1487 Oral and Maxillofacial Surgeon Jim D. Bates, DDS, MD on Repairing Faces with Orthognathic Surgery : Dentistry Uncensored with Howard Farran
Dr. Jim Bates, born and raised in Lubbock, Texas, attended Texas Tech University before graduating with honors both from the University of Texas Dental Branch at Houston and Texas Tech University School of Medicine. He completed his residency training in oral and maxillofacial surgery at the University of Texas Health Science Center at Houston and is a Diplomate of the American Board of Oral and Maxillofacial Surgery. In 1995, Dr. Bates founded Texas Oral and Maxillofacial Surgery, which is currently celebrating 15 continuous years of Joint Commission accreditation as an Office-Based Surgery facility. He is a Fellow of the International Team for Implantology (ITI).
VIDEO - DUwHF #1487 - Jim Bates
AUDIO - DUwHF #1487 - Jim Bates
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**Please excuse any typos as this was digitally transcribed.
It is just a huge honor for me today to be podcast interviewing dr Jim Douglas Bates DDS md oral and maxillofacial surgeon at Texas oral and maxillofacial surgery diplomat American board of oral and maxillofacial surgery fellow American association of oral and maxillofacial surgeons fellow international team for implantology man dude i got a treat for you today this guy's amazing he was born and raised in Lubbock Texas attended Texas tech university before graduating with honors both from the university of Texas dental branch at Houston and Texas tech university of medicine he completed his residency in oral and maxillofacial surgery at the university of Texas health science center Houston and is a diplomat of the American board of oral maxillofacial surgery in 1995 dr bates founded Texas oral maxillofacial surgery which is currently celebrating 15 continuous years of joint commission accreditation as an office-based surgery facility he is a fellow of the international team for implantology um what the reason that i got him on the show and i can't believe he took the time to come on um is uh his orthognathic surgery cases are just mind-blowing i mean they're mind-blowing and I’m also surprised you came on because after the Arizona cardinals just destroyed you this week in Dallas in front of your hometown i thought for sure you would just cancel and say I’m not talking to any Arizona cardinals man today I’m very much on the fence [Laughter] i honestly don't follow the cowboys but I’m sorry to hear that they lost anyway oh my gosh um so i um i mean you um your cases are shared on social media i don't even know if you're aware about the case i see cases all the time on social media and it's like i know who did that and it's you um first of all um talk um i want to start with Dallas Texas um you're a DDS you're an md this is October 10th um a lot of people are saying that uh covet is having a comeback accelerated cases uh you would know for far more about it than i would uh what what do you think do you think we're gonna have a fall surge i think we will have a small fall surge we are having one in Dallas already august September dropped way down and now we're starting to see a rise again now are you the dentists are mostly scared about you know they may just close down for two months right so if you've got a 12-month business and you get a doughnut for two months in a row it's it that that's really hard on the income exactly the profit because you're still going to pay your bills you just don't want to have any profit do you fear that maybe a second shutdown will be coming that seems to be the biggest fear on dentists minds is that a possibility i think it's possible in Texas we have a governor dr uh governor abbott who's a pretty reasonable guy and he's the one who shut us down in the spring along with our county judge jenkins and we were closed for about seven weeks and then allowed to open back up i think if we see cases continue to rise as they are right now we may see a closure of schools we may see a closure of movie theaters but i doubt if we'll see another closure of health care practices I’m only worried about the bars but that's just you didn't mention bars how did the bars look the bars are uh you know they're they had they they're open but they allow only for limited attendance i can i can sit in there alone no problem no problem um uh you're i mean if you're uh manny if you got to go to his website it's texasoms.com Texas oms for oral maxillofacial surgery go to forward slash orthognathic surgery um my illusion of you is that that's all you do i mean is that what percent of your practice is orthogonal it's probably 60 percent yeah and uh the other 40 is tmj surgery reconstructive oral surgery bone grafts guided tissue regeneration dental implants taking out impacted wisdom teeth dealing with impacted canine teeth doing distraction osteogenesis corticotomies are getting to be a really big deal for orthodontic assisted orthodontic accelerate surgically accelerated orthodontic treatment like i feel like I’m interviewing a uh mermaid riding a unicorn i mean this is a uh barrier i mean my oral surgery friends over the last 30 years here in phoenix told me they said you know orthognathic surgery is 90 of my stress and five percent of my income I’m just going to delete it and they've never been happier and then there's guys like you just said uh i'll keep taking them um is it a um is that per is oral surgeons doing what you're doing is that trending downwards is it been trending downward for decades yes ever since managed care came along in the late 80s early 90s the reimbursement from