Ep. 46: You Asked, Dr. Dan Answered

Part 10:00

This is Beyond the Arches, where full-arch dentistry meets real talk. Let's get into it. Hello and welcome to Beyond the Arches. I'm your host, Dr. Daniel Noorthoek. With me today I have Erica. Hello, Erica. Hello. And we have Nick. Hello, Nick. Hey, Dr. Noorthoek. Welcome back. Thank you. Thanks for having me. Today is always a fun day because we are going to do another FAQ. So we have asked the people on our Facebook group. And they have replied with some questions. And so we're going to get some of those questions answered today.

And it should be sort of a lighthearted way to get some of those questions answered. And maybe somebody is listening that hasn't thought of these questions and they'll get a question answered for themselves. Absolutely. And we are taking some of these questions from our Facebook group and some of the questions that patients have texted in or called us. If you are listening today, any questions. If you don't have a question or you have a question that didn't get answered, we do have a post up in our Facebook group now that you can go in and comment on, shoot us a DM, text Erica or Lilia, or just write us a letter and we'll try to figure out how we can get that incorporated into this.

In three weeks when we get it. I do check the mail every day. Okay. Then it might be next week's episode. You never know. So I wanted to get this episode kind of kicked off with something funny. It's something that me and Dr. Dan talk about pretty often. Lilia as well. Anybody who's kind of in the front of our office. It's something that we hear often. You hear patients walk in and they're like, Oh, am I the only one being seen today? Or like, are you guys busy today? And we're always like, Oh, it's the Dio waiting room theory. And we always talk about how we're going to include it in a podcast. And now is the time to shine. So Dr. Dan, what is the Dio waiting room theory?

The waiting room theory. So it's more like less, less of a theory and more of just a fact. act. Um, sometimes we have patients that will come in for a consult and they'll make a comment, a comment, Oh man, you guys don't really have anyone in here before. And we hadn't really ever thought about it. Um, truly like consciously put some thought towards it until we had one consult come in and he said, well, the other office that I went to their waiting room was full.

And so, you know, it's kind of, I like you guys better, but, um, their waiting room was full. So they probably do a lot more and et cetera, et cetera. And the truth of the matter is you don't want to go to a place that has a full waiting room all the, all the time because maybe they're having bigger issues and that's why the patients are coming back or they involve more steps or it's not as straightforward or they're having complications for repeated visits and follow-ups.

So, um, you know, we feel like, uh, an empty waiting room is the biggest compliment that we could have to our system and to the way that everything flows. We, we don't, we very consciously do not schedule patients to get in a crowded waiting room. We very consciously schedule our patients to not have to wait. Uh, it's very rare that a patient would have to wait. Um, and we do that because we're more efficient on the inside, uh, versus we don't have enough patients. And that's why our, our waiting room is, is not, is full.

And isn't that even kind of funny because when we moved from our old office off of military trail into our new office in Mizner park, I remember walking through that with Dr. Dan, Nick, Lilia, and we were all like, Oh, the waiting room is kind of small, but it doesn't really matter. It's kind of okay. And we threw that waiting room theory at it. Yeah. For those that haven't been there, our Mizner office is a very intimate feel, very intentionally. There is a seat, there's a couch and, two other sirs. Yeah. So there's max seating for four, maybe five.

Yeah. Yeah. And you know, even in our Tampa and Jacksonville offices, it's the same way. Like you don't want to have patients sitting in the waiting room. Cause I mean, as a patient, if I'm scheduling a two o'clock appointment somewhere, like I'm probably leaving work and I have an hour or an hour and a half and okay, what I'm going to go sit in and be like, here, I'm here for my two o'clock appointment and then wait 20 minutes to be seen. What am I going to do? Scroll on Tik TOK, scroll my emails at that point. I'm going to go sit in and be like, here, I'm here for my two o'clock appointment.

I'm getting frustrated. I'm now frustrated at the process. I'm going into the back. I'm frustrated with the hygienist, the assistant, and it just snowballs into this kind of like catastrophic event. Whereas if you just run on a very operational, like efficient manner, it, people are going to love that. And it's one of the reasons why they give us such good reviews is like, they're not wasting my time. They're, you know, valuing me. I feel like I'm a part of the team.

I'm a family member, not just like, Oh, Hey, take a number at the deli and we'll call you once you're ready. Yeah, totally. And I know myself and Lily are in constant communication with patients, letting them know, Hey, we're ahead of schedule today. You're welcome to come in now. Hey, we're a couple minutes behind. Do you mind coming in 15 minutes after go grab a coffee downstairs just so they're not sitting there? Cause it's so frustrating. We, when we used to have the waiting, you know, when I used to work at locations where the waiting room is full, what I can tell you is that there's a subconscious effect that plays on the doctor because you know, you're behind. And so, you know, you have to pick up speed and you know, you have to get that person out and that can somewhat compromise the results. And, and just at the base level of what it is subconsciously, it's going to affect the results because it's there and it's present. And then it affects the front desk staff because the front desk staff is having to manage both sides. And it's a kind of a no win scenario.

So, uh, uh, congested waiting room could, could be a sign of, of not great things, and could also be a sign for not great care. So that's why we've, we've really taken great effort to make sure that that's always stays pretty even keeled when it comes to the volume. Yeah. It pulls everything together and just everybody is getting that VIP experience at the end of the day. Absolutely. So you want to jump into the next question? All right. So this is going to be the first question from our Facebook group and it's going to be from a Christine and we're picking her because she has her profile picture is a retriever, which to Dr. Noorthoek, he has two, a Sadie and Boone. So love me some golden. I know you do. So here we're going to, this is Christine's question. How do you handle patients with high blood pressure? Depends on, it really actually has to depend on what the scenario is for when, when the high blood pressure is coming to fruition or when, when it's apparent for a patient who's, who has high blood pressure preoperatively, we're going to recommend that they go to, their physician and they see somebody and get on medication and they take that medication appropriately for somebody that we identify. Maybe they didn't have high blood pressure before, you know, at the consultation and the initial exam, maybe that blood pressure is elevated because of the stress and such. So managing a high blood pressure patient as they come into the surgery is a little bit different than ahead of time.

