Very Clinical: Getting Ahead of It, part 5: Extractions and Grafting

[00:00:00] I'm the kind of person who uses the self-checkout lane every single time because I just want to grab what I need and get back to what I was doing. If you're tired of calling sales reps, waiting on mystery discounts, and decoding hidden shipping fees, you need Net32. Net32 puts distributor pricing side by side so you can compare costs, delivery speed, and vendors in one clean dashboard. Upfront pricing, zero hassle. Check them out at Net32.com. Still dreading ClearAligner IPR? Ditch the bulky discs and standard diamonds that risk ledges.

[00:00:29] The new Proxiburs from Garrison Dental Solutions are purpose-built for interproximal reduction. With ultra-thin profiles and precisely calibrated thicknesses, they make gross reduction of .3 millimeters or more fast, controlled, and tissue safe. Pair them with Garrison's FitStrips for seamless finishing. Upgrade your aligner workflow at GarrisonDental.com. This is a production of the

[00:00:52] Very Dental Podcast Network. Welcome to the Very Clinical Podcast. In about the time it takes to do an MO on three, we will entertain and amaze you with tips and tricks on regular daily dentistry. Here's Kevin and Zach.

[00:01:17] What is up, Very Clinical listeners? Welcome back to yet another episode of the podcast. I am Zach Miners coming to you from Kansas City, Missouri. With me as always, my trusty co-host, Dr. Kevin Hair Fryer, Kevin, what is cracking in Cleveland, Ohio tonight? It's a beautiful evening. Uh, very warm outside. Very unseasonably warm for November. What is it? November 2nd? 3rd today. I still haven't put my shorts away. We're also having unseasonably warm weather in Kansas City.

[00:01:47] Wait, you haven't taken your shorts off? Well, not yet. I'm letting the podcast get a little warmed up here, you know? I'm starting, we're just gonna get heated up, you know? Unexpectedly hot, guys. Yeah, absolutely. Uh, if you've ever listened to this podcast feed before, you probably have heard our third voice before, Dr. Alan Mead. Alan, how are you going? Greetings and salutations. It is also unseasonably warm in the mitten state. Three cheers for global warming.

[00:02:15] Yeah. Yeah. It's like 65 degrees right now. Same here. I don't even know what to do. I'm gonna leave my window open. I love it. Are you wearing shorts? I'm not. I'm wearing, I'm wearing flannel pajama pants. Okay. That's a ho, ho, ho on them. Whoa, you're getting it. Have you put up your Christmas lights? No. Are you one of those? I haven't. Have you put your Christmas lights up, Kevin? No, I'm not wearing pants. Oh, okay. Excellent. Great. Thank you. Thanks for that. That definitely helps out the podcast for sure. That gets us views. That helps us paint the picture.

[00:02:44] Yeah. Helps us paint the picture. Absolutely. Speaking of painting the picture, I have the bit for this episode. Do it. So, okay. So, we live out in the country and our water, our water is delightful. I think it's well watered, but my kids and my wife don't love to drink the water and particularly through the coffee machine because we have a lot of minerals in our water. And so, it would gunk up the coffee. So, we go into one of our parents' house and we'll get gallon jugs of water. And we

[00:03:13] have 10 or 15 of these gallon jugs. And so, whenever we're in town, we get these jugs of water. So, I had jugs of water in the back of my car. And apparently, one of my knucklehead children did not put the lid on very well on one of these things. And it fell off in my trunk. And so, about a half a gallon of water. And the trunk's got carpet or whatever. And so, I thought I had

[00:03:40] mopped it up pretty good. I had not mopped it up very well. And right now, my car smells like it's somewhere between a really bad sweat sock and a dog poop. Somewhere in my car smells like that. And I just today... Okay. So, the carpet in the trunk continues to be wet.

[00:04:09] I actually... And actually, it soaked right even through. So, underneath the carpet in the little... There was actual standing water in there. It was only for a couple days. But my car just freaking reeks. And I... So, I... Do you guys remember the Seinfeld episode where... Oh, yes! The bad BO car. Couldn't get rid... It was the guy... One parking attendant, like, made his car reek. And he couldn't get rid of the car and all that stuff. I feel like I'm going to be having this issue with my car.