insurance companies four covered procedures has been extremely low and it's just it's a sisterhood with medicine it's the same way medicine and general surgeons and ob gyns are being handled um and so most neural surgeons find exactly what you said it's ninety percent of my headaches and stress and five percent of my income so they quit there are a few of us that have continued to maintain it and actually grow our practices as a result of that and we're able to do that because insurance companies don't pay for everything on a patient's treatment plan and the rest of it is where the reimbursement is adequate enough to make it worth your while plus that's what i enjoy doing that's why i went into oral surgery was specifically to do orthognathic surgery so you were just you were raised with so much pain and suffering you just wanted to stay and get more is it for punishment so when you say first of all when you say managed care i think that's so funny because uh managed care it's like uh they always name something on the enemy like uh like i always say um you know when they advertise two scoops of raisins and every box of raisins brand you know there's no raisins uh when they when they advertise a warranty on a car you know it's no good it's like the free trade agreement it's like okay when you spend six years and it's a million words a free trade is like hey you two are free to trade so it's not free trade it's the exact opposite of free trade it's the most highly regulated crazy stuff but uh or do you still participate with the managed care fee schedules i do for covered services that's the key phrase um so much of what we do to get a patient ready and to do the actual surgery is considered not covered so the patient's responsible for it the part that is covered is so small that that we can manage that and live with it and because of volume we can make up for it interesting so um orthognathic surgery is that just basically lefort one two and three it's really uh primarily lefort one in multiple segments it's we typically do a horizontal maxillary osteotomy at the lefort one level below the nose or at the nose and then segment the maxilla vertically so that we can expand the maxilla and then we move it up down forward back wherever it needs to go lefort ii involves including the nose and will afford three and involves including the cheek bone so those are pretty rare and then there's mandibular surgery which is primarily sagittal ramus osteotomies so I’m so old i can remember when they were doing subperiosteal uh implants and ramus frames i remember those i remember those very well and actually wrote an article on alternative implant systems and subs and ramus frames were really popular back in the 80s well i want to get right to the chase um when you're talking to a dentist a hygienist they're getting a teeth clean they're talking to the hygienist they talk about i don't have a chin when i smile my liver shows and they start talking about the surgery everybody freezes up because they're worried about paresthesia yeah and um is that um compared to 1980s to 2020 40 years later is there significantly less paresthesia than there was in the 80s yes we know that across the board if you take all comers from teenagers to people in their 70s orthognathic surgery causes a temporary nerve injury in virtually 100 percent of patients but in eighty percent of those patients it completely resolves now isolated maxillary orthognathic surgery at the lefort one level results in numbness of the skin of the midface but it always comes back a hundred percent the lower jaw from the mouth to the neck has about a twenty percent long-term neurosensory dysfunction rate which means simply that people probably don't gain a hundred percent of their sensation back about 20 of the time now that's usually in older patients uh because nerves heal very slowly and even more slowly in older individuals and they may never completely recover in people over 50 or 60. i heard a scientist say on television one time that to take superman they say superman's spinal injury was actually healing it just would have taken a couple of centuries for it to uh um work is that what you're kind of saying that it's healing just not gonna heal in his lifetime right um so um now are you doing this um out surgery or is this a hospital-based or i would say most of our procedures are inpatient meaning that patients spend one night in the hospital and they're not truly on an inpatient basis they're there on an observation basis according to the government if a patient is discharged within 23 hours don't ask me why but it's 23 hours then they're considered observation if they say more than that they're impatient so most of our patients are on observation basis they spend one night in the hospital and go home our single jaw patients like if we just do an upper jaw or just to a lower jaw we're doing those on an outpatient basis where the patient goes on the same day or we do it in the office under general anesthesia because we're in accredited office based surgery facility we can do that and send patients home with a nurse to watch them overnight wow and um i guess um the anesthesia is one issue i guess the better issue would be um have you ever asked them if you had to do this all over again would you still do it or knowing what you know now a year after the surgery would you not recommend it what kind of feedback do you get on that that's a really good question howard i ask every patient that very question at the end of their treatment after their orthodontic treatment after their surgery after their cosmetic dental treatment