The Fixed Podcast

Roadmap to Remote Anchorage with Dr. Clark Damon: Part 1

July 08, 2024 • Fixed Podcast

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Ever wondered what it takes to become a master in implant dentistry? Join us as we sit down with Dr. Clark Damon, a leading expert who transitioned from running a denture clinic to managing a high-production practice. Dr. Damon walks us through his journey and outlines the essential steps to advance from handling removable overdentures and single implants to mastering fixed treatments and All-on-Four cases. He emphasizes the importance of hands-on experience and specialized training, shedding light on how visual aids like x-rays and CT scans can be pivotal in enhancing your learning curve.

Discover the transformative power of cadaver training in dental education. Dr. Damon shares his experiences with advanced cadaver courses offered by the Texas Implant Institute, highlighting invaluable mentorship and the collaborative spirit fostered by professionals like Rick Klein and Juan Gonzalez. These immersive courses are more than just a learning opportunity—they are a gateway to forming lasting professional relationships and accelerating skill development, especially in full arch procedures.

We also dive into the nitty-gritty of guided implant surgery and patient education. From the crucial need for comprehensive training and effective communication with staff, to transparent discussions with patients about procedural and financial aspects—Dr. Damon covers it all. Learn about the benefits of using six implants to reduce cantilevers, the importance of anatomical landmarks, and essential preventative measures for patients who have undergone head and neck radiation. Equip yourself with the knowledge to navigate complex medical considerations and ensure patient safety and successful outcomes in your practice. Don't miss this episode packed with insights and practical advice to elevate your implant dentistry skills!
Tyler Tolbert:

My name is Dr Tyler Tolbert and I'm Dr Soren Paape, and you're listening to the Fixed Podcast, your source for all things implant dentistry. Hello and welcome back to another edition of the Fix Podcast. So this is our first guest episode and we are coming in pretty hot. We are back with the venerable Dr Clark Damon, so he's going to be on here to help us establish a roadmap to take you from being a competent full arch surgeon doing removable overdentures, doing single implants, and then make your way into some fixed treatment, get into some standard.

Tyler Tolbert:

All in four we're going to talk about how to do that super well and start from the beginning, doing excellent cases. Then we're going to move through very logically into we're going to take you to your hundred arches. Then we're going to take you to your thousandth arch. The thousandth arch is just going to, you know, consist of much more advanced cases, starting to dabble in some road anchorage, incorporating some more advanced techniques, so you can be taking on up to 98, 99% of cases. And then the tail end. Here we're going to get into what we really needed. Clark for no-transcript. Soren and I have been to several of his courses and we've gotten to know each other here and we have been enriched so much just by knowing this person and listening to what he has to say. So, clark, thank you so much for being willing to come on, and this time in video.

Soren Paape:

Well, that's awesome and congratulations to you guys.

Soren Paape:

I think y'all took the other podcast you know really far, and now you guys got this new thing. That's, I think, going to be even better. So I think that the really cool thing with our discussions that you can have, with going to be actually able to overlay some x-rays and some panos and even some photos, right, and I think that's going to be even a better learning experience, right. So, if you talk about the podcast or the train to listen to, I think this is the one. I think it's another step up right One. I think it's another step up right. Other than just hearing people talk, now you're going to be able to see, right. So the only thing you guys got to work on is how to get smell through, right.

Tyler Tolbert:

We're going 4D next. It's happening 4D.

Soren Paape:

There you go, teleportation.

Tyler Tolbert:

I don't know if people really need the smells of full arch to come through. I don't know if that's really a desirable thing.

Soren Paape:

Well, you know it may be a good, uh, a weed out process, right it's always nuts when my non-surgical assistants come by the surgery room and you know the surgery will be over and they'll be like, oh smell you know, uh, I'm like. What does it smell like? And the best thing they can say is it smells like a meat locker and I get uh, I get my assistant's thing.

Clark Damon:

It sounds like doritos, smells like doritos. Maybe I'll ruin doritos for you guys, but wouldn't put the the bone in the bone, I wouldn't I wouldn't buy that flavor.

Tyler Tolbert:

Wow, that's a forbidden flavoritos.

Soren Paape:

I think you would see that from Colorado. Maybe you need to drug test your dental assistants or something.

Clark Damon:

Oh, hey, we're really excited to have you, and that is our goal from this podcast is to bring in more learning content for our listeners and viewers. Now we're talking. If there's any cases that you want to in particular highlight, just send us over those panos or those CTs and I'll incorporate them into the episode, and then you as our viewers can take a peek at those.

Soren Paape:

Yeah.

Clark Damon:

I think it'd be great, absolutely.

Tyler Tolbert:

And Clark, if you wouldn't mind, just for those of our audience that have been living under a rock, would you mind doing a little bit of an introduction, just to let everyone know who you are, what's your experience like, where are you working and why were we just dying to get you on this podcast? Sure?

