Dentistry Uncensored with Howard Farran

How to perform dentistry faster, easier, higher in quality and lower in cost. Subscribe to the podcast: https://podcasts.apple.com/us/podcast/dentistry-uncensored-with-howard-farran/id916907356

Blog By:
howard

Howard: It is just a huge honor for me today to be podcast interviewing Dr. Robert Bryan DDS FACS FACD oral surgeon on the left and that a handsome dude on the right is the other oral surgeon Dr. Jeremy C Goodson DDS waive Jeremy so basically Robert grew up in southern Ohio after receiving a bachelor's degree at Ohio University he earned a dental degree scholarship award and went on to attend a surgical residency to become an oral and maxillofacial surgeon. In 2006 he attended the University of Oklahoma for a four-year oral surgery residency he currently practices oral surgery at Mercy Health Center Baptist Medical Center and Oklahoma University Medical Center. Outside of the practice and local hospitals he teaches at the University of Oklahoma Health Science Center he likes to spend time with his wife two kids fishing shooting firearms and a new drone that he recently acquired. On his right the Dr. Jeremy C Goodson received his Bachelor of Science degree in biochemistry in 2007 from Brigham Young University and then continued to dental school at the University of Iowa College of Dentistry achieving his DDS in 2011 he did his oral and maxillofacial surgery residency at University of Oklahoma College of Dentistry in Oklahoma City outside of practice he enjoys spending quality time with his wife and kids swimming biking and running Dr. Goodson began taking lessons to learn to play the piano and trumpet when he was in kindergarten inspires to introduce the art of music to his children as they grow up. I had them come on the show because something is really on my mind they basically the press was all carrying that their revolutionising dentistry in Oklahoma with the first ever robot surgery I post this on dentaltown you guys got the the Yomi and it's just the Yomi robotic implant and it's just kinda nice because there was a period of time where dentistry had no robots and now and that time in Oklahoma was before you guys did one thing you change Oklahoma from the pre robot to now dentistry with the robot and so I would ask you what made you want to bring a robot into your oral surgery practice?

Robert: Well I think if you look at the history of our practice and you think of oral surgery specialists of Oklahoma you automatically think of implants and when I saw when we saw the robot I think we recognized it as as as something that we really wanted to embrace in our practice because we actually believe that this is something that's gonna make us better I think it's pretty revolutionary piece of equipment there are other navigation devices that are on the market this one's different it offers something that others do not and I think I think when we saw it, we recognized that and you know there's a part of being a specialist and being an expert that obligates one we believe to embrace technology that we believe is actually going to make implant dentistry better and we believe that that's what the yomi robot offers and so that's part of the reason that we wanted to have the robot as part of our practice and bring it into state of Oklahoma for the very first time.

Howard: You said some very distinctive that it was that Yomi was not just a navigation device that is that what the word you used?

Robert: That's correct

Howard: You said it was it was more than are you said there were other navigation devices.

Jeremy: Yeah so this whole concept of navigation surgery and even robotic-assisted surgery as you know outside of the field of Dentistry and in the maxillofacial world or the neurosurgery world a craniofacial world there's there's navigation devices that have been used for a while and I've done surgeries using those devices and they're pretty amazing.

Howard: Can you name what name a company or a technique or device?

Jeremy: I've worked with Stryker navigation and a few different surgical types a few different types of surgeries they're a little bit a little bit more unusual that you probably just you see one and you may not receive that type of surgery again kind of a frequency so yeah striker navigation I don't know the names of other types of robots but you know there's robotic surgery for other parts of the body or robotic prostate surgery and things together there's lots of these jobs. So the thing about the robot that's different than a navigation device so a navigation device basically can register the patient position and also the position of your instrument and you look on a screen and you judge with your own eye am i where I am supposed to be and the difference that the robot brings in is it has that plus another layer on top where we've input a 3d digital treatment plan into the software with the comb beam CT scan we basically placed the implant into the software program and not only can we see where we're drilling in relation to that but when we convert it into something called the guided mode let me as we approach that position and that long axis of the implant it will actually lock into place in the axis so that as you're drilling through the depth of the implant placement it will not deviate left-right mesial-buccal facial  distal in any direction only will allow you to go in and out essentially so it assists you in maintaining angulation and also provides a stop for depth so there's quite a bit of control over position so in addition to just verification on your own it actually guides you on the position you still move it it doesn't move autonomously but it basically locks you into a position and so this this concept exists outside of dentistry just in speaking with some orthopedic surgeons I know that this type of technology exists and hip replacements and so forth where it'll lock you into an exact angle so you can only move the instruments in that angle and you get the cut exactly how you want and so that's now come to dentistry and oral surgery we have it for implants so it's so when we heard about that we were on that because this is a technology that takes us to a higher level. It offers the advantage to of over for example a surgical guide where you know he planned something you 3d print or however you make your guide you obtain the guide and if you do your first drill take out the guide take a look at it and you don't like the position then you're left with free handing it which as we know can be very very good and is very good in many cases but you no longer have any more guidance other than other than your own visual aid and landmarks so nice thing about the yomi is if you do your 3d plan and you insert that first drill and you say yourself you know what I actually wish I would have planned that one degree more to the mesial you just go back to the software tweak it, it updates automatically your next drill you're right in line with where you want to be so it's this idea of live of updating also that really takes it to another level it's like it's it would be analogous to saying well I didn't quite like that cervical guide I'm a 3d print another one real quick and they need us all the sudden have one so it's it's pretty awesome.

