Dr. Daniel Noorthoek: Hello and welcome to another episode of Beyond the Arches. I'm your host, Dr. Daniel Noorthoek. With me today, talking with us, is Robert Odom. Hello and welcome, Mr. Odom.
Robert Odom: Thank you for having me.
Dr. Daniel Noorthoek: Today, we are going to be talking about managing full-arch complications. Nice. And we're going to get into some nitty-gritty, but I think that the best place to start is going to be just talking about a variety of complications, things that can happen, things that are unexpected, and realities of doing surgery on the human body, right? So, let's start off with essentially just discussing or naming off things that we can think of that could be considered complications. You might have the advantage here. So, I'm going to start off with implant failure.
Robert Odom: That's a great complication. I don't see how I have the advantage here!
Dr. Daniel Noorthoek: Implant failure. Yes, implant failure can be several different things, right? You can have immediate—what's considered immediate implant failure—where you do not get stability upon placing the implant. That would be more of an in-surgery complication. When we talk about immediate implant failure, as confusing as it is, we more or less mean in the first three months while it's trying to heal. So that would be anything that is related to maybe you have an infection right away. Actually, let's list those things off as we kind of come back circle through it. But you can have immediate implant failure. So within the first three months you can have a delayed implant failure, which would mean that we saw it at three months, it healed fine, and maybe two years later you have it fail down the road, which can happen as well.
Part of this podcast is to inform people, right? When I started doing this, regardless of the technique and the protocol, it was always sort of considered good salesmanship to not discuss these things. And I would end up doing these surgeries not understanding how misinformed this patient may or may not be, right? And that can really be a complication in and of itself. Like these can fail long term. It is a human body. This is an inanimate object going inside you and being implanted, right? And so there are things that we have to cover to discuss the good, the bad, and the ugly. Changing that has always been a little bit of a platform that I've wanted to advance because that makes my life a lot simpler in the future. So implant failure is a good one and that can be a variety of different things for a variety of different reasons. And I guess to some level you could say, let's say infection, right? You can have an infection. That infection can be as a result of poor implant placement, prior existing infection, things like that. So, we have infections. What else can you think of?
Robert Odom: I have one quickly. Mechanical failure. So, if the bite is wrong or too off, it can overload and cause implant failure. But a complication would be the bite being off.
Dr. Daniel Noorthoek: Malocclusion is what we call it, right? But the bite being off is a big thing and very underrated. It's hard to get a consensus. It's hard to get a group of dentists to agree on what a perfect bite looks like, right? Acceptable bite? I'm sure we would all pretty much agree on the same thing. But in terms of the mechanics, there's a lot of mechanics of the bite that most people only associate with biting down on paper and sliding their teeth around and "does it touch?" right? But there's a lot behind the scenes and a lot of people have dedicated their entire career, not just in hybrid dentistry, but regular teeth, to how teeth are supposed to slide and where they're supposed to slide and what teeth they're supposed to slide on. But the gross mechanics of the bite being wrong is a big thing. We want to know that if you can feel something that we didn’t see—something that’s going to cause TMJ issues if you're out of where you should be. Absolutely.
Robert Odom: I think nerve damage can be another complication.
Dr. Daniel Noorthoek: Nerve damage, yes. Sticking with surgical complications, you could have nerve damage. The measurements were wrong or the approximation of what size implant was placed could invade into the nerve canal and put pressure, undue pressure on it. Sometimes you can get a little bit of swelling from the implant and maybe it doesn't invade and create permanent pressure or permanent paresthesia—tingling, numbness, that kind of thing. Sometimes that post-surgical swelling itself can essentially—you know, we've all sat on our leg wrong and had a leg go numb—similar to that, where once that surgical pressure is off, that swelling is off, then that can go down and go away. So it doesn't even have to be invading into the nerve. It just has to be around it or creating pressure.
And while we're on that topic, a random small little one—and this podcast, by the way, is more to awaken people to these things that can happen so that it's a very transparent discussion on what we're considering. The likelihood of these things happening is exceedingly low when done properly. It's of course a risk going into it, but you know, we could even list death as a complication. Something I've never come remotely close with, right? So these things can—just like you can die on an airplane as a complication of boarding an airplane. These are the things that we are discussing. It’s a finicky conversation because we don't want to have people overbalance this as being a fearful, scary thing that can happen, right? But we also want them to be open-eyed and understand that there's a part here that can be played by many different factors.