Soren Paape:

Well, I've been in practice for 12 or 13 years now. Immediately I started, I purchased a practice. It was a denture clinic the Texas Denture Clinic and it was doing about a million a year and it was great because it allowed me to do my IV sedation. Prior to purchasing the practice, I spent six weeks or six months in corporate dentistry and within three weeks of that I knew it wasn't for me and I immediately went to a practice broker and I was like, okay, I've been in corporate dentistry for three weeks, fresh out of residency, this isn't for me. And I was like I need a practice that's like the VA where I did my training at which was veterans, it was a dentulation and it was surgery. And he was like, man, have I got the practice for you? It's a denture clinic. And I was like, okay, that doesn't smell very good or taste very good just on the surface.

Soren Paape:

But when we really got into it it was high levels of production. It was high levels of production per patient and it was surgery. So it was a way where you know, once you take an entire patient's teeth out and sedate them and do the alveoplasty, even dentures is expensive. We give quotes all the time for $8,000 to $12,000 just to yank all their teeth out, knock them out and put them in dentures, and so you do four of those a day. That's a $40,000 day and you can go to the bank with that.

Soren Paape:

And yeah, so the general practice residency that I did at the VA it was one of two residents six weeks of anesthesia training, three months with the oral surgeons, spent time at MD Anderson, six months of prosthodontic work and you know what I'll tell anybody who's looking to potentially go to a general practice residency or an AGD it will be what you make of it. When I was doing the anesthesia rotation they were like, oh, you're the dental guy. They're like we didn't see the past six of them because none of the dental people ever showed up. But I was like, hey, I'm going to be here every day at six in the morning and I probably did a hundred intubations and toward the end of it.

Soren Paape:

we were in the bronch lab and there was one of the one of the bronchoscopy or whoever does that, I guess it's the pulmonologist. It was the attending and he mentioned to the CRNA that I was with. He was like hey, that anesthesia resident knows his stuff and, which was really funny, I'm like nope, just the dental guy not even in anesthesia residency.

Soren Paape:

But the thing is I took ownership of all of that. I showed up. All of that. I showed up, I was present. I went to as many meetings as I could. I went to tumor board, I went to call with some of the oral surgeons. They even had me put in a calf on a guy Not that that translates into anything, but the fact is just being present, taking advantage, and I think that can significantly elevate you to it.

Soren Paape:

Interestingly enough, I didn't want to do the general practice residency. I'd just gotten married to my wife, who's a pediatric dentist. We were talking and I was like honey, I just want to go out and be a dentist and make some money. Thank goodness I did not buy into that because that would have set me back 10 years, and so anybody who's considering that, do it. So, anyways, a little bit of a segue there. But that propelled me to want to tackle full arch cases within six months of me purchasing the denture clinic, and we then changed the name to the Texas Denture Clinic and Implant Center and through that, after doing a bunch of snap-ons maxillary snap-ons I quickly learned avoid those at all costs. Mandibular snap-ons do those all the time.

Soren Paape:

And then, when it came to the All-On-4, which, again, this is 2012, 2013. All-on-four wasn't completely around. A lot People were still like, oh, there's a clear choice. What is that? The verbiage wasn't out there and we started incorporating all-on-four as early as 2013. So we were doing, I think, the first year out in private practice. I think I was doing 50 to 60 arches of all-on-four. So we were doing, I think the first year out in private practice. I think I was doing 50 to 60 arches of all on four and they were rough. Man, I was doing my own IV sedation and if anybody you talk to, you can do a single arch under IV sedation, but the time you start tackling a dual arch, I don't care if it's hard or easy, it's a rough day. But the oral surgeons out there that can push propofol, they won't do it okay, because it's going to be a fight.

Soren Paape:

At the time in 2013, there was really only one place that you could go and get quote unquote all-on-four education and that was to go to Nobel, right? So we went and you'd hear the whole thing and this full arch today is totally different than what it was 10, 12 years ago and it, you know, that was even more different than it was 10 years before. So 10 years before so let's say early 2000s doctors were given patients 10 implants per arch, right, so as many as you could. And then Molo came out and was like it's only four. And the mantra at Nobel, at Y Belinda when you went, was the fifth implant is for your boat payment. And everybody kind of jokes about that. Hey, the surgeon's yanking your chain, you don't need the fifth implant. Now, obviously that was a shot at mish, but it was a big push just to do four. And now it's like I think we finally have the perfect today. I think we have the perfect amount, which is four in the front.

Soren Paape:

You do your standard and then you do your two retroframerally to eliminate cantilevers on the mandible and then do your pterygoids in the maxilla. And my practice today is everybody gets six as long as they can handle it. It's a little bit of an added revenue center. To be honest, I don't charge for the extra two on the mandible, the reason being half the time I don't do the consults my associates do, and so sometimes they can miscalculate as to which is a good candidate to have the six implants, fifth and sixth on the mandible. So all my mandibular six implants. They get two for free and we charge for the two in the pterygoids, so it's an extra $4,000 added revenue. But when you're doing 300 arches a year, okay, now that starts to really add up right. And for anybody who's wanting to develop their own DSO, have a multi-doctor office, okay. When your group is doing 1,000 to 2,000 arches a year and you're gaining an extra $2,000 or, sorry, $4,000 an arch, now you're really talking about 8 million bucks. So it's a significant revenue booster and so I would say it's worth the hassle. The financial reasons to do so is least amount. That's the least consideration. It's really just the benefits of no cantilever. So that really brings really full circle.