Howard: So did you ever think when you were an oral surgery school that one day you would be doing this?

Robert: You know I think there are a lot of things that go through your mind when you're training as a resident you probably this was not on our radar at that moment but as you as you get into private practice you begin to realize you don't know a lot and it takes time so you're actually continuing to learn throughout your career and I think really when we started hearing about other medical specialties bringing robots to their practice we certainly had some idea that that would be part of our practice as it pertains to dental implants we've always maintained such a strong interest in implants and implant dentistry not only from a surgical perspective but from a restorative perspective we don't restore the implants but we study that aspect of it which helps us become better at placing them so you know when we see guide surgical guides come into play we start seeing navigation come into play and robots used in other specialties we put two and two together pretty early on and really felt pretty strongly that we part of our practice at some point.

Howard: and where is robotic-assisted surgery where did it land in medicine the most important I mean was it working next to the spine the brain I mean I could matter I got you're a podiatrist who have it first?

Robert: I think I'm not sure who had it first but I hear a lot about you know robot assisted prostate surgery as Dr. Goodson mentioned robot assisted hip replacement surgery so I think neurosurgery of course has been using guided surgery for some time now that's an area of keen interest to all of us because mapping the brain out is of course very important knowing which areas are responsible for the problem at hand so we're really to take following the lead of some of these other specialties that we work closely with to make sure that the technology were using is good.

Howard: Well I'm sure you paid a chunk of change it was probably a six-figure investment would you mind saying how much something like this cost,how much you paid for it?

Robert: Well sure I don't mind telling you it was definitely six figures I suppose from the company that sold it to us from their perspective perhaps the best way to go about that will be to check with them I don't know how they do their pricing but um it's about what you might expect it to be.

Howard: So a hundred grand or...

Robert: That's pretty good ballpark.

Howard:100 grand?

Robert: Yeah

Howard: and if you think that's a lot of money you obviously haven't gotten divorced yet because then you'll see what a seven-figure number is but you know they always say you know you guys are incredibly intelligent well-schooled if it's not broke don't fix it. When you pay a hundred grand what would problem were you fixing and then the other other reason I want to get you on the show so bad well number one my Oklahoma dentist friends were telling me to get you on the show but implants and clear aligners are the only double-digit growth in dentistry year after year for a decade so when you look at you know dentistry in the United States last year it is 108 billion but when you look at the globe it's 500 billion you know I say it's got two hundred eleven thousand but the globe has two million and when you look at the two million dentists there are ten million employees the only parts of Dentistry that are double-digit growth are implants and clear aligners I'm sure you heard smiles drug Club and Invisalign. So looking at this this robust growth of implants I would ask you why do you think implants is growing double-digit and what challenges do you see as implants are growing and of those two things how did a robot what problem was a robot helping you, see my style is I'll ask so many questions that may be one of them's good to jump in on an answer?

Robert: It's no problem we have the robot on the other side of the camera keeping track of your questions for us so it's not an issue so all it's part of that you know when you're asking what problem are we trying to solve I'm not so sure we have to have that question deciphered before we embrace technology that we believe in you know for example a few were in Europe and someone invited you to get on their small wooden ship you know back in the 1400s and sail across the ocean that may not have seemed like a great idea to you at the time but look what's come of it and so I think when you're when you're when you consider yourself an expert and I know just with great humility say that I think that we are as are my other colleagues and and you consider yourself pioneering you have as I mentioned earlier I believe there's an obligation to embrace technology that you believe is gonna make the specialty better that you can that you can find information that you can that you can gather information and use that to study how good aren't we how good can we be so you know I think from our perspective I'm not so sure there was a specific problem that we were trying to solve I think we recognize it as technology that's going to better our profession and make placement of dental implants better for our patients so that's that's my answer.