[00:04:37] Because this is like day two or three of me trying to get rid of the stench in my car. I literally left... Because it was unseasonably warm, I left my windows open and the trunk open in my parking lot at the office. Which was funny because, of course, people thought someone had like broken into my car or something like that. It was better. But as soon as you close the windows, it got stinky again. I got some deodorizers. I took some of the carpet right out of the back and left it

[00:05:03] out. And right now, I'm on probably hour three or four of my ozone machine running in my car out in the garage. I'm getting a little desperate here, fellas. My car... Can I double down on this story? I can double down on this story. So, yeah. That was my question. Have you ever had a car that you couldn't get the stench out of? Yes, I have. I once parked my car for a little while outside and a mouse got into my car and died. I was thinking about this. That's kind of what it smells like.

[00:05:32] And that car smelled like death. Yeah. And I did all of it, left the windows down, ran all these like ozone things through. Where was the mouse? Where was the mouse? I don't know. Up in the ventilation type stuff. Because I thought about that on the way home. It sort of smells like a dead mouse and I don't even know. I mean, Alan, it was months. It was months. And like, the car was unsellable. I just had to I had to ride it out. It was, but it was, it was, it was multiple months of... Yeah.

[00:06:01] I was lucky it was during nicer weather. I could walk with the windows down. It smelled so bad for so long. Yeah. It kind of smells like that, my car. I hope it's not. Yeah. But I think it was the water. I'm pretty sure it was the water. Yeah. Although maybe the water drew a mouse, a very thirsty mouse to my truck. No, you would know the difference between dead mouse and... It's wet sock. And just like, yeah, wet sock or BO or whatever you want to call it what you do. Yeah. How about Kevin? Can you trouble down with this story? Kevin, you got any stinky car stories?

[00:06:28] I have a stink story, but it does not involve a car. Okay. So in high school, I was in a lot of plays. You know, so you were a drama guy. Yeah. You were a drama guy? Yeah. Okay. So you'd have like play practice, right? Yeah. So I come home from school and I walk in the house and I'm like, what's for dinner tonight? And like, I don't really need to ask because the house smells like fish.

[00:06:55] My mom was not a good cook and the house smelled like fish. So I barely ate the fish because it tasted gross. And I go to play practice and like, I'm not in the scene, right? So I'm just sitting out in the audience with my friends and someone goes, do you guys smell fish? No. No. No. No. Not at all. And so I kind of, you know, you're like 17. So very self-conscious about everything. So like I get up and I walk away to another group of friends.

[00:07:25] I sit down like, do you guys smell fish? I'm like, this is not good. And I remember like, uh, whatever scene I was going to be in, I was like waiting in the wings and whoever I'm standing next to you, like, you smell like fish. So, uh, I was mortified and embarrassed. And I came home and yelled at my mom. We're never having fish again. And, uh, we didn't.

[00:07:52] So I guess in the end I won because, uh, we never had my mom's awful fish. It is, it is wild how, how smells can stay like that. Yeah. I feel like just lately, since I'm very sensitive to this car smell, I smell terrible things everywhere now. Dental offices full of horrible smells. Just, you know. Oh yeah. Some people, I mean, they really hate it. If you are smoothing out some margins without water and. Oh yeah. Yeah. They don't like that one bit.

[00:08:20] I probably haven't used former creasol in, I don't know, 15 years. And, and like you can come into my office and it still smells like a dental office. Dry socket paste. The dry socket paste has a very distinct smell. There's some dental, dental smells. And what's funny about it is none of those things, I use none of those things and it still smells like that to me in my office when I sneak in, like on the weekend or something. I don't know what's going on there. For me. Maybe as I get older, I get more sensitive to smell. Maybe that's what it is.

[00:08:48] As other senses are decreasing, your, your scent is increasing. A lot of hair on my head. But more hair in my nose. Maybe that's it. Maybe that's it. We are sticking with the getting ahead of it series. And these next two episodes are on the more, the surgical sides of things with extractions, grafts, membranes, implants, all that kind of good stuff here. We're going to save the implants for part two of this.

[00:09:16] This is more just the good old fashioned extraction, graft. And grafting. Um, post-op stuff for extractions, et cetera. So let me just open it up. Alan, what's something you say to patients to get a, get ahead of the complaints when it comes to anything, anything involving the, uh, extraction process? You know, it's funny, uh, anesthesia with, with extractions. I don't struggle.