If when they come into surgery, if their blood pressure is high, we have a couple of tricks of the trade to, to get that to be lower, including getting them to rest and relax and sort of wear off that initial anxiety and that fear. But if it doesn't come down after those things are, and I'll tell you most of the time it comes down because most of it was white coat syndrome and just the stress of getting there, et cetera.

Drugs not taking effect for sedation, et cetera. That's probably the number one thing. And that almost always dissipates once you get them comfortable and you get them settled down. The second thing is most, I would say the second most common high blood pressure in a surgery typically will come because they forgot or consciously did not take their high blood pressure pill medication the morning of the surgery. In which case that's a pretty easy fix. You give it to them and wait until it comes down to play into the waiting room theory.

There's also an effect where we're so efficient in the surgery that we don't ever get into a situation where we're scheduled with surgeries that really jam up the day. So if it takes time to get a person settled in, or if it takes time to get their blood pressure to settle down to normal, then so be it. That's, it's not going to run us behind. It's not going to, it's not going to make us subconsciously rushing through the surgery. So that's always been really nice as being efficient in the surgery allows us the space to take our time and have that be in effect. To wrap it up, when a person, when we cannot resolve it, generally it's through those two methods, but when we can't resolve it past that, typically, and I can think of probably two times or so, we've had, you know, you have to dismiss them and recommend that they go see urgent care.

And get that under control. One specific time, it was so high that there wasn't any medical, how do I want to put this? It was, it would have been medically irresponsible for me to have let them go to urgent care on their own. And so we had to actually call EMS, not as an emergency, but as a, will you transport this patient? Because I don't trust anything not happening on the way there. That man specifically was an interesting one. He spent the evening in the hospital.

They got his blood pressure under control and they cleared him for surgery the next day. And it was fine. The blood pressure was fine. So how we manage it depends on the person, depends on the situation, depends on the case. But it is something that we're actively looking at and that we're assessing and addressing. But they stay medically safe and comfortable. Now, to expand on that a little bit, I know you're, like you mentioned, you're getting clearance prior to surgery. You're monitoring it throughout the entire surgery with the pulse hocks. Is there any medications that you prescribe for either pain, sedation, antibiotics that would interfere with the blood pressure, like on a typical regimen? Like, you know, are you, you know, not a candidate for this procedure if you're on a plethora of blood pressure medication or even blood thinners?

Well, blood thinners is a whole different question. Okay. I threw that one in there on my own. Yeah. Yeah. I should have, we should have, should have, I should have commented on my Facebook group with that blood thinner question. Right. Yes. Blood thinners is a whole different lecture series. But when it comes to blood pressure medications, the, I would tell you that more of the environmental and the big issues that you would see are going to be the, the predominating, predominating, like a predominant issues that surround precluding somebody from getting surgery. So what we just described, the interactions and the concerns for if I'm on a blood pressure medication, can I have this surgery? The answer is almost invariably, absolutely. You can, as long as it's a managed pressure that reduces the bleeding in the surgery, makes it cleaner, makes it easier to get the blood pressure. So if you're on a blood pressure medication, it makes it a better, safer procedure. It just plays into their, their own safety, but also our cleanliness and able to, to do the work correctly. So we're aligned. The patient is aligned in terms of safety. I want to be safe, but there's also the cleanliness and the stress of doing a surgery on a high blood pressure patient, which isn't really worth it. So medications can, if you read the label, you could probably find this interacts with X, Y, Z.

Okay. Okay. Okay. As a general rule of what we prescribe and what a person is on, they generally don't interact. ▶And we will always identify that, or I can't say we, Erica, you and Lilia will always identify that with the treatment coordinator in Tampa and Jacksonville. They'll always find that and work with a physician ahead of time if there is sort of some sort of contraindication or interaction. Yeah, absolutely. Thanks. Yeah. So with that being said, I know you normally take a couple of minutes to get surgery started.

Like when the patient's actually sitting back there, they're in the chair as well. Why does it take you a couple of minutes to get started? Is it because of that blood pressure calming down? Is it actually for the numbing like we normally say it is? Is it a little bit of both? So we, a long time ago when I was in residency, I worked in a clinic that had absolutely no windows and I had an interior room of that, of that clinic. And we were coming back from lunch one day and my, my director mentioned, are you going to do surgery without the light today? He was always kind of doing off the wall kind of stuff or saying off the wall kind of stuff. And I said, why do you just, do you know somebody that does that? And he mentioned a doctor that does it all the time. And you know, that guy's a weirdo, et cetera. Well, I said, sure, I'll, I'll try doing it. And what I found was it really helped set the tone for the patient.

And really had almost like a better effect than even say most sedative medications do. I know that's crazy to say, but, um, from that moment on, I've pretty much always done surgery with just my own surgical lamp and then the overhead, but no external lights on in the room. The point being to your question is I'm a big proponent, proponent of setting the tone and getting a patient comfortable. Yeah. Not only through medications, but also the environment. So the staff is pretty calming.

The environment is calming. And so those, that time and that process to get the patient to actually being in surgery is part of setting that tone and part of setting that sort of calm, relaxing mode. Funny enough, it kind of does play into the blood pressure sometimes because maybe they are high, but we start that process. And as we get into that process, we start to get the patient comfortable. And so that's, that's, that's a process. It comes down into being low on the exact same timeframe as we would be normally doing that surgery. So that, that time to sort of ease a patient into it, prove to them that it's going to be safe and fine, kind of get that medication to kind of kick in under low stress, sort of spa calming environment, uh, is crucial, critical and key to the way that we do our cases.

