Very Clinical: Changing Dr. Lance Timmerman's Mind About Heroic Dentistry

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[00:01:20] [SPEAKER_00]: Welcome to the Very Clinical Podcast. In about the time it takes to do an MO on 3,

[00:01:26] [SPEAKER_00]: we will entertain and amaze you with tips and tricks on regular daily dentistry.

[00:01:31] [SPEAKER_03]: Here's Kevin and Zach. What is up, very clinical listeners, and welcome back to

[00:01:35] [SPEAKER_03]: another episode of the podcast. I am Zach Miners, coming to you from Kansas City, Missouri,

[00:01:40] [SPEAKER_03]: with me as always my trusty co-host Dr. Kevin Herr Freier. Kevin, what's up man?

[00:01:46] [SPEAKER_03]: We're currently in a rain delay. I saw that. I'm also watching the game for obvious reasons.

[00:01:52] [SPEAKER_02]: Yes, obvious reasons. Zach and I are mortal enemies tonight. Yeah.

[00:01:57] [SPEAKER_02]: I don't know if there it's really was coming down hard. So who knows what will

[00:02:05] [SPEAKER_03]: Cleveland Indians, sorry, Guardians, sorry. Indians. Yep. And Kansas City Royals are locked in a very

[00:02:11] [SPEAKER_03]: tight divisional battle. There's only one game separating them in the middle of a four game

[00:02:16] [SPEAKER_03]: series as we speak and it is under a rain delay. So but the Royals were winning. They

[00:02:23] [SPEAKER_03]: should probably just call it. That's just the way to do it. Well, we brought in a premium

[00:02:30] [SPEAKER_03]: guest Lance Timmerman from all over Seattle. Dr. Lance. What's up? My Lance.

[00:02:38] [SPEAKER_03]: Frequent guest on this podcast network. So. You know, I do what I can.

[00:02:43] [SPEAKER_03]: Indeed. And we appreciate that. We're lucky to have you. Right, right. We'll go with that.

[00:02:50] [SPEAKER_02]: Yes. All right, so let's suppose that Zach and I are dating and we are. We are. And we are kind of like

[00:03:03] [SPEAKER_02]: you know, like the kind of couple that just sort of jetsets around the country.

[00:03:07] [SPEAKER_02]: And we happen to go to Seattle. On purpose? On purpose to visit you.

[00:03:13] [SPEAKER_02]: Where are you going to take us for a great dinner? It's our anniversary. Yeah. Well,

[00:03:19] [SPEAKER_01]: you can't go to Seattle without getting a bag of dicks. So probably

[00:03:27] [SPEAKER_01]: Dicksburgers are just classic here in Seattle and you know, they're cheap. They

[00:03:33] [SPEAKER_01]: recession proof used to be 59 cent burgers, but that's really showing my age because I think

[00:03:38] [SPEAKER_01]: they're two bucks now. But I always take people visiting to Seattle to go get a bag of dicks.

[00:03:44] [SPEAKER_01]: But we might go down to Pike Place Market and there's a little seafood place. Cutters is a pretty

[00:03:50] [SPEAKER_01]: decent, not over the top like Candles is super famous in the Seattle area for five star and

[00:03:57] [SPEAKER_01]: overpriced kind of stuff. I'm not fancy. So I mean, hence the bag of dicks. So

[00:04:04] [SPEAKER_01]: probably going to do some seafood. And it's right down by the market. So that's where

[00:04:08] [SPEAKER_01]: they had the flying fish where you buy a salmon and they'll throw it at you. So and hope you

[00:04:13] [SPEAKER_03]: catch it. What is salmon the most native, freshest fish in Seattle? Or is it probably

[00:04:22] [SPEAKER_01]: there are a lot of choices? There's a lot of choices. We're so close to Alaska. So you're

[00:04:27] [SPEAKER_01]: going to get all the people that want Halibut. They're going to have some here. That's good

[00:04:31] [SPEAKER_01]: stuff. So you know, Copper River Salmon is just north of us. So we get our when they're

[00:04:43] [SPEAKER_01]: the Copper River, I believe in British Columbia. So we're we're just there are hat. So we're

[00:04:50] [SPEAKER_02]: able to get plenty of fish. Well, I think you see food guy. Yeah. Yeah. I think

[00:04:59] [SPEAKER_02]: Zach would be all in for the bag of dicks. But oh yeah, for sure that yeah. Off air. We

[00:05:07] [SPEAKER_02]: talked briefly, Zach, have you ever been to Seattle?