[00:09:44] You ever notice it's harder to get someone numb for like endo or a crown prep than it is for surgery? Like somehow, maybe cause you're not like drilling on the tooth as much as you're drilling on the bone or whatever. You know what I'm saying? Like, I feel like anesthesia for surgery is, is not as hard. I don't know what, but I, the, the thing that this is the most common thing everyone says, but I always tell people we're going to get you very numb, very comfortable, but you're going to, you shouldn't feeling sharp, but you will feel a lot of pressure and a lot of

[00:10:14] pushing and, and there will probably be a lot of noise, but I always tell them that it's, it's so in other words, I mean, you're doing surgery on people that are awake. And when you think about how wild that is considering how like no medical specialties do any kind of surgery on awake people or hardly any, um, we have that weird thing where we have to kind of explain to them some of the, you know, the, the, the less comfortable things about surgery while they're awake.

[00:10:42] So I, I generally, and I have to tell you, I feel like anesthesia for surgery usually isn't my problem with surgery. It's if I have trouble with anesthesia, it's almost always a hot tooth. I'm trying to, trying to save with a root canal or something like that. So I, I generally have that conversation right off the bat and patients seem to, I don't know, they seem to get it. They seem to get it. Like, and, and, and so if I'm, if I'm luxating a root and they go, you know, they're not, they really aren't numb enough. And I feel like that, I feel like they're relatively normal with that.

[00:11:09] So I always kind of explain what to expect that might be different from other dental procedures that we do anesthesia for. Does that ring a bell with anyone? Um, yeah, I, I get what you're saying. Um, I think that I've maybe flood teeth a little bit more when I'm taking them out. Almost, I guess I do when I do endo also, but I think I tend to do more, more PDLs and those kinds of things before I even, always even get given, get started with that.

[00:11:38] How about you, Kevin, with the anesthesia process of, of extractions, any, any differences or anything you say that's different than anything else? Really? Not really. I, I, that's not really an issue. I think one of the things that, uh, since, you know, what we're teaching is really like dismantling the tooth. Yes. You know? So, um, I'm cutting a lot of crowns off. Uh, so to get ahead of that.

[00:12:04] So like today I was taking out number 19 on a guy that had a crown, an Emax crown. So I want to get the crown off first before I do anything. So, uh, I will get ahead of it by saying, I'm going to, your tooth has a crown on it. I'm going to try to break it off on purpose. So if you hear some crunching noise, I'm doing that on purpose. I'm looking at me in the eye when I'm saying that.

[00:12:33] So if it does, you know, crack or hopefully break off, which this one didn't, of course. Um, and it makes that sound, then they're not surprised. That's, that's a huge getting ahead of it. No, that is talking about noises and those noises being normal. Like, okay, you're going to maybe hear a little bit of a snap, crackle, snap, crackle on this. And I'm doing that on purpose. Yes. And yes. And you're doing it on purposes.

[00:13:02] Otherwise sounds are alarming, very alarming. Yeah. And these are sounds that they're not hearing in other procedures. You're right. No. The surgical sounds are definitely interesting that you say you, you're breaking the crown off. Are you, are you taking a forcep to the crown and just seeing if you can pop the crown off? I'm squeezing it as hard as I can to break it off. Yes. With the hope. So you're like a cow horn and you're just trying to smash that thing. Not necessarily cow horn. Just, yeah. Okay. What are you hoping will end up being there? Are you hoping to flat top it?

[00:13:32] A hundred percent. Yes. Okay. Because he's going to, he's going to section. I'm going to section the mold. For sure. For sure. But I'm guessing. I'm going to tell you, I'm a little funny this way. I like to actually flat top it with a burr if I can, unless the crown is like zirconian. It's going to be sparks and exciting stuff like that. But I, I feel like, I feel like my luck, I'm going to break one root in a way that's going to make it harder to section or some stupid thing. So I think getting everything down to the bone level makes everything way easier. Makes it faster.