Jeremy: Yeah we we really but both of us Dr. Bryan and I both we feel a passion and and a responsibility to elevate the world surgery profession and there's a lot of oral surgeons doing that all around us we're just happen to be two of them and we're honored to be a part of that so we want to be getting better all the time we want to be learning more all the time in fact I've sort of always thought to myself that well I'll tell you I learned something new almost every day and I thought to myself if you know the day that I stop learning you know maybe that's the day I need to stop practicing that it's there's always something new to learn and always some way to improve now so to speak to the question of what problems, you know the placement of dental implants why is it so successful I think because it works it works so well yeah the success rates of implants are so high they just they are and people like them they love that they can chew they love that they can have good cosmetics there's so many long lists of reasons that they're so successful and so how can we make them better because despite the fact that they're so successful there are still challenges that are encountered by both the surgeon and the restorative dentist and and some of those challenges have to do with the position of the implant the way it's put in and how that influences how easy or hard it is to get a crown put onto it or a bridge put onto it or a denture or whatever what have you and so some of those challenges with implant positioning you know those that's kind of what drove the whole idea of getting a surgical guide to guide the drill into the right position well it's a great concept and it works very well sometimes but there's study and studies have shown this and my experience Falls aligned with these studies that a surgical guide is not a fail-safe it is not a you know close your eyes and drill at the end of the day the guide that's getting the implant the right position is the surgeon the eyes and the hand in the brain that think through the case and get it done right and I think that I have found plenty of surgical guide cases where I've inserted the first drill or two and found that I need to make adjustments not because my plan was wrong but because for whatever reason some time and there's various reasons sometimes the guide will not position the drills where you planned it in your in your 3d planning setup and so that's a fault that's a you asked what's what problem are we trying to fix well once you get to that point like I said you're back to free handing it and then the studies show that you know surgical guides they can have a range of error of degrees and millimeters and when we live the implants with implants we live in a world of millimeters and degrees fractions of millimeters tenths of degrees and so if you're off by a millimeter on a tooth that's six millimeters wide that's a lot. So basically there is there's been a lot of efforts in the profession to improve our accuracy and you know surgical guides were good they are good but they have limitations and they're not perfect you know and the other thing is it it blocks your ability to view the surgery a lot there's a lot of visual issues with it so whereas the robot it's just the drill and the patient like you would normally do the procedure so it brings back to visibility so you can have instant visual feedback and also allows you to change it so it just in my opinion it takes the problems with surgical guides and essentially wipes them away so.

Robert: To address your question of the growth of dental implant industry I think in an aging population where people value having their teeth more and more that really speaks I think to a lot of the growth that we see in implants that you know we can we certainly wouldn't ever say a name but we could go through the list of patients that we have in their mid to late 80s early to mid 90s that drive themself to the office have a consultation make the decision that they would like to have a dental implant and then proceed with the procedure and then go on to use it for any number of years later so I think that really is as part of the reason why we're seeing such growth.

Howard: You know if you google what is the success rate of dental implants of course WebMD comes up first because they're just big and they understand SEO and write their big letters 98% success rates of dental implants have a 98% success rate I'm do so yes it just comes down to how do you measure success I mean you have others other people saying that in five to nine years up to 40% of implants at peri-implantitis how do you I know how my patients determine success because I might be really concerned about an implant there's peri-implantitis there's bone loss but he has zero pain and he can eat a cheeseburger and you know he's a happiest guy so how do you define success of a dental implant?

Robert: You know it's funny you bring that up, I saw a lady yesterday in the office who had a dental implant placed probably ten years ago and it if you ask her how she feels about it she's going to say I love it fact I'm so happy that I have it however if you do it an oral exam you'll notice about two millimeters of titanium exposed on the lingual aspect of this implant and it's a lower molar the surrounding soft tissue is pink it's not inflamed there's really no probing depth there's no mobility to the implant is completely asymptomatic she loves it in my mind that implant is successful still maybe if you look from an academic standpoint if you maybe were to look in a textbook you may find a reason to argue at that point I think if if the patient is asymptomatic if they're happy with it if it's healthy, I think that's successful.

Howard: This is Dentistry Uncensored so I don't want to talk about anything everyone agrees and I like to go right to where the issues are I know oral surgeons like you two of them in the room practice together where one of them will place implants on smokers and the other one draws a line and says no and in some offices it feels like well if you're a smoker well you know you better go see the crazy man over there because he'll do but I wonder and so they went back to the academics you know they tell you what is the ideal case and it's always Karen your yoga instructor who's a vegan eating yogurt but then when they show up in your office oftentimes they're billy-bob and half of my cousins are from Oklahoma City I was born and raised in Wichita Kansas so I've been to your neck of the woods there's a lot of there's a lot of the Oklahoma boys that chew and tobacco everything they're not supposed to so how do you how does affect your diagnosing and treatment plan?