[00:05:10] [SPEAKER_03]: No, no, I actually have not. I have spent a little time in the entire Pacific Northwest

[00:05:16] [SPEAKER_02]: at all. So I've been to the last on the list, but never Seattle Vancouver I've been to.

[00:05:21] [SPEAKER_01]: So well, you know, once we, you know, burned down a park on Capitol and renamed it Chaz,

[00:05:27] [SPEAKER_02]: you know, that's when I really wanted to visit.

[00:05:31] [SPEAKER_02]: I'm all about the mayhem.

[00:05:34] [SPEAKER_01]: There's plenty of mayhem it's it's Portland and Seattle are like neck and neck for out

[00:05:38] [SPEAKER_02]: competing each other with weird and my one niece has moved to Portland

[00:05:45] [SPEAKER_02]: and is working for the FBI. Shh, don't tell anyone. So all right, might be finding my way

[00:05:51] [SPEAKER_01]: out there someday. That would be great. We'd love to host you. I've even have people that

[00:05:56] [SPEAKER_01]: just I'm in Portland. Is that close? And I'm like, it's close enough. And so we just head on down and

[00:06:01] [SPEAKER_01]: I went to dental school in Portland. So I know Portland well enough to even entertain down there.

[00:06:06] [SPEAKER_01]: So very cool. What's the what's the distance there? I got I assumed that was a long,

[00:06:12] [SPEAKER_01]: a long way about 175 miles. Oh, that's two and a half hours. You know, but being from here,

[00:06:20] [SPEAKER_01]: two and a half hour drive is nothing. I filled in for friends. I have a friend that runs a

[00:06:24] [SPEAKER_01]: DSO and he's shorthanded or something. And so I'll drive down to Vancouver,

[00:06:28] [SPEAKER_01]: and which is across the river from Portland and work a day. So to me,

[00:06:34] [SPEAKER_01]: you know, I'll talk to my friends in Europe and, you know, they won't even go 20 minutes,

[00:06:39] [SPEAKER_01]: you know, or 30 miles might be two hours with the traffic and everything there. So they

[00:06:46] [SPEAKER_01]: they look at the map and they're like, you know, hey, I'm in San Francisco,

[00:06:50] [SPEAKER_01]: maybe I'll go to Vegas for the weekend. And you're like,

[00:06:52] [SPEAKER_01]: you spent the entire time driving. Yeah, no, yeah. That's it. It's a massive distance.

[00:06:58] [SPEAKER_03]: Yeah. Okay. So podcast listeners, we are continuing the Change Our Mind series of where

[00:07:07] [SPEAKER_03]: we're interviewing mid to late career dentists on things they've changed their mind about.

[00:07:12] [SPEAKER_01]: I'm officially old then, huh? Is that what you're saying? Yes.

[00:07:15] [SPEAKER_01]: Am I mid or am I late? You're mid. Well, do you want to be late or do you want to be

[00:07:20] [SPEAKER_02]: mid? How many years have you been practicing Lance?

[00:07:23] [SPEAKER_01]: Too many. 26, someone asked the other day. So that's why I knew the number pretty quick.

[00:07:28] [SPEAKER_03]: Yeah. So I guess that's on you. Do you want it to be late?

[00:07:31] [SPEAKER_01]: Years ago, I thought this would be, I would have already left by now.

[00:07:35] [SPEAKER_01]: But with some bad decisions and poor financial planning, I'm probably just going to die in

[00:07:42] [SPEAKER_01]: the op. So I'm probably more mid than late. We don't want to, we don't want it to happen.

[00:07:49] [SPEAKER_01]: All right. So Lance, have you changed your mind at all?

[00:07:52] [SPEAKER_01]: Oh, I changed my, was it Tuesday? Yeah. Yeah. I mean, I change my mind daily.

[00:07:58] [SPEAKER_01]: Super. Constantly changing my mind.