Robert Odom: I think that's important. I mean, like we always talk about, we want informed patients. Informed patients are happy patients. I saw a post, maybe on Instagram or something—I don't want to say it was a meme, but it was text and it was maybe like a chart or something—and it was titled "Expectations from healthcare patients." And it had all these different services listed. Expectations of a breast implant: these are the complications, this is how long it can last. Cochlear implant: these are the complications, the side effects, these are how long it could last. Angioplasty and on and on, 10 different ones. And then it went to dental filling: no complication, lasts forever. Dental implant: no complication, lasts forever. And it was a take on how uninformed in general dental patients are compared to medical patients.
Dr. Daniel Noorthoek: In medicine, if you need an angioplasty, yes, there are some elective—or a breast augmentation—there are some obvious elective portions to it, but mostly it's going to be non-elective and be part of your medical insurance. And somewhere in the ether your bill appears, maybe disappears, maybe you pay a portion of it, right? There's this who-knows-kind-of-float. You just know that you're going to get it. And they can be a little bit more raw and realistic with it because ultimately reimbursement doesn't come from a sales pitch.
And so dentistry, I think, has a massive problem from top to bottom. Ethical to non-ethical dentists having to sit into a sales role, right? I daily have to balance how much I disclose of complications depending on the patient that's hearing it because they may hear only complications, right? And that's tough because ultimately I do have a business that has to survive. So the sales definitely gets in the way. The sales in the small business definitely impedes dentistry from being altruistic towards revealing complications and the management of such.
The lucky portion that I've had is that I've always been in a role where the volume is there a little bit regardless. So, I can be very straightforward. I can't say that I don't care about the sale, but I very much want that person to make a very informed decision and understand the risks that we're headed down because ultimately my lifestyle is better by not having to worry about going into a room. When I used to work for other offices where I didn't manage that message, it was always like: who's going to tell them an implant failed and all of theirs failed, or whatever it may be? And that could have been a self-created problem because if you don't tell a patient that an implant fails, you're not going to tell them that they need to be on a soft diet because why would they need to be on a soft diet if you're not going to tell them it's going to fail? Totally. And so if you're going to hide that just to make the sale, now you've created a huge downstream problem. Absolutely. For little old me. It's not anybody's fault necessarily other than the system that we're stuck in. And so ultimately that was the biggest thing that I hated about my life was having to inform somebody of all the complications that just happened to them and why it would happen even though they didn't know it could. So that's—and to circle back—the advantage of the nice part that I've always had is that even though ultimately it's still a sale and I'm trying to sell them on coming to see me and my team and everybody that's involved, we don't want to ever have that downstream problem. And so we've tried our best to mitigate and manage that all the way down.
Robert Odom: On one hand you have the con of, well, if I'm honest and transparent with this person and just preparing them for the what-ifs—not the "likely-to-happen," but these are things that can happen because this is, as you say, the human body. They could go down the road and talk to another dentist that says, "Oh, never had a problem ever in my life, I've never heard of that. Everything's going to be fine." They promise them the world. But I think the benefit of being honest and transparent is, like you said, letting them know what's at stake. This is why we need you to take this medication, this steroid, or this antibiotic. This is why we need you on a soft food diet. This is why we need you wearing this night guard. Because you're kind of leaving it up to them. If you want this to work and want the best chance at success, here are the things you need to follow because here are the repercussions if you don't.
Dr. Daniel Noorthoek: To take a sports analogy, we're going to call "wins and losses" being sales and persons found. A loss would be somebody goes somewhere else, right? The nice part about being in the position that we are today is that we're more like a baseball team. So the wins that we get are more—you know, higher in number—so we can manage the in-game specifics and the losses matter less. Losses, again, not being with complications—like we're not saying we flippantly look at complications. What I'm saying is the loss of a patient, not selling that patient, that patient going and believing somebody else that says they have no complications. It's an unfair advantage because we're a little bit playing like the MLB. And so we want our wins to be true wins and a loss is just—it racks up and by the end of the season we're in the playoff race.