[00:14:00] So I'm just going to, I'm potentially going to bust it off like with some finesse. Like, yeah. Sure. Telling them that you're breaking it off on purpose and to expect the noise is excellent. That's really good. And you're doing it on purpose. Not only saying that that's normal, but I'm doing it on purpose. I really like that. Like, this is my intention. I think preparing people for sounds in general that are, shoot, even when I'm on the like,

[00:14:29] you know, even with going back like the crown episode, sometimes you're taking off a temper and you're like, you're going to hear like a pop. Yeah. You know, you're going to take that temp off. Like it's not your tooth breaking. I'm doing this. It's normal. And it's the temp, you know, just anything that you could prep people for on sounds. When we get into the putting in implant crowns, we're going to talk about sounds again, you know, when it comes to like torque wrenches and stuff like that. Sounds are just so big to prep people for. So I think that's great. I think that's a good one. What, what's next on?

[00:14:59] How about anything with the, with the actual process of taking, let me back up a little bit. But do you prep, do you guys prep people in a way based on, especially in Kevin and I's case, the cone beam, maybe in your case, Alan, just from experience of teeth that are going to be, you can tell are going to be more of a bear than, than others. Like, you know, like there's some extractions, you know, you don't really have to talk about a bunch of stuff because you know, you're going to be done in five minutes.

[00:15:25] You just know, periodontally involved, you know, ice cream cone root, whatever. But you know, the ones that you're probably going to have to put in some more time on. Do you, is, is that something that you get ahead of it and say, Hey, this is going to be the tougher than the average bear kind of a tooth. Kevin, how about, how about you? What do you, I will, anything like that that you say? Yeah. So I think the, the level of where that's going to happen has lowered or risen for like, I'll, I'll take on almost anything.

[00:15:55] I know that you will at this stage of the game, but if it's a previous root canal on, you know, and you can tell it's really thick bone or whatever, I'll, I will preface them by saying, you know, this tooth had a root canal before these teeth are notoriously difficult to get out. I always, I always mention that. I always mention that they're going to break. Yeah. So, um, you know, and you know, your tooth has extra long roots or whatever, whatever it is,

[00:16:24] just even if it doesn't, cause that's easy for them to understand. Um, this one may take a little bit longer and then when it does inevitably at the end, that's why I warned you ahead of time. Gosh, that seemed like it was difficult to do. Yes. That's why I warned you ahead of time. Yeah. Yep. Well, I want to put my knee on their chest. Yes. I definitely am going to be putting my knee on their chest. Yeah.

[00:16:52] You want to be with the knee on that's, that's a nice thing to do. You know, that's, that's, uh, you know, they'll probably put that in the Google review. He at least told me he was going to put his knee on my chest, you know, for sure. I mean, and that's a pretty good technique that it seems like a lot of practitioners use. Yeah. You know, for sure. Historically. Yeah. A hundred percent. You've done it, right? Kevin, you've done the knee on the chest, right? You've been, uh, you've been told that you did that technique. I've been told that I've done that and just like looked at the patient dumbfounded.

[00:17:21] I, it happened like last year or something when someone said that. And I looked at my assistant, like, but whatever, I don't, I'm unfazed by it now. Like if that's what you remember and that's what you believe, you know, that's some weird It's not a lie if you believe it, right? Yeah. That's some weird psychological, um, actually, what is it called? Epigenetics where we remember things from our past? Yes.

[00:17:54] People in the world believe that that actually happened. Yeah. Like we're afraid of snakes or that sort of thing. Um, yeah, exactly. Yeah. On the other hand, if it worked, we'd all fucking do it. Yeah. Right. I mean, it did. There's no advantage whatsoever. I, you know, it doesn't work. If it worked, I'd do it. Come on people. That's my thought. But yeah, if you're going to do it, warn them. And then they, then they'll think, oh, this is normal. He told me he was going to do this. That's it.

[00:18:20] Kevin, when it comes to doing, um, like handpiece base extractions or even for you, Alan, I've certainly, you know, since I have my little Kevin Fryer on my shoulder telling me how to do these extractions now. Well, what do I sound like? What does the little Kevin Fryer sound like? I listen to you all the time. It's in your voice. Don't worry. Okay. It's in there saying, hey, get that number tuber up. I would like it to be a miniature version of my voice. Oh, okay. A mini me version. Yeah.

[00:18:47] Well, anyway, so I feel like there's a lot of patients that haven't necessarily had that kind of an extraction done where there were all the hand pieces getting run. And so I will kind of say, hey, you know, this is a multi-rooted tooth. And, you know, in my experience, I've found that if we kind of take the tooth apart into some smaller pieces, it's less traumatic than trying to pull them. That is it. Yes. Yes.