whatever they're going to have when it's all said and done i always get them back for a final set of records photographs and the last thing i always say is exactly what you said if you knew knowing what you know now would you do it again i would say that i've had one patient in the last 30 years say no most people are very appreciative of the outcome people can breathe better they can talk better they can chew better they can swallow better they're free of pain we relieve obstructive sleep apnea those patients in particular are very appreciative because they don't have to be on cpap or a mandibular advancement device those people who are in pain from temporal mandibular joint problems are very thankful to have undergone treatment so i hate to put you on the spot like this but someone under orthognathic surgery under oral maxillofacial surgery asked um hello can anyone explain to me what is the dirk lek procedure and how it is used to correct a prognathic mandible is it considered orthognathic surgery and if yes where can i find information about this procedure thank you have you heard of that procedure you know i have to confess i have not say it again dirk lake der click d e c k l e r k well that's news to me howard um and then i heard a uh then the guy replied he goes ella clark procedure is performed on the zygomatic arch most often for chronic condylar dislocations not sure if any of this a name for prognathia do you think do you think when he sees said dirk luck he's thinking i'll look clear yes that's probably what he's thinking the clerk procedure is actually an imminent where we make a horizontal osteotomy and the articular imminence right in front of the temporal mandibular joint and down fracture it as i recall unless I’m misunderstanding him down fracture it to prevent the condyle from dislocating repeatedly okay so um you know humans you know the number one goal of the species is to survive long enough to reproduce so is most of this you know i call it the peacock syndrome you know my when i grew up in kansas my neighbors had peacocks they were beautiful they were loud and noisy and crazy but um i understand it when animals and birds of feathers go out of their way to look as pretty as a peacock is what percent of what you're doing is just to make me look prettier uh so i have a better chance of reproducing and having offspring versus form function chewing breathing all that you know that's a really solid question i think it depends on who's looking at it from a patient's perspective it's very that's a that's very high on their scale of importance and value on my scale it's probably down in the middle or lower third everything we do is a combination of function and aesthetics there's nothing that we do including dental implants or uh taking out wisdom teeth or anything else that's not a combination of function and particularly orthognathic surgery because function and aesthetics are so intimately connected they're so interconnected that the way a patient's jaws are formed will affect their function very prominently and if we fix one we fix the other and so commonly the it's been shown studies have shown that the main reason patients seek treatment is for aesthetics but their improvement in form and function are what they really are thankful for at the end my gosh i got so many uh um questions i could uh start asking you on i just want to go in um is there anything else you want to talk about orthognathic surgery i mean um for my for you know for our listeners right now at 25 are still in dental school and pretty much all are under 30. podcasting is a young thing you know they're on tick tock and instagram not uh are you on tick tock or instagram or not i am on instagram not tick tock but are you on it personally or just marketing for your business just marketing yeah um everybody thinks I’m big into social media i don't realize i it's only for dental town it's not for you know if i want to call my mom i just call my mom i don't facetime or uh facebooker or something but um on orthodontic surgery what do you think the kids in dental school um and uh and the dentist fielding questions from consumers about that because on these instagram and social media influencers i mean gosh they're doing butt implants calf implants but it seems like the most common question that i see on social media and asked by the patients is when they don't have a chin they should i get a fake chin or should i get the lower jaw surgery right and then the and then the opposite is the maxillary when they smile and half their liver shows they don't know if they should do to periodontist cosmetic surgery or should do orthognathic so could you answer those two questions well certainly there are degrees of correction that we can accommodate in other words we can compromise on somebody with a really short lower jaw and small chin we can do a chin implant or do a sliding genioplasty which is actually a better procedure and not do the full blown mandibular advancement it's less surgery it takes about an hour to do a chin operation and it's clearly outpatient and patients say yeah i want that i don't care about my bite but when we look at these people critically they always have malocclusions and that's one of the thing one of the things i'd really like for your really young dental students and young dentists in practice to really be aware of is to look for those occlusion changes look for those malocclusions those severe class ii occlusions those open bytes those class three or cross bite or underbite malocclusions those are the things that where they can really make a difference in a