Now if you look at that and compare that to maybe you have less exposure—and you don't do this for a living and this isn't your main focus—you're more like football, right? That one loss, that one patient that decides to go and believe somebody else, is a huge factor to your overall management and your bottom line and your sales technique. And so you're more motivated on a lower amount of games basis to get that however you can. And sometimes that means obscuring or hiding the real facts, sugar-coating it. And that's unfortunately one of the values of a high-volume marketing practice is that the losses mean less. The loss of a patient to somebody else that wants to believe there's no complications? No problem. I didn't want that win anyway. Whereas if a game means more to you and it means whether or not you're going to be able to pay your staff at all, then you're going to obscure the facts maybe or just not reveal them. Totally. And that's a little—I consider that to be unfair, because we should be on an even playing field where it's by merit and value and "I believe and I trust this person 100%."
Okay. So, circling back, complications. So, we talked about nerve. There's one that's very underrated that I have seen occasionally and it's been more or less to do with like soft tissue grafting like gum grafting than I've ever experienced with a full arch—but you can actually—where the nerve comes out of your lower jaw and provides lower lip sensation—that actually can get disrupted or hurt or stretched during the middle of surgery because you are able to see it. I see it all the time, almost weekly. And if that gets pulled or yanked in a certain way, just like the swelling, you can get some tingling or numbness associated with that. And it's generally temporary. It's not permanent type damage, but that's something that could be a complication just from the art of doing surgery. Regardless of where the implant ends up, it's just from doing the surgery.
Robert Odom: That's reminiscent—and sorry, I don't mean to cut you off—but when I did have this bicep surgery, my arm afterwards was completely numb. And I let my surgeon know. And he's like, "That's part of it. It got stretched in the surgery." I said, "Well, will it come back?" "Maybe, maybe not." And it did. I'm 100% again.
Dr. Daniel Noorthoek: That's amazing.
Robert Odom: It took about a year, but I was nervous.
Dr. Daniel Noorthoek: Nerve takes a long time to regenerate and repair, and it's one of the lowest amounts of turnover in our body. So you cut your skin, those cells replace very quickly. So healing happens quickly. You hit the nerves, nerves don't turn over as quickly and so it takes a long time to repair. So that's pretty normal.
Robert Odom: When I was at the six-month mark, I'm like, well, if it's not coming back, if I'm still numb after... I remember you were concerned about it, but 100% again.
Dr. Daniel Noorthoek: And the art of managing nerve situations is also a practitioner-specific mindset. If you've never had an issue with a nerve—okay, I have had two or three in my life, enough that I can recognize or am at least prepared enough and experienced enough where I can raise the hand and say, "Whoa, whoa, this is serious." Like, go right now, see somebody that can fix that because that's a big deal. Luckily that has only happened one time a long, long time ago. Versus, "Oh that's transient, don't worry about that." Because if you're on record saying "don't worry about that" and it was serious, right now you're in big trouble with the patient and with the state, etc. And it's hard to communicate but it's a fine balance of trying to reveal that this might be an issue, having that conversation with the patient and then managing it correctly and successfully. Every patient wants to know that everything's fine, so let's just go down the road and say that a person is not experienced or they're scared to tell a patient, which can happen. But they have serious nerve damage, we'll say, in this world. Well, if that practitioner thinks, "Oh, well, if I just ignore it, it'll go away," and that patient's like, "Oh, well, he's not too worried about it, I'll just ignore it," that's where things blow up into being huge issues. And if you're in practice long enough, you start to see those things around you or case studies in the records, etc. That's where you kind of get this sort of flowchart where you kind of can think through it. But it's very common to sort of hope that the worst-case scenario isn't what's for you, the patient. We all would do that same thing, right? "Oh, it's just transient nerve damage. Okay, great. I don't have to talk to a specialist." But the practitioner also wants that to go away. So identifying when it's serious to refer and when it's not serious to sort of dissipate through comforting them and "these are the actions that we're going to get to to monitor and make sure it goes quickly." That's a balance that really only comes with gray and lost hairs and experience over time, but it’s something that has to be learned. And again, as a consumer, it's really difficult to go out there and say, "Okay, which one of you is going to be straightforward with me?" It's tough. I'm glad I don't have to make the choice, right? Actually, if I had to make the choice, I have no idea who I'd go to. And that keeps me up at night. I think about that a lot. Not to get too into the other side of it, but that's a conversation I will never have to have in my life.