[00:19:14] And so you're going to have a little slightly different experience with me doing a little kind of cutting and sectioning of this tooth that is going to take a little longer up front, but save us some time in the back end of things. You know? I say what I'm doing because if they've, a lot of oral surgeons don't section teeth the way GPs do, I feel like. And so there's a lot of people that haven't had that kind of an extraction and are wondering what you're doing maybe. I don't know. Your thoughts? What do you guys say?

[00:19:43] I like to do the thing where if it's an upper tooth, I use my fingers like this. Well, this tooth has three roots. They're kind of like this in your jaw. Or it's got two roots. They're kind of like this in your jaw. It comes out a lot easier when we can take them out one root at a time. So I'm going to just take them out. So you kind of use a visual and talk. Yeah. What about you, Kevin? I think I do that less. I know in the past people have asked, what are you doing? And they just don't anymore. I just go for it.

[00:20:12] If you're already buying dental supplies at retail, you're doing it wrong. Crazy Dental already has practically unbeatable prices on everything your practice runs on. But I want to make sure you use my code, VeryShip. Why? Two very good reasons. First, entering promo code VeryShip at CrazyDentalPrices.com knocks out shipping fees entirely. Second, pure self-interest here. Every time you punch in that code, Crazy Dental cuts me a check. You get top-tier dental supplies delivered for free, and you directly support the Very Dental podcast network without paying a dime extra to do it.

[00:20:40] Go to CrazyDentalPrices.com, load your cart, and remember code VeryShip at checkout. Yeah, I think the prefacing of breaking stuff off on purpose, that's great. But after that, I'm just going to go for it. And if they ask afterwards, they're like, oh, yeah, I sectioned a tooth and have to get it out easier. Divide and conquer or whatever. I kind of nonchalant that. Maybe that's not the best approach in the world, but whatever.

[00:21:09] It's whatever works for you. Yeah. Okay, so we've gotten the tooth out. How about, what are we talking in terms of, you know, let's assume this is a tooth that's not getting any kind of replacement or grafting. This is just your standard extraction here. What kind of things are we saying so we don't get the dreaded callbacks later about this, that, or whatever? What kinds of things are we doing to prevent callbacks on these extractions here? Alan, I'll let you go first on that.

[00:21:38] Whether sutured or not sutured or whatever, the thing that people don't understand is the solution is just to keep a ton of pressure on this for the first while. Like, I'm putting a bunch of pressure on it after, you know, for a while. And then, and I think a lot of times people will call and say, oh, it's still bleeding. And 99% of the time, they just weren't putting very much pressure on it. No.

[00:21:58] So, I, and I, so I think you can't really, I think it's important if the person hasn't had something like this before, they're not, or a person that you don't think will really hit, you got to let them know. It needs a lot of pressure. And, and if, if it, if it continues to ooze, it means you haven't put enough pressure on it. Just put some pressure on it. So, just, you know, set them home with something. Now, if you've sutured it up and you don't need to do that so much, that's, that's all the better. But I still feel like keeping pressure on it early on makes for a lot of, a lot less calls back in my, in my hands.

[00:22:28] What about you, Kevin? How are you, how are you, uh, avoiding the post-op callbacks? I, everyone on our team has been trained to say that your peak pain is going to be in 48 hours. Cause that's when you get a great one. That's when you're going to get the call back. That's peak swelling, peak pain, whether you take a tooth out or you had some other surgery, like your appendix out or whatever. Yep. Your peak swelling is going to be in 48 hours.

[00:22:54] And, you know, everyone has their different style of saying that to patients, but, you know, if someone says something like this might feel great tomorrow and then not the next day, that's 48 hours. That's peak pain. That's good. That's normal. It is really good. Um, so we, we expect that. And, you know, if it's been one of these really difficult extractions, I will at the front desk, look them in the eye and say, that was a really difficult extraction.

[00:23:22] You're probably going to be in some discomfort for a few days up to a week. Like that's normal. And that's so important that that's normal thing. I've, I've just those two words, I've been incorporating them more into my talks because I mean, I feel like that's powerful because that's always the question. Is this normal? Yeah. You know, that is the question. The other thing that, that I find it's humorous, but also true. We just removed a part of your body. We just removed the body part.