Yeah, absolutely. It's an important step. We did some filming yesterday. And we had to start the surgery under lights because they needed it for the, for the cameras. And I can't even tell you how it now sort of unseats me because it's so jarring and I can't, it's too much, too much light. So it looked like you were under a microscope. Yeah, it felt like it was crazy. Okay. I have another question that's going to come off of our Facebook group. This is from Gary.

Real quick. Gary has a, no, I was just going to talk about Gary. Cause I was going to try to snipe that question from you. Gary has is posted up in front of a yellow Hummer, which is an H1 or H2 probably always was a dream car. Like I love the Hummers growing up. So Gary, love your style. Love it. But Erica, what's the, what's the question from Speaking of Hummers, I just learned that the new Escalade EV, the electric version of the Escalade is built on the electric chassis of the Hummer.

I thought you were going to tell me it can do the crab walk. And I was about to get so excited. The crab, have you ever seen the crab walk from it? No idea what you guys are talking about right now. After this episode. All the wheels turn so you can go all in one direction, basically. It's pretty cool. What purpose I would ever have for it. My car always goes in one direction. I don't know what your car does.

You don't turn your car at all? Yeah, but it's going in the same direction. It's going wherever I turn it to. This helps the turn. Yeah. Now I'm going to touch that one. You can just jump in to Gary's question. All right, Gary. So Gary said, when I had my consultation, I wondered why you only looked at an x-ray, never looking in my mouth, teeth or gums. And as a side note, I actually remember doing this consultation with Dr. Laks. And this was an in-person consultation. This was not a typical virtual consultation where sometimes we do, sometimes we don't have x-rays.

We did have an x-ray for Gary. So I'm going to touch that one. I'm glad that we talked about this because this was a question that accidentally at the very end of the last FAQ that we did got left off. And it's an important question to address, no doubt. Um, the answer of why we generally will do that is because, um, at its heart, most of our patients don't like the discomfort of being in a dental chair. They don't like the exposure of having teeth. They don't like the discomfort of being in a dental chair. They don't like to face and see what, what is going on. They don't like to have to face pain on the first minute in the first day. The, and so that's where that sort of comes from.

And as a background, typically we do our consultations in our consultation room, which is set up as essentially a desk and a couple of chairs. So like an office room setting, it is not a dental chair setting for anybody who has not been into our, our location. That's a good point. And, and, to that point, it is just a consultation. So it's just a consideration of this is what we see, and this is what we think needs to happen. The, as, as jarring or as crazy as it may sound to a person who is just experiencing getting treatment plan for full arch, the, for the most part, these cases from the x-ray, we can see a lot. We can see how much bone is available, where it's available, where those, some plants will probably go into, and, and therefore kind of be able to determine how successful or how easy or straightforward that case will be. We can also determine a lot from the teeth. And, and I don't say from a point of really nailing out every single tooth. That's not the intention of a consultation. If you look up the definition of a consultation, it's not to find out the exact, um, end point of every, of every little nook and cranny.

But what it does do is it gives us enough information to determine whether or not that's going to be a case that should be acceptable to go to full arch. So it's not like we just take an x-ray and say, yep, implants will fit here. Go, go on for, I'm just going to make up a number totally transparently. I'm going to make up a number. I'm going to say 85 to 95% of the cases when we see the x-ray it, because of the way that, the person found us because of the way that they get to us with that x-ray or the x-ray that we take almost 85 to 95% of those patients are open and shut closed. There is no other option for those teeth. So the way that I kind of explained it the other day to, um, Robert is on here quite frequently. Uh, years ago when my wife and I bought a house, we knew we were going to knock it down and we're, we're going to put a new house and we knew there was a 0.000 chance of ever moving into it or restoring it. It was just a total dump. There was no fixing it really for anybody. And as such, we purchased it and my wife never saw the inside of it. I did cause it was the first home I ever purchased, but we didn't have to go inside of it to know that it was going to get knocked down.

And then we were putting new there very similarly. I've done 6,000 of these cases. We've, we have, uh, eat, sleep and breathe full arch. We can determine or look at an x-ray and say that house is going to come down and there needs to be a new one. If it requires additional look or additional discussion, that's where it turns into from consultation to full exam. That's where it turns into. These are other options. Do you want to explore those? It's not that every house needs to come down and become new. That's a very, I feel like that's a very key point to delineate a lot of people. A lot of people are going to hear me say, he said that everything is going to come down and it needs to all always need a new house. And these are predators that always do full arch.

No, that's not the case. I can tell if it can be saved. Okay. We need to do more of an exam here. We need to determine, we really need you to vet out what you want done here because these are salvageable. But when it's a home that we know we're going to destroy and build a new one on, no matter what, because it's just not going to cut it. We don't have to do a lot of that initial exam when we're discussing how the following and how we achieve that goal. Right? So to further go on to the home building and demo, when you first look at that home and say, this is the home we're going to knock down and we're going to build a new one in, you're not sitting with an architect that day.

The next time or following that is when you start to pick your builder and you start, once you pick your builder, you're looking at your architect, et cetera. So we do full exams, but they're sort of after that consultation, after we've already made the decision, okay, this one's coming down and then we're going to build the new one. Got it. And on the same note as that, you then decide where the implants are going to be placed as well off of that x-ray. Right. Off of the x-ray, off of the, for me, personally, it's always been a lot of surgical direction because I find that I feel a lot more comfortable for my patient's safety and my patient's long-term results by making that decision for them in the surgery with using it against my, we'll say experience flow chart. So a lot of that is determined from the x-ray, I'm determining like the bone width and the bone volume and the space going to put them, but so much can change between then and putting them in that you always have to have a little bit of a loose idea of where that's going to go, in my opinion, because sometimes that bone isn't great. Sometimes it's really soft, sometimes it's really hard. And so you always have to kind of be able to be on your toes to react to it, to get the patient their best long-term shot and result. Okay. And then this is something else we often, this is not from Gary, but this is something else that we often get asked in the consultations and it kind of flows in.

