipping the nails off, right? It's just the little portion at the top that's going to die anyways. And in that clipping, most of your, we'll say, mainstream techniques and how to do it involve bone saws or burrs that cut the bone, which require irrigation, which when a patient is sedated, sort of overcomplicates...

I found that it overcomplicates things. Yeah, and it extends the time of the surgery. Extends the time of the surgery. Unnecessary. You get extra water, and it's uncomfortable. Yeah. And loud. Patient feels like they're drowning. Yeah. It's a weird little thing, but when you're cutting that bone, there's still blood vessels that work in there, and so you used to get a lot more... I used to get a lot more bleeding when we would use the water. I remember that, yeah.

Because you kind of nick little veins and arteries that run through the bone, and instead of the way that we do it now, which is with essentially nail clippers, when we clip that, we're sort of crushing the bone together and keeping that blood supply sort of intact and in the bone. And that's just one of the ways that we've sort of simplified things. Because now when we do it that way, we don't have to interrupt our surgery because the patient's choking on the water.

We don't have to calm the patient down because they feel like they're drowning or being waterboarded. At all costs, we try to avoid surgery being anything that is any experience like waterboarding or any sort of torture. Yeah, I think... The patients appreciate that. Yeah, and so keeping that surgery sort of boring, you know, when I look at, say, Dina now, or I look at you in the past, it does look a little bit boring. You know, it kind of has turned the surgery portion into somewhat of a root canal, right?

And that's a big thing that in the professional world, oh, you want to go to specialty school to be a root canal guy? Like, how boring will that be? But for us, keeping it straightforward allows the patient's personality to vary and us still to get very similar results. Like a more ideal outcome. Safer. It's been a fun career, and you probably, of all people, have seen the most change out of me in terms of techniques and such.

I know you've worked with a couple other surgeons, and so... Yeah. Yeah. Yeah. Can you think of an example, or can you give an example of another surgeon that makes it a little... What makes it a little bit more hectic, or why is boring... When I say the word boring surgery is better to you, what does that mean to Nadia, being the person that's sort of first-hand experience? So it's just... For example, one of the surgeons I worked with, he would do his full-arch surgeries with...

What is it, in sequence? ▶And so it was like a stackable surgery, and it guided the surgeon on where to place the implants, how much bone to cut down, where the teeth are going to be, so you would think you would have this perfect outcome. Yeah, because it's like Legos. Yeah. Yeah. It's like putting pieces together. But what we found a couple times, it was always strange to me, because for you, you were always like the chef in your kitchen, right?

Like you set the stage and whatnot. And so in this doctor... So in sequence is driven by, I think, labs. I think they come up with the whole game plan from the ground up on how much bone you're going to reduce. And we don't even know who's planning it. Like if they know about anatomy or if they even care, like the sinus is right here. So a couple times we ran into the situation. I think it only took two times for it to happen before they just pulled the plug on it.

Or the implants were still sitting halfway, like outside of the bone. It's like... Oh, after placement. After placement, after reduction. So it's like you've already, like, what's your saying? You measure twice and cut once. Sure, yeah. Yeah. So they've already, like, you know, measured and cut. And I guess the measurements were over by a couple millimeters to where the implant was sticking out. Yeah. Yeah. So then it just kind of like it throws off the whole surgery.

So he kind of sat there like thinking.

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And I looked at him and I was like, like, why don't you just freehand it? ▶Like every surgeon that I've seen freehand it, you and the one that I worked with before you, it was freehanded and it was, it always came out more ideal. If freehanding allows you to really be able to make the decisions and know that you are the quarterback and have to make the decisions, you are the person in charge, you're the president or however you want to say it, and having that control may be concerning for some, maybe if you don't have the experience.

But for me, it was always empowering. And for most, for most guys that I know that guys and gals that do the surgery that I know most of them would prefer that decision making be in your, in your court. Because if, if one thing goes wrong and you have a seven step process that is reliant on that, those seven steps and that first step is wrong, you're, you're in trouble for the rest of the way. Thank you.

Did you ever find that you had a patient or, or a, a, a person that you worked with, a, a surgeon, did you ever find that if they were freehanding, we'll say, that they ran into any difficulties with getting the implants stable and in the right position because they didn't necessarily have a system. They didn't make it sort of a boring, sort of diluted down system. Some, sometimes, like there was one, there was one that his technique was different.

Also, different types of surgeons, different techniques, periodontist or more. Oh yeah, you had, you had a, a surgeon that you worked with one time and didn't he do all four sections of the mouth instead of, Yes, at different times. He would do like upper right, lower right, upper left, lower left, because it would, I don't, I guess it was kind of like cutting hair. Like you, you cut this side first and then you kind of like guide you.