So, I feel like as a surgeon, not only do you need to juggle this kind of expertise and know this kind of stuff, but you got to be able to have those hard conversations with patients when they're necessary. Let's go with another thing that I see more frequently that's a little bit more of an ostrich-in-the-sand. It's a way smaller deal, but occasionally I'll see cases from other practitioners. A tooth can fracture the root, right? Sometimes people don't understand the way that a tooth is. So you have the tooth that we all see and can brush and there's essentially an interface or a sleeve of gum tissue around it, right? That needs to be kept healthy. That's why you need to floss. That's why you need to brush. Below that, what's held into the bone is the root. That's the base. That is the tooth. Okay? Inside of the tooth are blood vessels and different nourishment devices. That's what can get an infection inside of it if a cavity goes too deep or it breaks off. Requires a root canal; you have to remove the bad and replace it. And a lot of people don't really understand that. But roots can be very, we'll call it spindly. They can be resistant to fracture, but they can fracture off when you're removing the tooth. The best of the best tooth removers, Exodontists, can have that happen. The worst ones can have it happen more often than not. But sometimes that is identified right away and sometimes it's not.
Inside the surgery, sometimes it seems like your whole tooth is out. It may not be able to translate, but sometimes you can take the whole tooth out and then see on the X-ray that there was a piece left behind. And sometimes that doesn't get recognized and the permanent bridge gets put on top of it. And I saw a case from another practitioner that came in a couple weeks ago and there's a root tip underneath where the implant is. So, I can see where the root of the tooth is. I can see the implant was placed essentially over top, right? And in order to get to that, I got to take—if I'm going to be 100% transparent and honest and straightforward with the patient—I then have to take that practitioner and throw them right under the bus, take that whole thing apart, charge for my time, all of that stuff that's entailed, right? It's just a waterfall effect. And the point isn't that I'm the greatest. I saw it and I'm going to replace it. That's not the point of this part of the conversation. The point of this conversation is me as Dental Dan seeing some random guy's work that I don't know from, we'll call it Indiana. We're in a competition here. Because we already talked about how sales is a motivating factor for those that are playing football games and need the wins and losses, right? And for the most part there's a lot of dentists really ready to jump on, "Well, I wouldn't go to that guy. He puts root tips in there and puts an implant on top." And so it becomes this very slandering, sloshing sort of world when in reality it’s a human mistake. It's a bad thing that happened to, we'll say, a good person. These things happen to the best of the best. And maybe a practitioner is out there saying that that never happened to them? Well, whoever you are listening to this, you are a liar, a big fat liar because things happen, right? This is the wild west of surgery and things happen. Managing it and managing it with a patient can be very difficult because of the situations we kind of end up getting put in because of the way that the world works.
And that's tough because I want to tell that patient, "Hey, it's not a big deal. Don't blame him." I'm not trying to throw him under the bus. Even if I don't see them as competition, no matter what I say, the problem is there is a tooth root there. So ethically, what am I supposed to say and also not throw him under the bus because I don't want to be thrown under the bus either. So this is one of those postulates: what do you do? Like the kid on the train tracks and the dogs, you know, those little ethical exercises. What decision do you make? And those are things that we daily have to navigate and you don't want to obscure information from your patient either. So it can be a very difficult world to navigate in. And the best I've found is just saying, "You know, hey, there's an issue with this implant. I don't know for sure why it happened," because I don't. I see some bone loss over here which may be from the tooth root but obscuring it just enough so that they understand it needs to be addressed. They can go back to that practitioner and get it done or I can do it and this is what it would entail. So letting them know that there's a problem and not throwing the fellow practitioner under the bus. There's like an art to it because you really want to stay ethical and straightforward with them as well. So complications are tough. This is a very deep, broad, philosophical conversation. It doesn't go deeper than just infection, right?
The other thing is surgical complications. So you can have bleeding, right? You can expose a blood vessel or something, intended or not, that doesn't clot on its own. Or it could be producing enough blood that you can't really see how to manage it and that can get in your way. Now, you can always calm it down with the type of and the level of surgery that we're dealing with, but there's also factors that go into that that can be as random as the patient's bone is a little bit more filled with blood and they have more blood flowing through. It's not as strong and solid. It's more mushy, more like styrofoamy and full of blood vessels, and these are complications that have to be managed and can't be foreseen ahead of time. So bleeding is an issue or can be an issue. For the most part, it's pretty easily prevented by getting a good medical history, by understanding what their history has been like before, right? And also sort of having a good flowchart in terms of how you're going to handle it and not freaking the patient out, etc.