Jeremy: Yeah so you know as far as where do I draw the line where it's Dr. Bryan draw the line what qualities make you good you know the things we learned about a dental school and in kind of the implant lectures and you know as far as stratification of risk and so forth I think they're pretty applicable to to real life practice you know you get someone with great bone great soft tissue great health and you know a non cosmetic zone tooth there's certainly gonna be lower risk to that type of a case compared to changing only one variable you're putting into the cosmetic zone even with great tissue and great bone you that's that's still a more difficult case so adding in the layer of health you know they're it's hard to make a blanket statement I'll say that I feel like treatment planning should be customized and tailored to specific patients there's many patients who smoke that I have placed implants in and they are just wildly successful implants and so I see implants being successful in smokers I see a little more bone grafting failures in smokers for sure I think that that's it's been that's a little more troubling area but you know there's just for example you know a patient comes to mind he came in for a consult recently he had scramisaur carcinoma he had radiation treatment so you know that the radiation is his oropharynx was you know around 7,000 centigrade and so he and if you look at the radiation mapping in the areas of the mandible or the teeth would would be present they needs to have remove there's you know it exceeds 5,000 and on top of that he smokes two packs of cigarettes a day so he's already got compromised vascularity from radiation treatment and now we have additional vascular disease from the smoking so that's different than someone who smokes one pack a day and is I mean I'll say otherwise healthy I mean if you smoke there's you know there's obviously some health problems that are that are going on if you know about it or not but so I just I guess I don't know if I answered your question clearly but I think that it needs to be customized and there's there's patients where I have not done it who smoke and there's patients where I have done it and it's been very successful so it's hard to draw a you know just a really strong line in the sand there I think all the variables need to take into consideration you know something that we see a lot of is diabetes there's a lot of patients who have diabetes these days and so you know those type of health problems come in to play for sure they if they're not gonna heal well and they don't have good blood flow then you know there may be problems healing that implant.

Howard: So a more calm dentistry and sensory issues I'm you went you're added a robot assistant to CBCT right well a lot of people are still placing implants with Panos and saying dude I place 5,000 implants for the pano and then some of the lawyers are in the middle saying well a CBC is now standard of care while other dental attorneys on dental town say man if you ever figure out the definition of standard of care please let me know so I'm gonna add just Ashley the impossible question is CBCT the standard of care and placing implants?

Robert: I'll answer it like this and I get this line from my good friend here Dr. Goodson there's rarely a time when I wish I had less information and if I'm the patient there's rarely a time when I want my surgeon to have less information about me there's rarely a time when I would want my surgeon to be a little more unclear as to where my nerve is or the sinuses or an adjacent tooth is or you know perhaps an important thing to note would be how wide is the vote how tall is the bone would it what are the real angulations of the teeth because you do get distortion on a flat x-ray so I would venture to say that in my personal opinion I think a cone beam is the standard of care if I'm getting a dental implant I'm getting a cone beam.

Howard: Okay and is that and when we look at these big technology decisions one of the biggest issues the the young Millennials are having is there's open format systems and there's closed formats as I mean like Apple I have an iPhone but it's a totally closed system on androids open does Yomi is Yomi agnostic to CECT and work with any, is it a closed system that works mostly with one?

Robert: I think the biggest issue to conquer there is field of view so the system is open I would call it open yeah and the question that you have to answer here is is the field of view that your cone beam CT scanner is able to capture is that large enough to give the robot computer all of the information that it needs to adequately mark treatment plan and execute what you're trying to accomplish as far as openness to other dental implant systems as far as the brands are concerned there's full openness there as well so I think it's less important for a manufacturer brand perspective do you have the information that's available to accomplish the surgery.

Howard: That was the perfect segue for my next question um I always get dental students they're always saying on downtown or email me saying that I feel like I need to know which implant system to buy first because when I look at all the available training and programs for implants whether it's placing restoring whatever they're almost of them are provided by the dental manufacturer so they're like do you need to choose an implant system before then the other people are saying well when you took driver's ed it didn't matter what car you used from driver's ed you applied it to the car you bought so she's she's 25 years old she just walked out of dental school I know her only question is what implant do you use.

Jeremy: Yeah there are a lot of implant systems out there and I mean more than I could actually number probably so...

Howard: It passed 400 now.

Jeremy: Okay that's good to know I was actually wondering so I'll just tell you what I do and maybe that'll be helpful so you know I the predominant implants that Dr. Bryan and I place in our practice we place a lot of Straumann implants replaced a lot of Nobel implants and I will say this one important lesson that I've learned that I think pertains to the subject you're addressing is is the concept of we can't fall into the trap of thinking that there's one implant that will meet all indications across the board again I come back to the idea that we have to be customized in our treatment planning there's  cases where I felt like you know okay well it's for example most often I'll place a bone double implant and then we have full control of you know shaping the soft tissues and the transition zones however we like with the prosthetics but there's still cases rive you know even today in the you know where all we do here it feels like it is tissue shaping which is a good thing where I've placed tissue level implants because it's been indicated that's been better so I would say I would say to you know start with something and try to gain an understanding of of the restorative aspects of the care and then what parts of the implant system influence those restorative aspects and then you'll be able to make a decision so you know the basic concept of most of the implant systems are fairly similar you know as far as the surgical side of it there's you know a series of drills and the implant designs you know differ somewhat but you know if for example if you've got someone with a very very porous bone where you know you won't get a whole lot of high insertion torque well that's the case where I want to have a little bit more engaging thread design or else I may not get primary stability and you know there's cases where you just need a wider or a skinnier implant you know to fit or to make the transition zones correct and they're shaped and so so I'll kind of go but that's kind of why I feel like I have both of those systems available to me I mean I feel like they're both very user friendly in terms of restorative aspects and the surgical aspects so does that help that answer the question.