[00:08:00] [SPEAKER_03]: We're going to kick this off with clinical dentistry. Is there any particular

[00:08:04] [SPEAKER_03]: one thing that stands out as something that you thought one way years ago and you really come

[00:08:09] [SPEAKER_01]: around 180 on? Yeah. It's a lot, but the one I decided to stick with was saving teeth. Heroic

[00:08:22] [SPEAKER_01]: dentistry years ago. So late nineties, early 2000s was kind of a heyday for cosmetics. And so

[00:08:28] [SPEAKER_01]: I fashioned myself as a cosmetic guy and she'd get people coming in that probably,

[00:08:35] [SPEAKER_01]: you know, and the economy was pretty good at the time as well. So people investing tens of thousands

[00:08:42] [SPEAKER_01]: of dollars to get a new smile or a full mouth reconstruction wasn't that unusual. I wasn't

[00:08:50] [SPEAKER_01]: doing it on a daily. So it wasn't like other people, especially on the internet claiming they're

[00:08:55] [SPEAKER_01]: constantly doing all those, but I did a fair share. And there were some people that come in

[00:09:01] [SPEAKER_01]: with the teeth are all crooked and bad positions really should be a combination of things, but you

[00:09:06] [SPEAKER_01]: end up spending tens of thousands to get a brand new smile. And you do a Kenny type thing where it

[00:09:12] [SPEAKER_01]: ends up being stripping all the enamel and maybe some vital endo to get the result.

[00:09:20] [SPEAKER_01]: And you're feeling pretty good about it for a while. But after if you practice long enough

[00:09:24] [SPEAKER_01]: and it comes back at you and suddenly they realize that they spent $60,000 and now all of that

[00:09:33] [SPEAKER_01]: investment is gone. How many years is enough to say that was a good investment? Whereas now I'm

[00:09:40] [SPEAKER_01]: getting people where I look at them and I do some math looking at, you know, hey, you're 55

[00:09:46] [SPEAKER_01]: years old, you're 60 years old. You could spend that $60,000 with this or we could take the teeth out.

[00:09:55] [SPEAKER_01]: Years ago, you'd be doing dentures, but half your teeth are going to have to come out anyway.

[00:10:00] [SPEAKER_01]: And we could do implants in the posterior and crowns in the anterior,

[00:10:04] [SPEAKER_01]: but I've had enough of those come back where they still spent quite a bit of money.

[00:10:09] [SPEAKER_01]: If it all on X was a consideration before, but as a compromise or as a secondary thing,

[00:10:15] [SPEAKER_01]: it's higher up on my checklist. And so there are teeth that I could have bought some time

[00:10:24] [SPEAKER_01]: and I have the patients part of the discussion. I don't make the decision for them, but I don't do

[00:10:29] [SPEAKER_01]: heroic dentistry as nearly as much as I used to. And I got far fewer complaints because they

[00:10:35] [SPEAKER_01]: spent $30,000 in a new smile and five, 10 years later, the teeth were needed to come out.

[00:10:43] [SPEAKER_03]: So what's the tipping point, Lance? Or throw me through a quick triage of where the tipping

[00:10:50] [SPEAKER_01]: points are between save or go. Well, I start trying to get them to help me decide on terminal

[00:10:59] [SPEAKER_01]: dentition. If the posters have a lot of the bone loss to the frication, so we know that we're

[00:11:06] [SPEAKER_01]: just buying time no matter how much we try to clean it, we're going to lose these teeth.

[00:11:10] [SPEAKER_01]: And so now we start looking at the bone levels in the anteriors. Quite often it's a mix. Every other

[00:11:17] [SPEAKER_01]: tooth is quite a bit of bone loss. And now granted, my practice has evolved to I'm only really getting

[00:11:25] [SPEAKER_01]: people that are coming in with a lot of hopeless teeth. Whereas before it was people a little

[00:11:31] [SPEAKER_01]: bit more towards, should we bleach the teeth or should we veneer the teeth or a combination,

[00:11:36] [SPEAKER_01]: things like that. So now even just the consoles I get are pretty much, are these teeth hopeless enough?

[00:11:43] [SPEAKER_01]: Are we ready to do this? But most of the time I might even recommend, hey,

[00:11:48] [SPEAKER_01]: let me should reconstruct. And when they hear the price tag of both options,

[00:11:52] [SPEAKER_01]: they'll go towards the implants. And so we're doing a lot more all on fours than I thought I ever would.

[00:12:03] [SPEAKER_01]: Interesting. So it's a delicate thing to figure out what is the tipping point.

[00:12:09] [SPEAKER_01]: I try to keep the patients part of the discussion, but it's a big enough discussion.