You're using a lot of drugs, right? You can have drug issues like prescribing the right medication at the right dosage can be a little bit difficult. By the textbook it makes total sense but in the real world it's one of those things that doesn't necessarily apply perfectly. So something like a patient doesn't really tell you that they have diabetes. They are—we're giving them a steroid. It's a short-acting steroid, but they can go in what's called adrenal shock by having a reaction to it with the way that diabetics work. And so you can have these complications that develop just like that. There's different infections. There's infections that can develop on the inside of the bone. There's infections that can just be surface, maybe from residual tooth left. It can be from residual inflamed and infected tissue being left behind. It can be surgical technique. Most of these complications can include at least one category or part of this category. It could always be self-inflicted by the practitioner. You know, an infection can be sloppy surgical technique. It can be unannounced or unknown to the surgeon if they don't have enough protocols dialed in in terms of their aseptic technique. Maybe they cut a corner on getting their sterilizer maintained and it's just not quite doing the right job. And those are things that you can't even figure out, right? It's very hard to figure that out. And so there's a lot of complications, especially in the surgical side, and we try our best to list it out in informed consent and make sure everybody has access and understanding to it, but the way in which you handle those complications is the important part.
And I don't want to get into that—I'd prefer that sort of be the wrap-up of this conversation because there's other parts of complications or failures that aren't even related to just implant and surgery—stitches and allergic reactions and things like that. You can have an aesthetic failure, right? You can have a prosthetic failure. A prosthesis could be made of the wrong material. Not "wrong" material, but could be made of a material that's inferior for that particular person's bite or habits or whatnot. It could be a production failure, right? In the next episode, we're going to be talking about materials to make teeth out of, specifically hybrids. That'll be you and I. And we're actually going to spend the week kind of researching that and we're going to really go through and kind of give some numbers and really vet out why we use what we use and why the industry is there. But those are things that can happen. Just specifically off the cuff, when you're putting your zirconia into the oven, there can be micro-fractures in there that exist from the manufacturer, right? And when you cook it, it just makes the crack a little bit worse that you can't even see. They're micro-fractures. And so you can have a person have a prosthetic failure that has no control of yours, right? Doesn't even have to do necessarily with the quality or the price point either, right? And so there's a lot of things in here that go into what are the problems, right? Not only what are the problems, but who's going to be managing this? Who's going to be the parent in the room? Where's our referee? You know, who's going to keep me calm? And that's kind of the bulk of what we wanted this conversation to be. More or less than the specifics.
Let's think of... you could have engine failure and not make it to the appointment. Sure. That's a complication. Happens every now and again. There's a lot. What's another? Can you think of anything off the top of your head?
Robert Odom: That's why I said I think you have the advantage here because some of these I hadn't even considered. And that's from—and you're one of the more informed people out there. So the average person, you know... and I see that a lot in the community, you were kind of touching on the blame game, and I think it's human nature to want to hold someone accountable and make it someone's fault. And it's a kind of a tough pill to swallow that sometimes it's no one's fault. It's just... it is the way it was and we're going to move forward. Whatever we have to do to correct this issue, whoever's fault it was is in the past.
Dr. Daniel Noorthoek: And that goes in... so, let's transition over. We kind of covered some specifics, right? And let's kind of merge over into: what matters isn't whether or not a complication happens. What matters more is how that complication is managed. Just speaking from personal experience because that's what I can go on—and we'll say even I've observed other colleagues succeed at the same thing—it's always being straightforward and upfront about what happened. But also, instead of it being "this is your problem and your random thing that happened," more sort of accepting it as "our problem and the thing that we're going to manage," right? And that it doesn't even have to be self-caused from us. Let's just say a patient went to Mexico and they have an emergency, some sort of long-term failure or pain or something like that. We see that occasionally, or local, wherever they got their teeth, and they come in to us. There's no pointing a finger at that specific—who cares about what the story is for them, right?