Howard: Yeah that does so what was it I don't want to be too personal but what was it like working with the company that you that makes this it's called Neocis and it was founded by an Alon Mozes a PhD how has your expectations everything matched up with this guy?

Robert: Well I'll give you a little background and how we got started with this as I was approached by the company on LinkedIn it's LinkedIn is somewhere I have spent quite a bit of time over the past several years building a network and when I when I was approached by the representative I recognized it as something that we were interested in and so I kind of took the bait I guess so to speak and they were really moving forward from that point just super incredible the gentleman that I speak of drove up from Dallas just a number of times it's a three-hour drive to not only tell us about the robot but they took it a step further the company actually has a type of dot 2 actually traveling buses that contain that the actual robot and so they drove the robot to our office and allowed us to to actually use it on a type of dot and so you know that was a big selling point for us we really felt like you know giving us an opportunity to use it and see it in action was very important in moving forward from there the installation was great you know they bring the robot to the office they spend an entire day setting it up calibrating it there's a lot of work that goes into that in advance even of that visit making sure that you have the infrastructure and IT capabilities to manage you know software and the robot itself not only from a hardware but software perspective then they spent a few days here training us on it and really if I were to grade the company on their responsiveness to our needs I would I would say an A.

Howard: Wow on dentaltown there's a case where a prosthodontist bought Yomi for his surgeons to use and placing them I thought that was a very interesting he just restores he doesn't place but he bought Yomi for his own surgeons to to use.

Robert: If you could just forward his name and number to us we'll be getting a contract contact with them just as soon as possible.

Howard: So has that crossed your mind?

Robert: You know it hasn't yeah as far as someone purchasing it for us or us purchasing it for someone else I mean we're you know we we we have great relationships with our restorative colleagues with our periodontal colleagues orthodontic colleagues other oral surgery call here in Oklahoma Cityin some other states as well you know we see a lot of people from out of state coming in from Texas and in Kansas in other places so we we really are about relationships that's really important for our practice. You know when we're thinking about a technology that's new like this and one that as I mentioned in a previous program I called a pioneering you know that's something that we feel we have a great responsibility for in handling it the right way not only for ourselves but for our patients and for our staff members we think that we have an obligation to handle in a certain way even as it pertains to the manufacturer because we really want to be a good team and so you know from our perspective you know we really like to be kind of in control of that so that we know that we're making really good choices for patients.

Howard: So this is Dentistry Uncensored so I don't pull any punches I go right to the most controversial stuff good luck with this one gentleman when you look around the world the anesthesiologist the epidemiologists have said that anesthesia needs to be a specialty and no longer in many countries are you allowed to go in the hospital and do the sedation while you're doing whatever surgery they've separated that and some countries England recently they told your profession that you guys can't do it anymore either when you're in the United States when you're in Oklahoma for example in all the hospitals I'm certain you have to have an anesthesiologist do this and a surgeon do this it seems like only dentistry is the place where the surgeon is doing the anesthesia do you think that'll still be that way in 10 20 a hundred years moving forward do you think that will come to an end,what are your thoughts on that anomaly?

Robert: I suppose there's several different things that would need to be considered when answering this question but what you know sometimes I give sort of subjective answers my good friend here gives very objective answers a lot of times from a subjective standpoint I don't feel the momentum or the pressure of that worry here in Oklahoma I don't have people calling me with concerns related to that I also think if you look at AMS if you look at oral and maxillofacial surgery in general the history of our specialty and the current mechanisms and parameters of care that we have in place I think we have a really good track record and I think it speaks for itself.

Howard: Would you you know just like Yomi robotic surgery didn't exist when I got out of school now it does do you feel the momentum is that anesthesia is getting safer and higher tech then say it was 20 years ago, 30 years ago?

Robert: Well certainly the types of medications that we use they're always changing and so you know one of the one of the problems with maybe previous medications that we would use would have to do with active metabolites and half-life and all that stuff so a lot of the things that we use now are so alternate cleaner they're short acting they're reversible a lot of times and you know in addition you know as I mentioned I think as an oral and maxillofacial surgeon we just have such a depth of training and a comfort level with those but I think as important we have a very very deep respect for what it means to be able to do the things that we do, we understand and feel you talk about feeling something that momentum what I think we really feel as it pertains to this topic is the gravity of that topic of the need for safety we also feel the need for redundancy you know you get onto an airplane and it the number of redundant mechanisms that are in place to make that safe I can't even imagine what the number is but I know that it exists many fold and the same thing exists in our practice of anesthesia and surgery in the private setting for oral and maxillofacial surgery we do have a checklist we have three people in the room at all times we have great monitors we have people that are that are on our team that are super smart and talented that care about our patients and they to feel the gravity of that and so that combined with our experience combined with the wonderful medications that we have and the equipment that we have in fact we just purchased recently a glide scope so glide scope is an airway mechanism that's a video actually type of laryngoscope that gives us even greater views of the airway so you know we not only invest in the things that we think that we need we also invest in the things that we hope we never need and that's one of them.