Try to match it to the other. What did that look like in terms of the symmetry? And now that, now that you could look back and think towards it, implant positioning. How did that relate to sort of what you would do today? You know, like how, how would that have affected your job? How would it have affected my job? Well, like if we're not reducing enough bone or if like the AP spread is off. ▶No, I'm saying more like if I was to segment my surgery in that way and didn't have the same system that I did, how would my, the results change by doing one section completely different than the other in terms of.

I mean, it would make for probably a lopsided prosthesis, depending on like bone level, how they. Position of the screw and all of that, right? Yeah. I always found that when I was looking, because when you start doing these surgeries, you want to be able to treat them in a very, we'll say like regal professional type way, right? You put on your white coat and you go, wow, this is the most expensive thing that will ever come through this office.

And we've really, we've really got to sell the case and we've really got to break it down and really have to treat each individual site like it's ready for an implant and all of that. And I always found when I did that looking at each location separately instead of being global more intricate in a way when I would do that, I always found that it was really difficult for me to get even the right positioning, but I also found that it was difficult to get even the implant.

Solid because you would adjust it and say, oh, that's not quite right and micro adjust it. And by changing that, you sort of loosen the bone that's holding onto the implant. And I see, I see when I've trained other officer, other offices, other surgeons, other people doing this. One of the first things that I look for is how much messing with that implant are you doing once it's in, you know, in our world, you don't cut that hole until you know that that's where it's going to go.

▶Because that bone is really important for holding me in the implant screw. And if you constantly are messing with it and you're looking at it and you're changing it, you can really complicate things because then you take that smaller implant, which is then wasted because you may not be able to use it. You have to get a bigger one out, spend the money on getting the bigger one out. Now you've kind of ruined that area of bone.

So those are, that's sort of the decision tree that a lot of people go through. I see. And they, they, in essence, they kind of handcuffed themselves by over overcomplicating it to me. But this was a surgeon, so they weren't dealing with the prosthetics afterwards. So I think that's why, that's why I was like, I'll just put this here because this is where the bone allows me to put it. And they were not thinking about, yeah, that's a good point too.

And yeah, getting, getting the surgery to be boring required a lot of cases and working with, with a lot of the tooth type side of it. Right. Getting, getting, getting surgical results that were boring and getting a surgery that was boring was dependent solely almost upon understanding where those teeth go and what are the things that get in the way, et cetera. It's, it's kind of wild when you look at it, you read in the textbooks when you're going to school and such like crown down, crown down means you, you want to think of where that tooth is going to go first and then you think of say the abutment and then you think of the, the anchor underneath and you, you think in a crown down way.

So you are thinking of the final result and trying to envision and picture where everything needs to go. And it's, it's wild because you read it and you go, yeah, of course you would think of where the tooth goes, but when you're in the heat of the moment, when the bone breaks on you and the patient's struggling to,

Part 416:21

to be a good patient and good, well behaved patient, it can be difficult to sort of think through that. And I think getting the system down and getting it. So it's very repeatable. I think it can be scary to people if they just listen to the words that they are, which is, I want this to be the simplest, straightforward surgery possible. And I treat everybody the same. Everyone kind of thinks, well, I'm different and I'm unique and that's scary to me.

Why would this guy treat me the same? Like different, you know, if I have a cold, I take different vitamins, et cetera. And I understand that completely. But when you're dealing with something that's so carpentry based and so predictable and repeatable coming to the game with the same game plan every time, almost has really worked out well for us, made it so that, you know, the joke in the lab used to be that they couldn't ever have a case that accidentally went missing.

▶It was mislabeled because with my surgeries, they couldn't tell where the screw holes are because it's always the same or it looks pretty much the same. Yeah, but that's just following the rules and following that straightforward. So being a boring surgery, you know, might have gotten a little bit boring for you, but it also makes it more predictable, not just for the patient, but for you as, as a person that works side by side by me, we never had any disagreements ever.

Uh, there were never any fights or problems because you knew, exactly what instruments I wanted to use and when I wanted to use them and what to set up and how to set up. And it makes it so that it's a lot freer, right? You don't have to stress too much about it the night before. Setup is easy. Makes your home life more straightforward. Yeah. You don't go home thinking about work. Social life. And the same thing for me.

I don't have to wake up and answer a text at random of what to set up or what implants we need to have, or let's sit down and figure it out. What implants we're going to order. Uh, and so that's, that's really helped things. And the other thing that's helped things is going with a system that's very much patterned off of a few things that, that work into making it like very efficient to make it so that we can sort of exchange pieces.