patient's life if they say hey you know you've got a really bad occlusion in addition to your weak chin why don't you go see the oral surgeon take a look and see what they can do and then we have the opportunity to discuss with the patient work them up for two plans one for the whole shooting match so to speak the upper jaw lower jaw chin and then the second one for strictly cosmetic reasons that won't address function won't address their occlusion won't address their pain but will very effectively address their cosmetic concerns nice tmj i even hate to bring this up because it doesn't seem like the endodontists really have any um big feuds or they don't really fight over much anything um per pediatric dentistry i can't believe after 30 years they finally got an issue to argue over with silver diamine fluoride right uh but tmj i don't think there's anything they agree on i mean it's kind of like international world religions i mean and they we have some good data now that's pretty solid we know that most patients don't need surgery most patients have myofascial pain in the side of the head and the side of the jaw and not joint pain and those patients who don't have an internal disc displacement are the really the only ones who need surgery now the ones with myofascial pain usually have a malocclusion and are usually nocturnal bruxers and may have sleep apnea and all of that goes together most of those patients can be managed non-surgically with muscle relaxants non-steroidal anti-inflammatory drugs and splen therapy but the splunk therapy has to be really good splint therapy i don't do splint therapy but i can evaluate and recommend good splint therapy and a splint needs to be hard acrylic and not flexible and not soft and rubbery not an essex retainer it needs to have anterior guidance with cuspid discollution in all excursions and that's a good splint now if those patients have pain that's in the joint itself and they're popping and clicking and they say that hurts those are the patients that we can help with surgery with minimally invasive surgery that's very successful arthroscopy is about 70 percent successful arthroplasty is about 95 success a minimally invasive arthroplasty through a modified endural approach on the inside of the ear with an incision that's about an inch and a quarter long allows us to pull the disc back and tie it down to a mitech mini implant and that's a two-hour operation patient goes on the same day and takes a few days off nice um so um god i guess so many questions to ask you um i don't know where to start but when you were talking about the tmj and the myofascial pain and uh things of these sorts um when i got out of school there were only nine specialties and now we've added some more um we've added oral facial pain we're oral medicine um what um what are your thoughts on that was that a good thing do you um when you have a tmj patient you're doing a workup do you send them to an oral facial pain guy or um you know i often do because I’m a surgeon that's what i do that's what i like to do that's what i prefer to do i don't do splint therapy i don't do iontophoresis i don't do physical therapy i don't do massage or laser or any of the other things that can be done non-surgically i think that kind of management is effective for about 90 days i think you ought to try it for 90 days and then come to a decision we're either going to keep doing that or we're going to go to surgery um when i was little and got out of school in 87 what i see is oral medicine that would i just would have sent him to my oral surgeon i mean you know I’m not going to send him to the pediatric dentist I’m um how does how was oral medicine if you were a young kid and you just started your practice and you're working um as an associate where what would make you want to send this person to oral medicine or oral facial pain versus um we used to throw it just throw them to the oral surgeon right and I’m very thankful for oral medicine being a specialty particularly oral medicine because those are people that really focus on soft tissue lesions um [Music] kind of traumatic ulcers dry mouth tongue sore tongue the kinds of things that i can't really diagnose or treat i can't operate on a dry mouth um you know i can't really help them but oral medicine a person a dentist trained in oral medicine that's done an appropriate residency or fellowship really has a whole cadre of support mechanisms particularly those that are in training centers that they can throw at the patient and you know something will stick something will help them but they can do little tongue biopsies they can have them change their mouthwash they can have them change their dentifice they can have them change their oral habits and that's not stuff that i can really do i mean i I’m not very effective at that I’m not very good at it i still see patients referred to me for dry mouth sore tongue but i refer them to our local dental school stomatology clinic to my knowledge we don't really have anybody in oral medicine yet in Dallas that's interested in doing those cases well do you hear that kid you're in the middle of the pandemic you don't know what to do go specialize and because the trend line two young kids um one of the biggest mistakes i see which doesn't make sense to me you know live your own life you weren't born to live howie's life but in 1900 there were no specialties and health care was one percent of gdp by 2000 there were nine specialties in dentistry 58 in medicine and it was 14 of gdp now it's 20 20. it's up to the 88 dentistry's up to 12 specialties uh it's up to 17 percent of gdp i mean we're