It flows into this, but there are some people who have been told in the past by like their general dentist that they, if they needed an extraction and implant, they may also need a sinus lift in that area. So when, at what point do you decide if that patient is going to need a sinus lift? Would it be at the consultation? Would it be from that x-ray? Would it be at the time of surgery? Is it even true?

So just to again, make up numbers, but they've got to be somewhat close. I would say 75% of the time that we end up doing a sinus lift for a patient, we're going to identify that. Actually, I'll say a hundred percent of the time we're going to identify that ahead of time. Yeah. 75% of it would be, this is the plan and we're going to stick with it. And this is how it's going to go because it's sort of open and shut with where that implant needs to go and how it's going to end up resulting. 25% of the time that we do end up doing a sinus lift, we're going to have, let the patient know that that's a high chance. We're going to try to avoid it. We're going to try to get the surgery around it and get the best ideal results without it so that we can do that in the future. But say 25% of the time that we end up doing a sinus lift, we'll have let them know. And then in the surgery, make the decision. No, it's actually going to be best for them to do that at the time of the surgery. Why do you think we hear that so often in our consultations? With?

With patients. Patients who come in with their x-rays and they say, oh, my general dentist told me that I need a sinus lift. And then we kind of have a different opinion of that. Is full arch different than the single implant placement or? Yeah, it is. So when you're doing an all on four type technique or an all on X type of technique, we're able to put the implants at an angle, which actually helps strengthen the overall prosthetic or the support from the implant. And then also conveniently lets us avoid most of the sinus for doing any of that type procedure. Typically when you're talking about like a general dentist or a periodontist tacking on a sinus lift, the implant has to go in that specific region for a tooth. And so the only available way that you can successfully put a tooth there is by building the bone under directly above it where it needs to go. And sometimes they're just not going to be able to do it. And so we're able to do it. And so we're able to do it. And so there just isn't enough room to put a good stable implant in. And so therefore you would need to build bone above it so that you then have enough bone to put that implant directly where it needs to go. That is where I would tell you that the goodwill side of it lies, right? You don't have enough bone. You need bone. And that implant has to go right here for you to get that tooth. We need to do a sinus lift. There's a small percentage in the dark side, the bad side of it is that that's sort of a tack on. So if the dentist, let's say, doesn't want to deal with a patient or let's say that they are just want to make more money on it, they can say, oh, there isn't enough room here. We need to do a sinus lift, even though maybe sometimes you could get away with not doing it. That's a very, very small percentage, but I did want to throw that out there. Sometimes we have counter opinions to another office.

And that counter opinion is generally because of those little sneaky fees here and there. Okay. That was an erratic question. Yeah. I've always wondered that. I hear that very frequently in our consultations. Like this doctor told me this, why is your opinion different? Or, you know, is this true? The thing that we didn't uncover, the stone that we left unturned is also that that person just genuinely believes that they need it there for XYZ implant or whatever they want to do for that patient. And we don't because we feel differently. And unfortunately for the consumer, differing opinions is where this is all personality. This is all experience. This is all everyone. It's not that whether they're right or we're wrong or vice versa, it can just be that way. Nine out of 10, dentists may not recommend this sinus lift. It may be five out of 10. Yeah. Unfortunately. Yeah. Yeah. Okay.

So we'll, we'll keep the, I'm going to pivot a little bit on the next question I had here. We're going to keep it on the surgery side of things. So I got a question here from Steve and he is asking it, you know, and you just gave this full answer in regards to how you're very methodical in regards to ensuring that we're, you know, reviewing x-rays and the consults getting a proper clearance from doctors, kind of setting the entire stage before starting a surgery. But Steve's question is, is there ever a fear of not being able to complete the surgery once it has been started? I'll say no, because once we've started it, we know the different flows of where that could go. What I, we, we try very hard and are pretty successful at preparing a patient for potential negative outcomes. If we see that as something that's a high risk for them. So if I don't see enough bone or I'm concerned, about the stability or the strength based on a couple of different factors that we're looking at, we're going to have that conversation ahead of time and say, look, so, and I'll usually break it into an, an approximate percentage. And I'll say, look, 67% chance we go this way, 33% chance that it goes this way. So the result, there will, will be a result in one direction. And that patient will know the approximate percentages of how that's going to go. And I'll say, look, I don't know, I don't know, I don't know, I don't know. I don't know how that result ends up. But we may not know, be able to determine 100%.

This is exactly where these implants are going to end up. This is exactly how your surgery is going to go. Of course, because we're dealing with a human body and it's a lot of carpentry and it's a lot of manipulation and patient behavior, everything that goes into it. Um, but I can tell you that I've never opened a patient before and said, Ooh, if we can do anything the one scenario actually i can tell tell you one scenario the one scenario would be if i'm just doing a sinus lift no full arch this is totally not related to full arch at all if i'm doing a single implant in the future and doing a sinus lift and a very tough there's not a whole lot of bone left there have been a time or two where when i make the access into the sinus the that patient's lining the they have like a you basically have i always just call it like a tissue paper lining on the inside and we have instruments that take that are painstakingly like avoidant of negative you know ripping that but sometimes you end up ripping sometimes a patient it can be variable by the patient that you don't know ahead of time sometimes it's paper thin and just looking at it just explodes or rips apart and um probably about twice i've ever opened up a sinus lift immediately saw a tear there you basically in that scenario cover it up and and kind of get it so that it's going to heal close it for six to eight weeks and then go back in and generally after that six to eight weeks of healing the body sort of kind of said okay we were not that we had a very thin tissue paper before we need to build it up and so it'll come in a lot um better and and because it comes in better is why i've made that decision before in the past but that would be the one very weird unique scenario has nothing to do with full arch so now see if i have a kind of second part of this question and now you know with dun and warren any surgeon that we have today tomorrow in the future is all going to be hand-picked you know hand-trained by you dr norfolk and has gone through countless hours and countless different scenarios to ensure that they're ready for any type of case so steve is wondering what could be the reason for a little bruising or swelling compared to some other companies and what's the importance of picking a highly skilled surgeon for your full arch case wow that's a deep crazy question to answer so the i would argue that for the most part you're not going to see a lot of bruising in one company versus another you would more see the variance between one surgeon and another and that's generally going to do because of surgical technique and the pathway that you take to do the surgery some have different considerations or different comforts with needing to see different anatomical structures so they always reflect it and make sure that they see it which i think is really important which is the pain that's the road sign if you have a past surgery you know a post-surgery surgery has some kind of warm up in terms of the process which creates more trauma which creates more swelling etc so there's that aspect but i wouldn't and certainly there are rough surgeons out there that just are going to inherently cause a lot more trauma than somebody else who's more gentle or more conservative.