[00:23:51] So just remember this is, you know, being sore, being swollen in your face. Yes, exactly. We removed part of your face. And so, yeah. And I mean, what's funny is so many people, even when you've kind of beat them up, when you ask them, oh, isn't that big of a deal. So I find there's people on, on different, different ends of the spectrum of, of discomfort. And so I'd rather warn them that it's going to be a nightmare and have it not be. I'd rather warn them about all this stuff. A bell shaped curve on that.

[00:24:20] But I, you know, I think doing, you know, 95% surgical extractions where I'm reflecting a flap. I do, you know, in all honesty, I think we get a lot, a lot of callbacks, you know? And so getting ahead of all of that is really important for us. Mm-hmm. You know, that's the part of the implant practice that sucks.

[00:24:46] In order to get the end result that you want, the beginning part of it is going to hurt more than the end part of it. For sure. Well said. Well said. What are we, are we sending people out of the door with narcotics very often with scripts or to, to get, to get ahead of callbacks on that kind of stuff? Or what are you guys doing for, for pain management for the most part? What's, what's your, what's your usual routine? Are you having people do the ibuprofen and Tylenol kind of regimen?

[00:25:15] Or what are we saying these days? Kevin, I'll let you start. Well, everyone leaves with a antibiotic prescription. I mean, I've reflected a big flap on you. I don't want anything to get infected. I'm, I liked the 800 milligrams ibuprofen. The, you know, I know a lot of people like the pain pack and that may be voodoo that I'm missing out on, but I just think ibuprofen's best for that. What do you mean by pain pack? Like a medrol?

[00:25:46] No. Alternating. In my, in my world, a pain pack would be alternating the Tylenol and ibuprofen. Oh, okay. I don't see the value to that. If it's a really difficult, and I may be wrong on that listeners. You can email me and tell me I'm wrong. I'll be happy to admit I'm wrong on that. But if it's a real difficult extraction, they're going to get a medrol dose pack. Also, just to get ahead of that.

[00:26:16] But you, but you're not slinging very much Vicodin around? Almost never. Okay. I mean, once or twice a year. I prescribe, if I prescribe it once a month, that's a lot. If I'm closer to where Kevin is, I probably once every quarter or something like that. And if some people, some people are particularly pain sensitive and I'll kind of gauge that as I go. But I really don't very much anymore.

[00:26:39] And I mean, what's really funny, you remember back when they started doing all the, you know, calling in to check on their history and all that stuff. Where they had us, the pendulum has definitely swung the other direction where I give almost no narcotic pain medications. And for the most part, people do pretty well. I don't have a lot of people asking for it. So. Hmm. That's it. You see, now, I rarely write the antibiotic. And I haven't written a medrol dose pack in a while.

[00:27:09] But I would say probably at least one out of three of the teeth I take out, I send them out with just a 10 pill Vicodin script. Which I definitely tell them, you do not have to fill this or take this. I would rub this one. You do. And I do. Unlike Kevin, I tell them that, you know, 3-ibuprofen and 1-X-Ring Tomadol. So I do like that. I do like that as a combined thing that has seemed very effective.

[00:27:38] I think there might be something to the combination of it mentally for the patient, too. Ooh, this is a little different than just what I've done before. Maybe. There might be something to that. Yeah, but then you get the people that don't take any, don't take it. Like I prescribed it for you and it still hurts. Are you taking your ibuprofen? No. Okay. Well, you could try that. Yeah. Yeah. Well, that's- I didn't get it filled. Okay.

[00:28:08] You provided a solution and yet they still have to call for an additional solution. Is that what you're- The other thing is when you are giving it a narcotic, if there's someone that you, for whatever reason, like you said, Zach, I tell them, you don't have to fill this. You don't have to fill this. Yeah, that's a good- But if you, you know, because the other thing is, is the one thing you know, if they call over the weekend, you can't call it in. So, you know, it's one of these things where- Unless you have the digital- Well, that's not true. We have an app that does- Yeah, we do have an app now that we can do that.

[00:28:38] Yeah, but also, I will say, like, if it's before Christmas or something, or I'm going to go on vacation, you might be getting some Norco. It's like, you put a little bow on it. It's like your Christmas gift. Like, I don't want to be bothered, so- I tell them, yeah, you don't have to fill it, but if you do, you could probably sell it on, you know, for some value. Yeah, I mean, this could- You might cover your- You get some value out. You can recover some costs here. Exactly. By selling these. Yeah. Okay, so let's pivot a little bit.