not going back and then i hear these young kids to say well i want to learn how to do invisalign and implants and endo and i love their youth and enthusiasm but when you live in a country that mails out 40 000 health care journals a month you can't be a jack of all trades and um and even Texas your home state you're in Texas there was even a lawsuit we're talking about especially is where um the Texas us district court sides with the American academy of implant dentistry on specialization lawsuit um these guys with the aid were saying well we specialized implants and it went to court and their the defense was well the ada doesn't recognize it and the judge basically said well that's a membership organization that's not a regulatory agency i mean um so what do you think that dental implantology will eventually be especially will orthognathic surgery eventually be especially where do you draw the line on these um right i do think that dental implantology will and is already seen as becoming a specialty by lots of folks i don't think orthodox or tmj surgery will just because there's just not that much demand i mean it's not enough to support that many dentists but i clearly think dental implants are a huge market share for dentistry for endodontists and periodontists and oral surgeons and general dentists and who knows with prosthodontist and i wouldn't be surprised if they do if they are successful in carving out a dental specialty um there are a couple of organizations the aaid you mentioned then there's the academy of osseointegration that have fellowships in oral implantology that are legitimate and they have boards and they take a test and they're you know legit all the way i think i wish them well i as long as they advance the outcomes and improve care i think it's I’m all for it and you're involved with another one you're involved um with the um oh i had it right here in front of me um on the iti the international team for implantology tell us about the international team for um for implantology well the iti is an organization based in Europe and it goes back decades many decades to the very beginning of implantology not only dental implantology but orthopedic implantology and other many other kinds of implantology it's it goes back to purring my brandmark uh it really was one of the very first European organizations to really develop the research to back up the legitimacy of osteointegration of dental implants they did the basic research they published it they have a journal the international journal of oral and maxillofacial implants and they they're very solid they have published textbooks on a variety of implant procedures from very beginner to very advanced and it's an invitation group i was very honored to be invited to join them um it's a it's a really super super organization you know one of the things that um has always helped me as um you know that we're we're one species um we have the same problem like i like architecture because when i go around the country i mean take something simple like a bathroom a shower i'll never forget when i was taking a shower in Austria i mean it looked like that it was designed for uh the space shuttle i mean it had right more plumbing and knobs and backup features and I’m like oh my god these guys are serious engineers but what i like to see in dentistry is where are is the same doctor looking at the same patient with the same disease and they're treating it differently um do you see any variances um i mean little things like um you know some countries it's all air driven hand pieces other it's electric hand pieces right um do you see any oral surgery variances where you think we're all really smart oral surgeons and we're seeing this differently any things like that i do in in Europe it's a little bit different system if you are a uh an oral surgeon in Europe really limits his practice or hers to procedures on the inside of the mouth in other words they really don't do orthognathic surgery or tmj surgery or facial trauma surgery or cosmetic surgery they pretty much specialize in dental implants soft tissue grafts bone grafts guided bone regeneration things of that nature then there are maxillofacial surgeons who are dual degree dentists and physicians and they're primarily involved with more advanced orthognathic and tmj surgery and facial cosmetic surgery so it's more of a division in Europe than it is here here in the states back in the 70s our organization our national organization decided to change its name from the American association of oral surgeons to oral and maxillofacial surgeons and we've kind of got the big tent of both true oral surgeons and dual degree oral and maxillofacial surgeons under one umbrella and i think that's i like it better this way because i can go to meetings and learn about dental implants and teach on orthographic and tmj surgery um and uh i can't really you can't really do that in Europe if you're an oral surgeon in Europe you're limited on what you can do so the um one of the things that kids point out and it's very obvious in America in our country um they come out of dental school they want to learn more about oral surgery but they look at all the available education and it all seems to be aligned with a manufacturer like you know the big ones you know strawman or or noblebiocare or whatever and they just routinely ask year after year um well do you have to pick an implant system because if i go take this course it comes with you know 10 implants or a starter kit and all this stuff and then of course they're going to um they're going to ask guys like you are are you agnostic to