[00:12:15] [SPEAKER_01]: I talked with Alameda earlier episode where I make a consultation video that I send them a link

[00:12:21] [SPEAKER_01]: to do to watch because it's information overload. And so it gives them a chance to really understand

[00:12:27] [SPEAKER_01]: all the options. And then so when we have a discussion the next time after the video,

[00:12:33] [SPEAKER_01]: it's a little bit more focused. They have a pretty decent understanding of their condition.

[00:12:37] [SPEAKER_01]: Because I'll show them the panone and the CBCT. And I'll explain how to read a CBCT,

[00:12:44] [SPEAKER_01]: not expecting them to really understand it. But when we do have a discussion at that point,

[00:12:49] [SPEAKER_01]: it's a little bit more detailed and focused. And we spend less time answering the same

[00:12:55] [SPEAKER_03]: questions over and over. Where does age factor in as a component of that conversation?

[00:13:05] [SPEAKER_01]: It's definitely a higher part of the equation. If you're 75 years old and there's teeth that are

[00:13:14] [SPEAKER_01]: we could probably, well if I'm going to buy you 10 years, my mother was one where we were

[00:13:21] [SPEAKER_01]: and when we finally decided she wasn't healthy enough to do the implants.

[00:13:29] [SPEAKER_01]: I start actually thinking of her when I look at someone in their current health,

[00:13:35] [SPEAKER_01]: are there things that are indicating that their health might not be good enough when they are

[00:13:39] [SPEAKER_01]: old enough when I normally would have said let's do these implants? And I'm kicking

[00:13:43] [SPEAKER_01]: myself now that have we done the implants when she was in her 60s then when she was in

[00:13:49] [SPEAKER_01]: her 70s and 80s would have been a different thing. Yeah, I feel like I see a lot of these

[00:13:56] [SPEAKER_02]: 70 or 80 year olds that had roundhouse crown and bridge or and it's just

[00:14:02] [SPEAKER_02]: failing in a catastrophic way. And if you reel back the time 20 years ago and all on X

[00:14:13] [SPEAKER_02]: wasn't as popular I just wonder if they'd be better or what happens when those start to fail.

[00:14:20] [SPEAKER_02]: But there's been enough of those where it just makes you sad. Yeah, and I've had some

[00:14:27] [SPEAKER_01]: consults where people have come in and they absolutely, all on X is what should be done.

[00:14:34] [SPEAKER_01]: Their medical situation is yeah this can't be done I'm sorry or you might be able to

[00:14:40] [SPEAKER_01]: find someone to do it for you but I'm not your guy. I'm not that good. So and I will say that

[00:14:47] [SPEAKER_01]: the technology 20 years ago of doing all on X was a totally different approach. I think we're

[00:14:52] [SPEAKER_01]: doing a much better job much more comfortably and predictably with the whole digital flow is

[00:14:58] [SPEAKER_02]: a totally different thing than it was then. The digital workflow for all on X is remarkable.

[00:15:05] [SPEAKER_02]: Yeah, it's amazing. That really is something that like you know for 35 years of practicing if you

[00:15:12] [SPEAKER_02]: would have told me you could do anything like that in 1989. I thought you were from Mars there's

[00:15:18] [SPEAKER_02]: no way but it really is a remarkable thing that's been brought to the profession.

[00:15:25] [SPEAKER_03]: What is the conversation likely as someone who's never done an all on X

[00:15:30] [SPEAKER_03]: or even actually so much has even seen one in my office? What is the conversation like in terms of

[00:15:35] [SPEAKER_03]: like an expected outlay of you know how would last or I mean or is there and is there a

[00:15:44] [SPEAKER_03]: different conversation between how long the you know teeth will last versus how long the implants

[00:15:48] [SPEAKER_01]: will last. I mean what does that sound like I guess? Yeah, we talk about that. A lot of it

[00:15:57] [SPEAKER_01]: is I'm usually getting people that are requesting it the implants and because they're sick of

[00:16:03] [SPEAKER_01]: investing the money you know every time I spend you know get these crowns you know

[00:16:09] [SPEAKER_01]: they're perio involved or something and they're just kind of tired of it and so I say well you

[00:16:15] [SPEAKER_01]: know we can redo some of the dentistry if you had some old bridges and crowns and things