Howard: Do did Michael Jackson ruined the brand name propofol? You know I was having a beer with an oral surgeon and he's not very happy with Michael Jackson because everybody says that drug...

Jeremy: Well I'll just tell you it's it's kind of so I've actually believed a lot of patients ask me am I gonna get what Michael Jackson got and you know the the the drug that he received propofol is one of the workhorses of anesthesia in our surgery world and so of course the answer is you know depending on the case and you know health criteria permitting yes and so my answer that patient will be yes but the big difference is you're gonna have somebody monitoring you. I wasn't there okay I wasn't there when that happened with Michael Jackson I'm just talking about what I've read from news stories and that sort of thing but my understanding was that there was there was the monitoring was not there's not in place and that was the problem and so the problem was not the drug itself with the lack of monitoring and so I think to speak to Dr. Bryan's point about about monitoring you know there is a lot of monitoring that goes on I mean there there are standards of care I'm not just talking about you know we monitored it because it feels good or it sounds good there's actually standards of care that we meet to make sure the patient's safe.

Howard: Okay so on that note you walked into a perfect segue a big issue of mine for 32 years is that you guys are oral surgeons you're not general dentists you have all this training you just bought this new scope all these things and then in the hospitals they separate the anesthesiologist with the surgery and then my homies they go take a weekend course at Docs and they want to start doing sedation and then when my friends in dental malpractice and they send me the reviews of their settlements for the year or this or that whenever it's a million dollar two million three million dollars that they all have the same thing in common sedation someone died so what would you say to a general dentist and she's 25 and she thinks that she's gonna add sedation to her repertoire because she thinks that'd be a good marketing decision people will come in and want to have sleep dentistry?

Jeremy: Yeah it's very alluring and there's a lot of people who want it and so I can understand the draw for that and the walk for that and I really can feel that I really can't the and and I think that you know and I don't have data to back this up but I I know there were a lot of general dentists who offer that to some some level of sedation and the safety record numbers I wouldn't be able to quote to you but you know as I learned in my training I would say to those dentists the same thing that I that I was taught to me which is in the world of anesthesia and surgery and really dentistry you have to be prepared to handle the worst case scenario and so if your training is in a level of anesthesia there's very light and conscious sedation yeah that's fine but you know you need to have skill level to be able to handle deeper levels of sedation and general anesthesia and advanced airway techniques because anyone that provides anesthesia can tell you know that you can't always predict a patient's response to a drug you can titrate you can have good a reasonable expectation of what they may have but ultimately you judge the patient's response based upon subjective viewing but also objective data from the monitors and so you just you have to if you're gonna implement it in your practice you have to be confident that you can handle worst-case scenarios and I'm talking about things like Dr. Bryan brought up the laryngoscope you know ask yourself the question do I feel comfortable intubating someone.

Howard: Would Joan Rivers have been better served if her doctor had what you just bought?

Robert: Hard to answer that question given our limited knowledge of that particular case.

Howard: It was a laryngospasm wasn't it?

Robert: That's my understanding I that's my understanding yeah then I think that the glidescope probably would have been probably helpful in that case but you know there's also there's also the idea of recognition that's important in anesthesia so early detection of problems is really a big issue and you know that comes that comes with experience in many cases and so it's difficult for us to be overly critical of things that have happened but it's easy for us to speak to the idea of being well-trained in understanding.

Howard: You guys are classic gentlemen I love you for it but I'll just be a little more blunt it's a bad idea don't put an IV in someone's arm and if you ever talk to an attorney who just finished a case do you know what you look like on the witness stand when they bring in some PhD MD anesthesiologist and starts cross-examining you on the witness stand and there's a dead person that they're talking about I mean it's just a bad idea, it's just a really bad idea.

Robert: That's the gravity of what I mentioned earlier and we you know we think about those things often times and you know we're put into a strange position as oral and maxillofacial surgeons just by nature and so kind of navigating the labyrinth of these issues is something that we can kind of deal with on a daily basis I can say this about it I feel really good having the training that we have and the level of experience that we have I also feel really good just being in live situations during those training years where things happened that required us to act in those ways and actually do those things in real life that's very hard to simulate it's very difficult to simulate so I think you know we're just we're just really thankful that we have the training that we do.