But you're not going to see that difference. That would just be like an in, that would be a difference that you would see between surgeons, not necessarily a company. The techniques and protocols between companies, we may feel like there's a big difference, but there's going to be maybe two of their surgeons that are excellent and two of their surgeons that are terrible and a bunch that are in the middle of the road. So it's not really another company that's going to create that type of scenario.

Their protocol may not be perfect, but that's going to be minute. I would argue that the bigger difference you're going to see is independent to us as humans, your swelling and your healing is going to vary by person. As an example, a 22-year-old, a 27-year-old, a 30-year-old, they're going to heal a whole lot better and a whole lot less swelling than a 70-year-old who drinks frequently and has addiction to taking Tylenol all the time because they're in chronic pain and on a blood thinner.

Blood thinner is going to be a huge factor. Diabetes. Diabetes can't take the steroid that we take and the short-acting steroid that we take for the healing afterwards. So there's so many factors that go into the trauma afterwards where, you know, you're going to have a lot of pain, but actually the perfect example... I was just thinking of it. I was just thinking of the woman from up north who came down and she refused any medication, no matter what we talked about, and did not take a single anti-inflammatory or steroid.

My surgery was just as normal as any other surgery and her face might have been twice as big as it should have been. And in that scenario, I can point to... Well, obviously, there's a medication-based factor that's gone. But also, maybe she's not really good at making good medical decisions and maybe she just doesn't have a great lifestyle as well. So maybe that plays a role. You know, there's a lot of things that roll into it to the point where when I saw her, it was jarring and shocking, but I also didn't go, oh, man, I really got to improve my technique or, wow, our Dunawan protocol is not...

Good. That was an independent scenario that we knew she was going to end up in. She just wouldn't listen and didn't want to follow through with that. So I would be leery, regardless of the company, regardless of the protocol, I'd be leery of judging someone based on a Facebook profile picture that they went to XYZ place and there's a lot of trauma. Ooh, I don't want to go there. They beat the crap out of those patients. The fact...

The chances of that being the real number one reason is very, very low. The higher reason, in my opinion, is medical factors, person, genetics, how they take care of themselves, all of those, post-operative care, those all play into bruising, swelling, what you look like afterwards. Now you have to talk about Jim because I brought Jim up, which was basically the opposite experience of that. True, right. So, yeah. And likewise, you can go into a case as well where you say, I don't think that person's going...

I think that person's going to bruise like crazy. Their lifestyle's terrible and they're on 85 medications that we had to work with the doctors for nine weeks on to get clearance, whatever it may be. And then you end up with perfect... No swelling, no pain, no trauma. And also where I wouldn't go critique myself over... over X, Y, Z because it's probably more their patient. I'm also not going to go pat myself on the back because that person didn't have it.

It's so independent to the person and the person's going to kind of know, man, I bruise really bad all the time. Like, I'm going to probably be pretty rough. Patient... And I'm going to go really down the rabbit hole. There's so many factors, but another factor that it could be, I've seen a big difference in the trauma when I have a patient really well sedated but still oral sedation where they're compliant in helping me do the case.

There's a time factor that is involved there. There's also sort of a trauma factor in terms of, let's just say, taking a tooth out. If a patient's sort of helping me work through this, their trauma's going to be a whole lot less than someone that's maybe over sedated or IV sedated in my experience. They can end up sort of causing their own problems because... It's just inherent to taking that tooth out is going to be more trauma because they're not really there to help me.

I know that doesn't make sense that you need help to, like, yank a tooth, if you will. It's not yanking. It's removing it, and by removing it, there's a sort of help pressure that a patient will give you when they're compliant and perfectly sedated versus over sedated and there's no help. So there's that that plays into the role as well. We have that patient who had to wait for a day for... She wanted to wait for a day for the try-in up in Jacksonville because in the surgery...

I knew it was going to be that way because in the surgery, there was just floppy. Yeah. Well, thank you for that.

Part 239:10

Eric, I'll kick it over to you for the next one. Okay. Sounds good. So I have another question that is coming off of our Facebook group, and this is a little bit more restorative, but can the upper dental arch shift slightly to one side and what can be done to correct it? So I'm thinking this is maybe like a little bit like of a lopsided arch, maybe like our first PTI a little bit, and what adjustments can we make to kind of create that more comfortable for the patient?

I'm not sure if that's what that is. I think that the question is, a year later, can it become lopsided? I'll read it again. Can the upper dental arch shift slightly to one side and what can be done to correct it? You think like later? That's the question. Maybe. The answer is no. Absolutely not. As long as the screws are tight and the implants are healed. Nothing is going to, if the screws are tight and the implants are healed, that baby ain't going anywhere.

It should never move. Those implants are fixated in the bone. Very commonly though, a patient will psychologically, sometimes you think that it's psychological and ends up being that there's a, screw that's loose or something. But sometimes you think that the opposite is true and where you think, oh, there's definitely gonna be a problem here. You go in and it's like tight as can be. Sometimes there can be a psychological component where a patient will sort of feel a give or perceive some sort of movement.