implants or is it just easier for you to only work with one system what would you tell a young kid in Texas who wanted to get into implants um i would say get really good legitimate training at a center i think the weekend courses put on by the manufacturers are okay for people who've had five 10 years experience in dental implants if they want to add a system but i think to get real unless they're getting this in dental school now and i honestly have to say i don't know i haven't been on a dental school faculty for the last few years but if they're getting in dental school basic science exposure to multiple systems then that's fine if not i think the dental the dental schools the continuing education departments really need to to supply that academic legitimacy to implant training i've been disappointed i know exactly what you mean every manufacturer has a course um and you can't be an expert in everything you can't do eight different implant systems in your office it's too expensive you have to buy a system you have to buy separate everything you have to keep an inventory it's just not practical how many systems do you work with i work with one system and that's i work with strawman because it's connected to the ipi uh that's really my connection to to strawman and the iti i i had the honor and pleasure of being invited over to Europe uh years ago when strahman first introduced the iti into the united states and we got to tour the facility and so i have a uh long-standing relationship with them but i'll do a nobel case if a restorative dentist or prosthodontist wants a nobel implant there are other systems that that are based on but really don't have the backup of the older systems that are just i just am a little uncomfortable [Music] using a lot of those systems and um i am really um i i had the uh the old ceo of um strawman marco godola um on the show and that was uh an amazing um he but it seems like strowman's also been doing uh kind of like a big wall street m a they've been buying uh what is it uh uh keep it simple in uh Israel or was it keep it simple i think it was keep it simple in Israel they bought neodymium brazil south America and they bought um a a and one of the orthodontic aligner companies i think it may have been clear correct or something yeah i could be wrong but strawman has its hands and lots of stuff and and i remember so so here's this is a um let me set this up for a second you know when when pierre brandmark who passed away um when he came to America i remember you could only go to the course if you're an oral surgeon and if you snuck in you know you were asked to leave and it was just oral surgeons and that might be product placement introduction he wanted to get his protocol out right and it took years before periodontists were allowed to come to the party and now it's opened up to to everybody but the but the young kids um they're afraid to ask you can i come watch you do an implant because they're thinking that you would say well that's how i make my living you go make you're living somewhere else and then they get on an airplane and they fly across the country and they go pay three thousand dollars for a weekend course and then when they get in trouble and they step in quicksand um that that guy lecturing you know 3 000 miles away isn't there and i always tell him you know if when i wanted to learn more about endo i drove over to the greatest endodontist i know and just asked if i could you know stand behind his assistant um is that really a thing and now also with all the big meetings cancelled because the pandemic everything's virtual people are saying well where am i going to get a hands-on course and i said in what and they go endo I’m like there's no endodontist in Dallas right really you have to fly to georgia you know we have an obligation as as professionals as people with advanced education we have to share our knowledge our experience with the new generation coming up that's our responsibility it's not optional in my opinion and yeah i get young dentists all the time who say hey can i come watch you take out a set of wisdom teeth can i observe you placing some dental implants and i am more than happy for them to attend physically and to help them get started in that any way they can now uh that's you know it's a little bit different when it comes to orthognathic surgery or some of the other things but most of the young dentists that i see that are calling me to say hey can i come watch are interested in two things that's wisdom teeth and dental implants and I’m more than happy to share any knowledge or experience of mine with anybody that's properly trained you know I’m not going to bring in a an accountant and show them how to take out wisdom teeth do you have any slide lecture presentations i do i have many oh my gosh i i do any i drive to Dallas to have you post them up on dental town that they just like really oh i mean we put up 400 courses they've been viewed over 1 million times and what they tell me is that um you know um um i mean it's cheaper to take an online course than it is to take a cab to the airport to go fly to a convention and now the conventions have been taken away I’m still confused about greater new york in two months after thanksgiving they still haven't officially yeah canceled or anything and i've i've gotten some notices from them it looks like they're going to try to still have it wow but the beginning of the show we're talking about a spike increasing um and and new york um i i don't want to get i never want to talk about religion sex politics violence but taiwan and new york both have the same