Howard: I'm so honored that you guys after a long day at work just like to hang out with me and my homies I'm trying to wrap this up real quick just hitting all the controversial buttons like can and temporomandibular joint surgery replacing custom joints you know you got to remember when I got in 87 they had that big issue and at LSU where they're putting in artificial joints and they were falling apart is is temporomandibular joint surgery getting better is it a growing part of the solution of TMJ issues, is custom joint replacement growing or is it shrinking what would be the update as we're going into 2020 so hopefully at 2020 I'm hoping everyone will be able to see more clearly at 2020 how does TMJ joint surgery and joint replacement look different today than say 10 years ago or 20 years ago?

Robert: You know I think I'll answer like this the custom joint replacement surgery I would say is better now given the high definition CTs that we have the CAD CAM capabilities that we have the material science that we have so from a I guess quality standpoint I would argue that the custom-made temporomandibular joint replacement is is better now though it was that several years ago I would also add that we're learning more and more about conservative therapy we do an awful lot of arthrocentesis in our practice you know there are a lot of people that have problematic joints that don't necessarily need a surgery and so oftentimes we can do something fairly conservative like an arthrocentesis with some physical therapy that will take care of a lot of the problems there's also the issue of

Howard: What's the word you're saying now can you spell it for me?

Robert: Arthrocentesis arthrocentesis arthrocentesis and so that's basically a procedure that we have these featured on our Facebook page actually where you put a couple of ports into the joint the encapsulated joint space ones an inlet an outlet flush fluid through it deposit any number of things sometimes steroids local anesthetic sometimes PRM.

Howard: Oh interesting so is that a is TMJ surgery a big part of a practice or is it more a rare thing?

Jeremy: Well we so we certainly see a fair number of TMJ patients you know the types of TMJ procedures were doing are definitely a lot more on this conservative end you know you use I like how you brought up so I'm gonna tie this into a question you asked earlier you brought up the idea of anesthesia and training and you know we can throw an implants or any number of things in there but you know as far as being able to perform a procedure really well that's something where you'd want to have a lot of experience so you talking about anesthesia if you've had months and months of experience and hundreds of cases that's experienced so that gives you it gives you knowledge and it gives you intuition and so if you look at an oral maxillofacial surgeon that's doing total joint replacements for the temporomandibular of the joint on a regular basis there's gonna be some experience and in training the understanding that they have that someone who does a very infrequently just wouldn't have and so it's really for that reason for me that I just I don't do total joint replacements in some temporomandibular joint I certainly learned about them in my residency and participated in those surgeries and I could have chosen to go that direction more but you know there's such a broad scope in the world of world of oral maxillofacial surgery and it's it's difficult to get a sense of expertise and everything and so if you really want to become an expert it's you know do a little bit better job if you narrow your scope just a little bit so yeah I say that but I do see a fair number of TMJ a patient's I probably see a TMJ patients every week but I'll say that there's you know there's a lot of success that we have with conservative measures and then you know in case you identify a case that needs something more invasive and are able to help get a patient you know what they need.

Robert: I'll say this too about it is I think dentistry in general would do itself a favor to keep this in mind you can be an expert in a few things or you can be mediocre at a lot of things and to speak to doctor good sense point we just choose to limit our practice to those things that we think we're really good at.

Howard: and the other thing I want to tell you kids is that you you can't fight centuries of macro economics so in 1900 healthcare is 1% of the GDP no specialists at the end of the century 2000 it was 14% of GDP the physicians at 50 specialties we had nine now it's 2020 healthcare 17% of the GDP and we just added another specialty so the trend is that there's so much information that everybody is specializing there specializing in economics are specializing everywhere and there's just no way in the world we're going back to 1900 with a super doctor that's gonna do it you know a place your implant do a bone graft treat your screaming three-year-old I mean it that's just not where we're going we're going and you said earlier you said there's rarely a time when you want less information well you well you can structurally have almost no information if you want to be a jack-of-all-trades it I just don't see successful people being an expert and everything just two more controversial questions I'll let you go I know it's in your day and you're tired. We have Millennials now there have access to a lot of information so there and they're my friends and Phoenix they're there where the doctor says yeah we circumcised all baby boys they're saying well hey slow down slow down we remove wisdom to slow down slow down so you're having a generation that has self-esteem access to information and they just don't believe and that every male born should be circumcised and have his wisdom teeth pulled out are you feeling this generational pushback where people are challenging this diagnosis that I need to have my wisdom teeth taken out prophylactically at 17, 18 years of age or something that might go wrong when I'm Grandma and Grandpa?