[00:29:06] Kevin, are there any additional getting ahead of its when you're now in the, like, you know, tooth replacement realm where you are grafting and suturing and maybe flapping some more? Tell me more about, like, that angle and what you have to do to get ahead of it for what you do if you're actually replacing a tooth. So we're doing PRF on everyone. So to get ahead of that, like, we've got to draw blood on people, right?

[00:29:35] So they may not be used to that in the dental office. And, you know, I don't do that. My assistants do. So they're just told to say that we're drawing blood to mix it with your bone graft material to make everything heal faster. Like, just real simple answer to the question. You know, why are you doing this to make everything heal faster? We're going to mix your blood. Do you get much pushback on that? No.

[00:30:04] I mean, people ask legitimate questions. That's a legitimate question. Why are you drawing my blood? It is a legitimate question. I would ask why you were doing it if I didn't know any better. You know? Like, what's the deal with this? And- No one's done this before. Yeah, that would be an experience I could give you that before. But, you know, when I'm talking to them, I'll say, unfortunately, we need to take your tooth out. We're going to graft that area. The graft is the foundation that your implant is going to be built on.

[00:30:35] So we're going to extract it and do a bone graft in that area. And I don't go any further than that unless they ask. Okay. If they ask a question, I'll answer it. But I'm not going to go into dental nerd mode and- You know, I probably do that. I probably go into it faster than I need to. I think that's actually the right move, Kevin. Give them as much as they need, but no more is probably a good way to do it.

[00:31:06] So, you know, that getting ahead of- So, like, if I made you numb, Zach, we're going to take out 19. I make you numb and I'll say, okay, Molly's going to get your blood now for the bone graft. And I just walk out of the room. And a lot of times I'll say, wait, what are you doing? And I'll just let Molly handle it. Sure. But regardless of whether you say it or she says it, someone has to have a script of something to say.

[00:31:32] So, even if I've explained it, you know, 10 minutes ago, I get it. Sure. You're nervous. That's all cool. And then I think the other part of getting ahead of it is I think we've solved this problem a little bit. We used to have a little bit of a problem with the membrane and the sutures being annoying. We switched our sutures to PTFE sutures.

[00:32:03] Sorry, T-Bone, if you're listening to this. But that has- He does not. We've reduced- And there's a reason why. It's okay. You don't have to get into that. Yeah. I'll just say it. It's a cost issue for the nonprofit clinic. Got it. Yeah, I can absorb, you know. Yep. Or Matt can. Matt, if you're listening, thank you. Thanks, Matt.

[00:32:32] They're less pokey. They're less irritating. They are less irritating, yes. So, we get way less callbacks for that. The downside is that we need to cut them out in a month, but they need to come back for their membrane removal anyway. So, it's not that big of an issue. We definitely need to get ahead of the membrane thing. We just call it a Band-Aid. Make the patient look at it.

[00:32:58] There's this, you know, white membrane in your mouth that's protecting the bone graft. That's going to stay in there for a month. You'll come back in a month, and then we're going to remove that and let the rest of the graft heal. And so, those sutures you put in, they'll hold up for a month? Yeah. Yeah. That's impressive. Yeah. So, the glycolon that we were using are supposed to dissolve, and they don't. Well, they do.

[00:33:28] But they dissolve poorly. So, they're pokey, and people don't like them. Or they untie themselves when the tissue swells, and then it goes back down, and that process unties things. Or I just suck at tying knots. But somehow, I'm better at tying the PTFE knots. Yeah, I was going to say, materials-wise, it's different.

[00:33:49] I've done more suture removals for my surgeons than they know, because a lot of times, like you said, that stuff, freaking, it lasts forever. It's there. You know, it's really well healed. The seam's all up. And they've still got these things poking out. It's driving them crazy. I had one. Steven, it was a number seven, so we should have been able to see everything. I had one where when I went to reflect the tissue for the implant placement, I'm like, wait, what is this?

[00:34:18] It's still a suture there. So, that was a little embarrassing. But, yeah. I think explaining all that, and then, you know, explaining the next processes, which, you know, you're going to return in a month, remove the membrane. It's like removing a Band-Aid. It's a really simple appointment. Getting ahead of that, so they're not worried about that. But also, when you remove the membrane, the tissue looks like crap underneath. It just does.