population and taiwan had seven deaths and new york had 34 000 deaths right so i i doubt they're gonna have the greater new york meeting of people flying in from around the world but i i don't know stranger things have happened i hope they don't here's a here's a question um that i think only you could answer a lot of the kids wonder um you know they extract a tooth so they bone graft or not and they just keep getting all these different messages so she's pulling a tooth uh when when would you recommend bone grafting and when would you recommend not well almost always i'll put it that way i think unless you're unless it's a situation where the dentition in general is just totally hopeless and you're going to go with an all-on-four or zygomatic implants or pterygoid implants you really need good alveolar bone within the dental arch now uh you can take out one tooth at a time and and bone graft that or you can take out a bunch of teeth and bone graft that but i think most of the time with the population that most of us are dealing with we're dealing with single tooth extractions on pretty healthy people and they're eventually going to want an implant if a patient says no I’m never ever going to have an implant then there's no point in doing a bone graft but i don't think many people will take that stance i think most patients will understand the need for a bone graft i think it ought to be simple i think it ought to be fast i don't think it should be complicated or difficult there are lots of products now that are available specifically for that purpose that are very effective and simple and easy to use and don't have that much cost to the procedure so um sometimes they hear that if they bone graft it only makes sense if you place an implant within a certain amount of months true or false no i don't buy that you don't buy that i i think if you're using it depends on what you're bone graphing with if you're bone grafting with allergenic real human bone that's true it's only valid it'll resorb in about it six to eighteen months but that's not what i use honestly i mean i i will use inorganic bovine bone that's cortical i'll use uh typically bios or bios collagen as a product that is resorbable but very very slowly reservable and is ready for an implant in six months i will also very more commonly use a product from Israel called augma bond appetite which is a bone cement and it comes with a syringe and you squirt it in the socket and you close it up and you're done it's very simple and it's it's resorbable but very very slowly reservable and a lot of these bone grafts it's it's more expensive per gram than heroin cocaine and crack that's true is it are the prices coming down any well uh they are for some products that i haven't used i see products advertised where you buy a a plug of bone and collagen that's designed to go in a two socket for you know 75 now that's probably more than it should be but it's it is what it is and i think patients should understand that you use that product there's a markup it takes time to place the product it's longer than a regular tooth extraction i think patients appreciate it understand that i went all the way through dental school graduating 87 they never even mentioned sleep uh sleep medicine i mean it wasn't even a thing in the 80s right some people are saying uh stanford's saying that this um guy that just died william demand md phd known as the father of sleep medicine dies at age 91. is that the father of sleep medicine to you well uh no he's uh the fathers of sleep medicine as far as surgery is concerned are based at stanford there's a guy named guiamono g-u-i-l-l etc and other people at stanford really developed the protocols for the surgically successful treatment of obstructive sleep apnea the gentleman you named i don't recognize but i suspect if he's the father of sleep medicine he's probably a pulmonologist or a [Music] sleep medicine physician who's not a surgeon so you would say um it's dr christian gulemenolt yes yemino given alt is that french or french or french well you got me you always i know when it's friends um so what um you know when i get out of school the first i heard about sleep medicine snoring all that is my ent got a carbon dioxide laser and was roto-rootering out of the back of the throat right and then just like i think is most important that you ask all your patients uh later if you had to do it all over again would you do it all over again and they all said no because they lost their sense of taste and smell and they said they're like eating cardboard um so how's the journey of um sleep math and now a lot of people are saying well you don't want to wear a cpap all the time go get orthognathic surgery um so would you what's your update on sleep okay as far as surgery for sleep uh we have a very very high success rate with orthognathic surgery they really don't call it that they call it teleneptic or telegraphics surgery and the name for the operation is the maxillomandibular advancement but it's not the gold standard cpap is the gold standard followed by mandibular advancement oral appliance therapy but uh as far as surgery is concerned there are really a couple of options one is soft tissue surgery like what you described the roto-rooter the palatal palatoplasty or uvulopalatopharyngoplasty or upppp and that has about a 50 success rate and that's pretty low i mean that's not very effective and then there's tonsillectomy which is a little bit better tongue reduction with radio frequency which is a little bit better but maxillomandibular advancement has a 90 percent success rate in eliminating obstructive