[00:16:21] [SPEAKER_01]: you'll experience what you've already experienced and they're already kind of checked out at

[00:16:25] [SPEAKER_01]: that point saying I don't want that. So then I talk about okay well nothing lasts forever we just have

[00:16:31] [SPEAKER_01]: things that last longer than others so if you're you know if you're in your 30s asking for this

[00:16:39] [SPEAKER_01]: you know you better plan at least the restorative aspect of prosthodontic part to have to be

[00:16:45] [SPEAKER_01]: replaced at least once probably twice depending on what material this because I do offer

[00:16:50] [SPEAKER_01]: different materials if we're doing zirconia versus you know a bar reinforced PMMA or something like

[00:16:56] [SPEAKER_01]: that you know I tell them the PMMA probably I think it's only FDA approved for five years.

[00:17:02] [SPEAKER_01]: You're good to get that now I have people that drive on bald tires and they should have

[00:17:07] [SPEAKER_01]: replaced it at 60,000 and there are under 100,000 miles already. Okay you might be able to

[00:17:12] [SPEAKER_01]: get that and if you're okay with that then fine whereas the zirconia probably would last

[00:17:18] [SPEAKER_01]: longer with its own set of risks but so we do talk about the longevity of the investment.

[00:17:24] [SPEAKER_01]: I feel pretty safe when you're 80 and I'm doing this for you that is probably a lifetime treatment

[00:17:30] [SPEAKER_01]: but when you're 60, 70 you know we're probably going to be exploring now I usually do tell them

[00:17:37] [SPEAKER_01]: that the implants themselves should outlast the prosthodontic part but even with that maybe

[00:17:45] [SPEAKER_01]: you know things change your bone density could change or something different might happen where

[00:17:51] [SPEAKER_01]: yeah maybe we do some revisions like I try to save zygoma type of implants for

[00:17:56] [SPEAKER_01]: you know not your first thing to do. Right usually your first go to is like 28 minis though

[00:18:04] [SPEAKER_01]: that's usually the first starting point if I can if I can fit a 29th in there I'll find a way

[00:18:08] [SPEAKER_02]: sure well that's the best thing to do first is the roundhouse sealants and then right

[00:18:14] [SPEAKER_03]: the minis. That's very good Kevin what is your take as you've started to get more into the

[00:18:24] [SPEAKER_03]: implant world and more into the 3d guys that do that kind of stuff what are your thoughts on some

[00:18:30] [SPEAKER_02]: of that? I think there's a lot of the aging population I had a consult today for

[00:18:38] [SPEAKER_02]: you know for terminal dentition this patient I've known for a long time and

[00:18:43] [SPEAKER_02]: you know just sort of limping along she wasn't ready yet now she is

[00:18:47] [SPEAKER_02]: mentally so I just think that it is a great treatment option that comes with some risks

[00:18:57] [SPEAKER_02]: and you know everything everything comes with risks. Yeah but I also think that

[00:19:04] [SPEAKER_02]: as particular people my age are aging it's it's remarkable what people can do to their teeth I guess

[00:19:12] [SPEAKER_02]: the way Lance started this off with the no more heroics thinking back to just trying to save

[00:19:23] [SPEAKER_02]: everything I could in the 90s and early 2000s I finally came to the conclusion that you know

[00:19:30] [SPEAKER_02]: some people don't deserve teeth and this is the I think this is the best thing that we can do for them

[00:19:39] [SPEAKER_01]: and we'll see what happens down the line. Yeah because in the 90s my option would be okay

[00:19:46] [SPEAKER_01]: dentures well definitely trying to save the teeth and heroics versus dentures fine heroics but now

[00:19:52] [SPEAKER_01]: we've got a better option than just dentures yeah for sure for sure. All right excellent well I think that

[00:20:00] [SPEAKER_03]: wraps up Lance's clinical episode Kevin. All right. Double downs or take back apologies. I loved it

[00:20:09] [SPEAKER_02]: I loved all the I love that we have a dinner date at a somewhat yeah get a bag of dicks you can eat a

[00:20:17] [SPEAKER_03]: place. Thank you Lance and Lance will be back next week I wonder if he's changed his mind on

[00:20:25] [SPEAKER_03]: anything about business I don't know maybe now yeah all right thank you guys for listening and we will

[00:20:31] [SPEAKER_03]: catch you next Tuesday see ya catch you