[00:34:48] But then over the next three months, it heals perfectly. I can show you photos. But getting ahead of that when you do it, like, yeah, it looks like that. It's all part of the healing process. Getting ahead of that for my attendees at the TRT class, I'll get it. Even though we've gone over this a million times, the first time they remove a membrane, like, oh, my God, look at this. It's like, yeah, that's what it's supposed to look like. So, yeah. Those are the big things.

[00:35:18] I got one for you. Is there any getting ahead of it for you guys with the talking about bone fragments that are going to work their way out? Because I hate getting those callbacks and then them saying, well, you didn't get the whole tooth out. Right. Every time, yeah. Well, what's the getting ahead of it on that? Kevin, you seem like you're hot on this one.

[00:35:45] Let me answer that because inevitably bone graft material will work its way out of the socket. It's going to happen. So we get ahead of that in our post-op instructions. You may see some little bone. I think Molly says something like they look like little grains of salt or sand. That's all normal. You're going to have some of that come out. That's part of the healing process. But the bone fragment thing.

[00:36:12] Yeah, that's super annoying because, you know, you know, the pride thing is that, you know, you got the tooth out. And if someone's accusing you of not, anything hard in your mouth has to be a tooth. That's what she said. But, yeah, like, I don't think there's any real getting ahead of that. That's almost a getting behind that. That's also what she said. And because you don't really know when that's going to happen.

[00:36:43] No, but I do think there are some teeth situations where the likelihood seems a little bit higher. Yeah. Like molars higher. Lower molars seem like higher. And if a tooth comes out kind of messy as opposed to just coming out cleanly.

[00:37:08] So I've kind of gotten like in the habit of if a tooth comes out with a struggle, maybe especially if it's one of those root canal teeth. And especially if it's on the lower, I mentioned there's a possibility you might have a piece of – I was like, I got this whole tooth. I want to say that the whole tooth is gone. Yeah. It is gone. That's a good point. I like that.

[00:37:33] If there's any fragments around, sometimes pieces of bone will chip off and work their way out through your gum. It sucks. And, you know, it's – I got a great story that goes along with this. So go ahead, Dal. I had a woman who – it was just terrible. She was being treated for cancer and she ended up having a bunch of abscessed teeth while she was on that – oh, you know, the methyl trex, whatever the stuff.

[00:37:58] The stuff that basically makes everyone heal really poorly, but we had to go in and do surgery after the fact. It's basically – it's like the bone density medication except it was a cancer treatment. And I mean for years she essentially just had open wounds there and, you know, just like bone sticking out and it was sensitive and painful. And so last couple of years she'd call and she said, I think I lost a tooth. I'm pretty sure I lost a tooth. And she'd come in and it was a piece – it was – she'd finally healed.

[00:38:27] And so a big hunk of this like this dead bone came off. And every time she comes in, I'm cheering like I'm cheering for the Lions Super Bowl. This is the best news. We got this – so it's happened several times. And now she's all excited about it because she knows – and you look in there, there's no – you know, the wounds are all healed up. It's very cool, but it is – she was – she thought, like you said, she thought it was tooth. And, of course, it's really nice when it's not a tooth that she thinks is falling out. We just sort of learned to know that she's actually healing, which is amazing.

[00:38:56] Clearly she's lived way longer than anyone thought she would. It's kind of a great story, to tell you the truth. Do you guys ever, after maybe a more difficult extraction where you struggled a bit, almost take like a post-op PA just to – well, maybe A, to make sure you didn't leave a sliver of root and B. So almost that you can prove to the patient that the tooth's gone. It's not a horrible idea. You've done that? I've done that before. Yeah. Just because I was like, man, this person sucks. And when this bone fragment comes out – You just know they're going to say something.

[00:39:25] There's no tooth here. Yeah. I've done that. You could do that. I'm obsessed with getting ahead of it. That's just all it is to it. All right. Hey, next time, implants and implant crowns. Kevin, anything you want to double down on, take back, apologize for? Suction your teeth, my friends. Suction your teeth. I agree. Alan? I'm with Kevin. Super. Hope you guys are enjoying this series. And we've got a lot of comments.

[00:39:54] People like it. So cool. Good. Oh, great. Good to hear it. All right. Super. Well, there's more. So if you do like it, there's more. There's more. We will see you next Tuesday. See you.