The hardest part about dealing with that on a patient is that they're convinced beyond the shadow of a doubt, totally convicted. And there's absolutely no way that has occurred. It's not, cannot go. Well, this is, I actually think that we've touched on this in one of our other episodes. But usually when a patient calls in and they feel like their zirconia arch is moving a little bit or they feel like they're getting, you know, something's going on.

They're not sure what, but something is going on. ▶I tell them, take your fingers to your zirconia teeth. Take your fingers to your teeth. Can you wiggle them? Are they wiggling with your fingers or are they only wiggling when you're speaking? Or when you're sleeping or when you're breathing? If you can't move, if you can't move them with your fingers, your zirconia is not moving. It's just that air sensation passing through, which then will assess for a reline at the upcoming appointment.

And this is totally, this is something that we explain all the time, a little bit nicer than what I just said. No, I mean, it's a good point for people to hear or understand that, I mean, there is this, this is a big, we've talked about all the time. This is a big psychological, this is a big psychological procedure to undertake. It's not like you're weak of mind or a lunatic. If you perceive this, this is something that happens between a lot of different patients.

Sometimes it's something that needs to be addressed. And sometimes it's just, it is what it is. And what you're perceiving really isn't reality. That doesn't happen that often, but that can, it can happen. It's a big, big procedure. It's a big change. But in terms of the mechanics, if the implants are fine and the screws are screwed in, those aren't going anywhere. What about like grinding and stuff? Like if you grind in a denture, for someone who comes from a denture, if you grind your teeth at, well, I guess you don't wear them at night.

If you were to grind your, well, if you were to grind on your denture, then what you're going to do is you're, it's going to sort of shift along the gum tissue and not have that much, like abrasive, you know, reaction to each other. But it's going to maybe potentially could feel a little bit more like it was accommodated. It's kind of like slipping on the gum tissue, whereas this isn't going to have any give. And sometimes the patient can perceive that as a slip or movement because it is so rigid.

I know that's counterintuitive, but we'll answer that in case that question was built a different direction. We'll, we'll, we'll answer it the other direction. Which is can something be done about it? If the first set of teeth is lopsided to me or the second seat set or third set. And the answer is absolutely. That's all just the digital file. So those, that all can be corrected. Let's stick on the restorative train here. So I've got a couple of questions here in regards to TMJ.

So I know this might be a little bit more in the Dr. Lacks world and the restorative side, but we got you here today, Dr. Noorthoek. So, so we'll ask you here. So kind of a two folded question. We've got two different, two different individuals asking this. So first off is, I guess let's, let's ask the first question here is if you are setting the stage and you are, you know, you're removing teeth, you're doing bone reduction, you're placing the implants and all this, how are you ensuring that we're setting the hybrids up in an appropriate way that we are not causing a patient to get TMJ if they've never had it before?

That'd be a thing. So there are, this is a very, I cheated. I did see this question. Um, I knew this one was coming.

Part 344:40

It's a very complex. I feel like every answer we go is like, it was very complex. It's a complex answer. And the first place I'll start is that when your teeth come in, let's say you get braces in there in the ideal position, then. Yeah. You shouldn't have, I'm sorry. Let me back up. There are courses all over the country at any one given moment to dentists and prosthodontist, all the different specialties that all feel like maybe they have it figured out or partially have it figured out.

And they all have different sort of modalities in terms of their viewpoint on how the jaw and the, and the teeth come together and how those should, should be adjusted. So for an ideal happy world at the end of the day, is it just a hinge with teeth and fit there? Yes. But the way that you treat it and the cause of what this frustration is and, and how to address those frustrations is highly variable. And people spend a lot of money and make a lot of money on different, different opinions on how to do it.

Generally how I see the world, which may or may not be right to others, and it may not be right, but it's functionally always been correct for us is when you have these teeth come together, like I had originally set up the answer and we say that they're in an ideal position. You should not experience really any grinding because they're in a perfect position. Your brain is not trying to adjust them or try to react to anything and your jaw shouldn't hurt because, because there isn't any muscular, any reason for muscles to trip and say, Ooh, we got to move around where that changes is when you, let's just say, get a crown put in or you chip a tooth or you lose a tooth.

Now you're starting to lose the support on that system in the position of where that hinge is supposed to be. Think about, you know, a door being sort of cockeyed and running on that hinge harder over time. It gets worse and worse and worse. ▶Same thing happens with, in my opinion, same thing happens with teeth. You lose a tooth, you lose three teeth, you lose five teeth. You're starting to lose what we call it as posterior support.

You're losing that posterior support. Those molars are important to the happiness and the contentness, if you will, of the jaw joint. So that's where you get a lot of the reactionary grinding. You get the pain because it's, your body doesn't really know where it's happy point is. Now, if you take a person and you just remove one molar, you're not really losing the posterior support, but that person also needs, let's say a full mouth rehab, maybe not on implants, but full set of crowns.

You have to be very, very, very careful about working them into the correct position. So you, let's say you cut their crowns. You can't just cut them all at once. And put in a new set of crowns and just say, Hey, we're going to figure out where it's going to be.

Part 448:05

You have to go a couple at a time or a segment at a time and make sure you're not adjusting that chain. You're not changing how that relationship works because they're already in their happy place. So you keep it there. Those are where those complex cases are really where the prosthodontist shine because they're taught exactly how to do, how to do all that. Some people can get into bad scenarios with general, dental dentists sometimes who don't understand all of that.

And then by the time you realize there's a big issue that's created, it's way too late. You can't really get that back. It's hard. So the vertical, the distance that you have, the height, if you will, of each set of teeth is important and how those come together. Well, when you have a person that's full arch many, many, many times, if not all of them, almost, you've got a patient. Who's already lost their posterior support. So they're going to come in.

I'm a grinder and I have TMJ, et cetera. And it's not to dismiss that they do have that. They are in a system that is a bad hinge. That hinge is just getting worn because they don't have any of the support and they don't have any of the proper positioning. So you're going to get that, but we have the opportunity in full arch to restore that as, as we want, as that patient would want, as you were, intended to, to have.