Robert: You know I would I would refer back to an earlier comment I made about AMS you know they put out a nice white paper on this I think it speaks for itself as far as the evidence goes to support the removal of wisdom teeth and I'll say this about Millennials first of all we love Millennials you know that it's really awesome in stimulating to sit down with somebody who has access to information because then you can have a conversation with them about what are the risks benefits and alternatives paternal medicine is over you know there is no such thing as paternal medicine no it is what are my options first of all what's the diagnosis secondly where are the treatment options then what are the risks benefits and alternatives and now let's have a discussion about that the other thing I love about Millennials is we can reach them very easily we just have to get inside their cell phone so Facebook makes that really easy for us to do Google makes it really easy for us to do I mean you could go on and on and on dentaltown I guess makes it easy for us to do and so I think it's exciting I love taking a Segway here I apologize but I love the marketing aspect of what that offers for our practice and it's all about connecting and forming relationships with people and such as yourself even in people that are in other countries you know we have conversations routinely with people that are that are in other countries that certainly are in other states all the way across the country and it's stimulating it's exciting and I think just like this robot we embrace that we're looking forward to more of that so I hope that answers your question.

Howard: Yeah it does that is a thanks for bringing up that paper I just saw post that as soon as we're done let's see I had a what was my oh yeah orthognathic surgery you work with orthodontist would you say that orthodontist or using orthognathic surgery the same way they did 10 20 30 years ago is it a procedure that's going to the wayside is it making a comeback what give us an update on orthognathic surgery as opposed to a decade or two ago?

Jeremy: Well as far as the number of people using it there's a lot because it keeps us busy so and orthognathic surgery is something that we feel both feel passionate about and we love to do and so that's an area we've chosen to include in our practice because we like it and we feel like we can do it well so as far as as far as you know how is that how is the trend changed to 20 years ago I'm not sure I'd be the best person to answer that trend type of question it's I'll say there's there's a lot of orthodontists we work with and they tend to be very good at identifying the problem and how to correct the problem and and recognizing when something beyond traditional orthodontics is needed to help correct the problem namely surgery now even when that is recognized it doesn't mean that the patient's automatically then wants to have surgery so they also have to be good at coming up with alternative ideas and so you know there's your plan A and your Plan B and so you know sometimes patients accept it sometimes they don't and you go out to Plan B but I can tell you that that's an orthognathic surgery just like dental implants and Yomi orthognathic surgery in terms of how precise we can get in our planning and our execution so you didn't ask this question but let me ant let me answer this question just because it's it's you know if it's with this whole topic of robotics and you know virtual planning so you know for many many years orthognathic surgery was you know it was planned with impressions and models and in your lab and your articulator and you know your model surgery that you cut them all you cut the stone models and you make your splints out of your polymethyl methacrylate sand that sort of thing and that's very good that's very good and it gets good results and so why change it well because there's ways to make it better and so nowadays we have ways where we can do all of those things I just said virtually so you take impressions get some models you get 3d files of those models and and you merge them in with the patient's CT scan and then using software you virtually perform the surgery you set the jaws where they should be and then using 3d printing you you create splints that in the surgery fit the upper lower teeth and position the jaws exactly where you positioned them in your 3d planning your preoperative planning and so the level of accuracy we have that is it far exceeds what we used to have 10 or 20 years ago so that's an area where it's really changing and so I'm especially speaking of Millennials you know you know technology speaks to them because they were raised with it and so you know I get people at church for people on my street coming up and saying hey I saw your videos about about your 3d planning for jaw surgery that's so cool I mean that's amazing I you know and then another parents will say oh I had that surgery when I was younger I wish I would have had you know the ability of you virtual planning that was just so cool. There's cases where they're super straightforward and you could you could totally easily accomplish them with the old methods but there's cases where there's subtle asymmetries or little changes where gosh you know without this 3d planning and ability to just fully control it it'd be tough to to get it right and so you know this whole idea of 3d scanning you know virtual software robotics all that that that plays really well into orthognathic surgery, orthognathic surgery is changing the world is changing were able to do the surgeries more accurately we're able to do the surgeries faster now than they used to be done years and years ago they're the hospital stays are shorter you know 10 or 20 years ago maybe they were wired shut they're not wired is that anymore so stuff is changing it's a lot more accessible to patients.

Robert: Yeah I think to speak to your question of is orthognathic surgery a growing thing logically speaking just from my perspective when I look at companies investing at Grit what I believe to be a great deal of money and coming up with virtual surgical planning software and techniques it's an indication to me that it's a growing practice and when I look at our own practice and the number of cases that we do it's it blows me away how busy we are with it and we just kind of revel in it and think it's wonderful you know it's kind of like dental implants dental implants work we know they work that's why we love doing them, that's why it's so easy for us to talk to people about them jaw surgery works and the results are incredible it's so easy for us to sit down with a patient and recommend it because we know it's the right thing and it works.

Howard: Well I'm sure at the end of the day you guys wanted to go home and have supper with your family and kids and it was just an honor and a privilege to have you join us after work today and talk to my homies about all things oral surgery thank you so much for spending an hour with us after work I hope you the rest evenings goes well.

Robert: Likewise, thank you and we look forward to coming back and visiting with you.

Howad: Hey if you ever want to come back and talk again and come back and talk and we'd love it that's fantastic.

Robert: Okay thank you so much.