I mean, one of the things, this is a little off topic with boring surgery, but you know, for you, if I come in, if, if I misplaced a, um, let's say an abutment worth, uh, an abutment is a part that if it sits into the implant and the abutment is what ultimately holds a set of teeth on right. And a hybrid next implant to the teeth. Yup. And so when you have that abutment placed, the screw is set in stone of where it's going to come out.

▶And if it's not aimed correctly with the teeth, then you can have that and be in a bad spot for the looks. And that makes Nadia mad because now she does the teeth. But, uh, if I do happen to miss that, or if we do miss the mark on that, what's cool about having that sort of very patterned system is that not you Nadia do not have to call me and ask me what I used and where I got it.

And if we have any extras, we have it all stocked, you know, what exactly what comp components I used and what height. And so you're able to change it with a restorative doctor sort of sight unseen without me, which makes again, kind of all goes into patient experience, your home life, your social life, your everything, because you can take care of that sort of, you know, on a whim, uh, without having to worry about me being the rate limiting step there.

That's always been really fun is figuring out how do I make Nadia's life as good as possible? Right? How do I make her surgery side, you know, her surgery personality as calm as possible? How do I make her restorative side? Um, so that's always been fun. So, um, you know, I'm sure that there are many, many, uh, stories we could get into thinking of trying to make things boring. Do you remember when we tried to use that electro scalpel, the radio scalpel, the, with the minimal surgery?

Sure. Yeah. Yeah. I remember the smell of it. I can still smell the tissue, the burning tissue. It didn't bleed much. It was fantastic for that, but man, it kind of burned. And then the surgery, the, the surgical site. Remember we had, I had a lady who, um, she got a, like, uh, some like nerve feeling from it. Um, but that, that, that lady was the last person we, we, we used it on. It was a highly highly recommended piece of machinery.

It was not cheap. It was really cool at the time. Um, but again, all of this, like you could take probably every single one of these episodes by the time we're done with this and gone. And sort of sum it down to what has been learned and how simple can it get and how straightforward can the results be for the patient, right?

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And keeping a system on track to that is sort of the fun part of the surgery for me, keeping the whole system kind of in the very, the less that Nadia calls me, the better, not because I don't want you to call me, but because it means that the system is doing its job. Exactly. And so that's what we mean when we're saying the more boring, the better, right? The show keeps going on. Even the show keeps going on without me there.

And even if I am there and, and the restorative dentist is not there, the show can still continue on because we're all speaking the same language and that patient didn't have some overcomplicated crazy thing. And that can be hard to differentiate yourself from because again, going back to it, it could be hard to communicate to the patient that me being relaxed and, and straightforward to your case, letting you know it's going to be an easy surgery can come across as being very cowboy, very, you know, cavalier with things and, oh, I want to go to the guy who poured up the models and really studied it.

But I think through this conversation, you can kind of get the, the appreciation that that's not, that's not how things go. You know, it can over complicating things can always lead to bigger problems and bigger disasters. And that's, we see a lot. And you, you see a lot of cases where patient will finally get frustrated enough with their process at X, Y, Z dentist, and they'll end up finding us and they'll come to us. And you just see that you just look at that set of teeth, right?

I'm thinking of one lady who, she didn't want, she wanted IV sedation. She went to, I think Utah. Yeah. ▶And you just look at her set of teeth when she came in and how it was created. And just, I can feel for the complexity and the annoyance that that was to create. Yeah. But at the end of the day, how awful the result was. Yeah. And she got to the end of her rope with that and then came to us.

And in that cool, like a very rewarding part of the job where you, you know, you can fix that and put it back together. Like instantly. Exactly. It was just scan and then it's here the next day. Yeah. At the end of the day, it's just not as, it's not necessary. Like the, the pre-planning, it looks cool. It makes for a really good, like Instagram posts and whatnot. It's a great way to justify the degrees on the wall.

Yeah. Yeah. It, it looks cool, but the result was always pretty much the same. Like. You mean in terms of the, the outcome of over-complicating versus being at straightforward? Well, nothing, there wasn't like this huge wow factor in the, in the final set of the teeth, right? It was still pretty much the same outcome. The patient has a nice smile and you can still achieve that. Keeping it simple. Yeah. Versus all this pre-planning and dark rooms and whatnot.

It's a, it's a complicated, it's a complicated topic, no doubt, but I appreciate you coming on and taking the time to hang out with us today. And we will explore the next one. ▶So stay tuned next week for, I forget what we're talking about, but we'll, we'll cover it then.

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But, you know, in summary though, keeping the system sort of boring and straightforward, alive ends up the staff. It makes the results better for the patient. It makes the experience better for the patient and it makes complications, honestly, a lot better and a lot easier to just keep it very simple. K K S S. Keep it simple, stupid. So we appreciate the listen and we'll look forward to you listening to us next time on beyond the arches.