And so we will painstakingly get it to a point where not only is that bite probably better than they even ever had, but it's also going to be the correct height that seats the condyle or the, the joint inside of the receiver of the joint, right? So the, that opportunity is awesome because there is sort of an anatomical height that you're supposed to have. That we need to get back to. And that's what we're working to, to strive forward to a good back tooth support, if you will, be it fabricated or not a perfect bite and get that, that condyle, that joint to be in a happy position.

If that's off, which I would argue really isn't the case anymore because of the way that we're able to prototype and get a patient into a good position. ▶But if that's off, it's just a matter of changing the prosthetic and altering the prosthetic to fit, which is entirely different than setting a whole new set of crowns or having gone the wrong way with crowns, because it's a very quick adjustment that can be done very accurately and precisely.

So if you're a patient that has gone through the entire process and you're, you know, you're extremely happy with the set of teeth out, you got through the done in one process and maybe a year later and you're starting to, you know, start to develop some TMJ issues, would you recommend just setting an appointment with the provider, come in, be reevaluated. And at that time, you know, maybe receive a new set of arches or something of that nature,

Part 551:13

or, you know, is Botox an option? I know we don't even want to ever kind of go down all these different alternative methods, but you know, it's not this and final, you know, you're going to have to deal with TMJ for the rest of your life kind of diagnosis. Is that correct? Mm hmm. So I would say, that there's probably three different paths in that person's scenario. There's three different things that it could be in my experience.

The first you mentioned Botox. So I have had one patient. It's really only been one patient, but we did have one patient who she didn't have jaw or joint issues. ▶She had before with teeth. We fix those with the correct height. But her musculature, from years and years of just being in a constant stress, bad position scenario, her musculature was just impossible to overcome. And it would fight you just in doing an exam to look at it.

And she broke a million sets of teeth just from how much pressure and strength that came from that. And so we did find her relief in sending her and doing Botox in her muscles to get those to relax. It's only been that one time, but it did work really well. So that would be one scenario that that person could be in that. The second scenario would be that the height was missed on the original set of teeth.

Okay. That's just, that's pretty simple. That's finding the actually correct position. It could be the bite position that's fixable in the mouth. That would, that's what I was going to mention as my third, it could just be a bite adjustment because bite being wrong plays more. Into it than you think it could be a bite adjustment. That's so off that we need to remake them and change the height in, in addition to the bite. So it's really kind of like three things.

All of them really require us taking a look at it. But none of them should be never should a patient get into that scenario with the way that full arch works, where it's really an irreversible solution or an irreversible solution. It's an irreversible problem that doesn't have a solution. Sure. Generally speaking, because of the way that full arch works and because of the massive amount of control we have over everything with making teeth and the materials and all of that should be very fixable.

Incredible. Love it. All right. I think I will say, well, sorry. So sorry. Last thing I'll say, cause this doesn't really relate to it, but it does. Um, patients that come in with grinding as like they check off bruxism or grinding and on their medical exam will always wonder or be tentative about how everything's going to go. And we don't see it generally afterwards because of how many of the, it's not because we do such a good job making teeth.

It's not the reason for it. I mean, maybe because of the result, but it could, but I'm saying that more it's full arch is awesome for restoring that problem. It's not working around it. It's creating the answer. And there's definitely, let me plug done in one here for a second. There's definitely going to be an added benefit to going through the process of multiple try-ins and ensuring we're getting the right bite height, lip support, all that different jazz comparatively to if you just surgery jump into a final, you're probably, you're probably a little bit more apt to having these experiences three, six months, a year from now compared to like, you know, doing that, holding the hand custom set of teeth to actually ensure that we're getting all those different data points.

Correct. A hundred percent. The difference in getting this done now versus only 10 years ago from a bite standpoint is bananas. I still look at the scans occasionally where that says exactly where all the pressure points are and where you're, what person's contacting and think back to when, and we still mark and adjust by marks, but that additional data you have at your back when you're doing it currently is unbelievably different than what it used to be.

Cause what it used to be is, is that a dark blue line? Is it a dark blue spot? Is it a tight spot? Is it a big spot? How big is the splotch? How hard is, you know, it's that's, that's not science. That's guesswork and art. Nice. Nice. Okay.

Part 656:06

I have one last question that is going to come from the Facebook group again. This is how many times can the original implant be used again in case of a failure, meaning before you have to move it to another location, would it be helpful slash beneficial to go with more implants to strengthen or distribute the pressure? That is such a good question that you might, I think that I wrote it, but I didn't. Um, so first we're going to put some definitions to the answer, which is implant is the screw that goes into the bone.

▶It is not the teeth. There have been some misleading marketing campaigns that have misled everyone into calling them implants as the teeth is not the teeth. It is only the screw that goes into the bone. And I, I don't think, I think I understand what the intention of this question is, but just for clarity, an implant can never be reused when it is gone. And when it fails, that bad boy goes in the trash and a brand new one goes in.

I don't think that they were asking that, but just to be clear, an implant always goes in the trash. It doesn't get reused. What they were asking is an implant site. How many times can an implant site be used over and over again before it can't be used again? And the, the answer is kind of zero. You can't really reuse that site over and over a certain amount of times. And then the fifth time you move over to the next one, which may sound very concerning to a person that is not, is just doing research.

However, it's not, it's actually better. So if an implant fails because of gum tissue getting in the lung and it not healing correctly, to the bone, a lot of times it will essentially form inflamed, angry gum tissue around it. And it will make the hole that the implant went into bigger such that probably 50% of the time, you don't want to go into that same hole at all. One, because it was already inflamed too, because it's so much bigger that if you put the next one in and that, that fails, that causes even bigger destruction, which then leads into the number of implant question.