sleep apnea that's on you you can ask for more on that um i was just wondering any other things on the 12 specialties i mean um um or we talked about oral medicine oral facial pain oral facial pain and oral medicine I’m glad those guys are there i i i love having a place to send patients that don't need surgery the one I’m most thankful for is a pediatric dentist i mean what went wrong in your life where your best choice was to hear screaming yelling children for the rest of your life right i mean i i don't know why they do it but I’m so damn glad uh they do it um some um i see um you're um doing liposuction um is that in the face or are you doing bellies and no no i don't do anything below the collarbone now there are people that are trained with my training that do that I’m happy for them to do that i don't want to do it i do sub-mental and cervico-facial liposuction particularly in people with mandibular retrognathism people with short lower jaws that have an obtuse chin neck angle that would benefit from that and it needs to be the good candidates for that are younger people with a little bit of isolated extra fat not the 300 pound obese sleep apnea patient that's 55 and already has platysmal striations the the ideal patient is the younger patient with a little bit of extra fat under their chin and I’m just curious this might sound bad but is that mostly all girls getting this done or are there guys getting that or i see men more often uh going for that and and seeking that out yes you see you see more and more men doing it but what what what percent are men it's probably 30 70 30 women to men so that that's interesting and um you know the first you know when any patient was telling me they get a facelift i i always try to talk him out of it because it looked like their face was an elevator and the first facelift i saw that was good is the oral surgeon explaining me goes he goes you know the non-oral surgeons they they make incisions in the skin and pull the skin back and it looks crazy but they were getting underneath and pulling the the muscles back and uh and they um i i have to tell you I’m even though I’m biased I’m in dentist it seems like the oral surgeons do better face lifts than the plastic surgeons well that's my feeling as well i don't do face lifts um but the best results i've seen are from people who do a full thickness facelift not just the superficial uh skin facelift that we used to see back in the 70s and 80s okay final question you're getting called for patience you're a busy guy um there's this steel long-standing um dispute on uh septicaine anesthesia there's still a lot of dentists that believe that it could cause a paresthesia if you give a mandibular block and then other people just say that that's just not true um do you use septicaine on a mandibular block you know i don't use septicaine but not for that reason it's just not as it doesn't fit in my personal preference i'd like something that has a very fast onset and a very long duration now there that drug doesn't exist right now and so i use a combination of carbocane which is just very fast onset without any epinephrine or vasoconstrictor and that carbocaine mandibular block really kicks in very quickly so that the mandibular teeth are very numb then i followed that with markain with epinephrine bubificane with one to two hundred thousand epinephrine and then they're numb for six hours and they didn't even feel the shot and they that for wisdom teeth for tooth extractions that's my go-to protocol and the other controversy is for pain meds are you do you still prescribe opioids or you know we we had a problem in Texas when they kind of blocked us from prescribing hydrocodone and some other class 2 and 3 narcotics i use a drug called tramadol in conjunction with a high dose of ibuprofen i use 800 milligram ibuprofen tablets i tell patients we're doing biphasic pain control we're doing one phase to raise the threshold of pain we want you to take it whether you want it or not regularly for the first 72 hours and then follow that up with breakthrough with tramadol of the narcotic for breakthrough pain and that's very effective and it's much more easy to prescribe than hydrocodone final question um some kids are scared to learn how to place an implant but they're removing wisdom teeth some older guys say well you know it's actually harder to pull a wisdom tooth than it is to place an implant no kidding so where would be where would the extraction skills be on a young 25 year old dentist where you thought okay if you can if you can pull that tooth you can place an implant to replace a maxillary second bicuspid with an implant i think you have to be comfortable with drilling in bone i think that's the limiting factor i think if you're just using forceps to extract teeth that's one thing but if you have to get out a drill and irrigate and keep the bone healthy and you know how to do that then you can do implants it's very straightforward using a drill to cut a tooth or to cut bone is harder and more difficult than placing an implant so if you know how to do one you know how to do the other it was a huge honor for you to come on the show today dr jim douglas bates DDS md out of Dallas Texas and if you ever want to write an article in dental town magazine or put an online c course we would just love it thank you for educating us general dentist on all the everything new in oral surgery it's been it was just an honor to podcast you my pleasure howard all right have a great day good luck on your surgeries today thank you all right bye-bye
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