Which is why I say it sounds like I wrote it. When I started doing these cases, we would do six implants no matter what five, maybe sometimes no matter what. And now we pretty much do four, no matter what, if, if, if the situation requires it, if a patient's got really soft bone, we'll do four and five and six and whatnot, or five and six and whatnot. But the, the normal rationale makes sense. Then the normal logic is more screws better, but that actually isn't the case because we're dealing with a system that's biological.

So we don't want to destroy more than we need to, or, or more than what needs to happen. And so if we have an implant that goes bad in that site, if it wasn't a very bad failure, if you will, we can put an implant back into that site. And theoretically, if it kept failing minimally, you could keep putting in, putting an implant into that site. There is no maximum. ▶I was going to say that is the tissue always super red and always super irritated.

Um, no, not necessarily. There was actually an implant that we used before that had a, a coating on it that would come separated. And every time invariably in that implant that I would have to go to replace it, there was no inflammation and no gum tissue. And we would just replace it with a different implant that didn't have that coating. So it's variable, like all questions. Um, but, but, but the way that we do our surgeries we'll have done for, if we have an implant fail, we'll find another location or use that location if it's appropriate, but we'll find another location, which is where your fifth or sixth implant might've gone in a less than ideal

Part 760:17

position because there were other implants in the way at the time of the surgery. So we'll use that fresh position that hasn't been mutilated and used with the extra implants bone graft, the prior place, and in a lot of scenarios we can, this is going to sound too casual, but we can kind of bounce between locations, the old one and the new one. And it, it's never going to come to that. Patients don't just lose implants left and right.

Like it's a full time job, but the idea is to be able to preserve what was a bad problem and leave that behind while still having a quick solution by having left intact, healthy, good bone. That wasn't destroyed by another implant because there's another part that goes into it more often than not. When an implant is lost, a lot of the factors that go into it are situational where if they're in that position, they're going to have the same sort of problem.

Like if a patient didn't really take the diet seriously and you put five or six implants in, not really going to change. The healing. But now you have five or six zones that are just completely blown out. You don't have alternatives. So having that other site with another implant doesn't mean that that could be used as a backup. If, if somebody lost an implant because of not following the soft diet, you're going to have now two implants with no sites to put in between.

So we've, and this was only possible. The mindset of, going with less implants is really only possible when you're building inside of a digital digital framework. And we already have where all those teeth go, where we can put an implant in, take a brand new scan and incorporate that into their own file of their teeth because it's not incredibly expensive to do gets the patient back in the ideal scenario without really putting a lot of pressure on the dental office.

▶Before when it cost an exuberant amount of money to make a set of teeth and was really hard to get the information on where the implants were, you wanted to build that insurance in so you didn't have to pay for new set of teeth as the practitioner. So it was worthwhile to build in that redundancy for the hope that everything was going to go better. However, since we now can replace it for less and much more expeditiously, we, we are more on the side of let's do what's better and healthier for your bone that gives us better alternatives.

But the fallout is we don't have to worry about the cost of the teeth and we also aren't going to fight you on it and it's really not going to be a big encumbrance on your life. Sometimes you even place a sacrificial implant cases in certain situations. Yeah, that's a, that's like a 20 minute answer. We'll go through that. We'll go through that. That is, um, to not scare people. A sacrificial implant is sort of a thing that we do that allows us to avoid going to zygomatic sooner than we want to.

▶So it's a play for a person that really doesn't have much bone and is a play that we have found successful to get them to set of teeth while still holding their teeth. So it's not anything crazy, but it is a, it's a crazy scenario that that person would find themselves in, that we would place that in. Um, but it has proven to be very effective and good for them. Heard. All right, we'll go deeper into that.

There'll be next time. I don't want to delay that, but it's, it's honestly about a 20 minute explanation. Sounds good to me. Nick, anything else on your end that you want to wrap up with? No, I got my questions in from here. I'm on Facebook, but I'll be Erica. Better check the mailbox for, for all these incoming, uh, questions and be postmarked for you. How much are stamps these days? I don't know, but the price of a mission for a question.

So it works out. Who delivers the, is it still the post office that delivers the mail or like is the post office subcontracting out Amazon and FedEx to do it? No, they still put it out. They're still running rain, sleep, snow, sunshine, whatever they're saying is. Yeah, it's new vehicles and stuff. They're upgrading their vehicles. So have you seen the new? Oh, I have. Yeah. It looks just like a Pixar vehicle. It's pretty cool. Yeah. Um, they're like terrible actually for like their battery range.

Cause they're all electric fleets now. They don't like, I was looking at them the other day, but they don't, they don't have a very good, like a range where you would think that they would be built for like, you know, 12 hours at a time, but they're not very efficient, but that's a conversation for another day. Well, they walk some of their routes. Yeah. They're not driving too much. I don't know. It's probably significantly more expensive to put a bigger battery in and charge those up every day and keep them charged.

Like sure. I'm sure that they did. Well, they got AC now though. See the big win. That's a huge win. That's a big win. I'm going to stick to dentistry. Yeah. You get your steps in though, Erica. So basically just let us know. We'll be doing these Q and A's every once in now again,

Part 865:56

and we'll be just posting on Facebook. So let us know if there's any questions. If there's anything else that you guys think of that you're wondering that could be, you know, beneficial coming directly from Dr. Daniel Noorthoek himself and some team members. I will say also let's, I know I just told you to take us out and I'm jumping back in, but I wanted to throw out that if you listen to this and you're a patient and you have an upcoming cleaning, now that we have our own location, let Erica know, cause we'll get you on this podcast and we can do that.

Yes. ▶And I'll throw in it's at the lab, which has always been like the mythical. We don't let people see. Yeah. So we built it out and we'll give you a tour. You can check it out. Oh yeah. Sounds good. Yeah. Let me know if anybody is interested in doing any sort of patient interviews. We are excited to have more of those in the future. Absolutely. Alrighty. Well, thanks guys. Thank you. Have a good one.