Soren Paape:

Today I've got two practices. I had a stint in 2016 to 2021 where I had three offices and man, was that a bad idea Trying to have one doctor do three offices? And man, was that a bad idea trying to have one doctor do three offices? Because once you go beyond two, then you get into between three and ten. You're not making any money, right, because you're having to invest in call centers, you're having to invest in centralized services and regional managers and stuff like that and the idea of working really hard and not making any money didn't really sound very good to me.

Soren Paape:

I didn't really want to grow that fast, but having the Dallas office allowed me to be doing 35 arches a month and it pushed me to do things that I normally wouldn't do, such as TV or billboards. But I would say that I'm where I am today because of that mistake and I didn't ever make a dime out of that practice. In fact, when I sold it I had a big tax bill. It was really frustrating, but it helped get me to the other offices, to where, between Fort Worth and Amarillo, which is where I would practice today, we're doing. I think this year we're on track to do about 300 and 340 arches. People always ask me what's a good month and I say 25 arches and a bad month is 30. I say that legitimately, because a lot of work, doing this type of work you need your days off, just not even for your mind, body and soul and then your family and, anyways, that's where I'm at, texas awesome, that's great.

Tyler Tolbert:

and can you talk a little bit too, just before we get into our whole approach here, about the education that you're doing as well? So sort of, and I have been really fortunate to go to your sort of standard intro to all four courses, as well as your Zygo and Terry cadaver course, which we have been. We're still buzzing on it, I think, six months later.

Soren Paape:

Yeah, my earlier story about we had to go to Nobel, so a long time ago. You go to Nobel, you sit in a lecture for a whole day, and then you sit in a lecture for another day and you watch them do a surgery, and then you watch them do the conversion and they do one arch and it takes from nine to two, and so half the people are dead by then. They're super tired and sleepy and at that time that was our education and really didn't, couldn't really do much better than that. And so in 2017, I said, hey, you know what I think there's an intro here I took a cadaver course one of the one of the Zygo courses that I took from a Dr Pedro Franco in Dallas, and we did it at the Synthes center. Eyes were opened. I was like man, if I had this for my full arch training, I would be five years ahead of where I am now. Right, like just to have training where you don't have to do it on patients, right, you get to do it on a patient that's not going to complain, a patient that's not going to hurt, a patient that you can have complications. And so I said, okay, I'm going to condense what Nobel did into two days with a cadaver, and we've had 40, 40, 45, 50 courses. I've been doing those since 2017.

Soren Paape:

And then I met Rick. Rick Klein met him in Barcelona at a Zygo course Carlos Aparicio's Zygo course. He was in yeah, it was very early 2019. And just Rick and I had just an amazing bond together. We had very similar treatment philosophies. He was in Houston and I was in Texas and so I invited Rick. I was like, hey, anybody in Full Arch knows Rick Klein. He was the pioneer, at least in Texas. I remember flying on the Southwest jet and going to college back in 2000 and seeing him advertise in the Southwest magazine for Teeth by Tonight, him next to a piano with Shiro and all the other different doctors that he had. And so I was like, okay, he, rick, will help give me credibility for people to come take the course.

Clark Damon:

And because I felt I needed that, and it's great.

Soren Paape:

Yeah, unfortunately, we're at a little bit of an inflection point, sadly, and it's great. Yeah, unfortunately we're at a little bit of an inflection point, sadly. Right after one of our courses, rick passed away and floundering a little bit. I need somebody else to come along and help and we'll get things rolling and going. We've got a August 24th and 25th. We've got an advanced Zygo and pterygoid course with myself and Juan Gonzalez, and if you haven't met Juan, he's just an amazing human being. He is super nice. He tells you like it is no BS and is in a, what he can do with his hand pieces and how he can get zygote in there is really amazing. So if you're wanting a great course myself and Juan we've got that in August and so you can visit Texas Implant Institute. And then in November I've got a surgical one course.

Soren Paape:

I think we're going to change that and just do another flagship all on four cadaver course. So really those are kind of the two courses that we have, and I hear all the time guys love our all-on-four flagship course. They always talk about the booklet that I give them, and so I'm a firm believer that you will never get my PowerPoints. You will never get my PDFs. However, I will give them to you in printed form and they are done really well. I've spent hundreds of hours going through them and it's just such a great resource. But the other thing is, is you get my cell phone, my email and attend? We stay in communication and the Texas Implant Institute is a labor of love. It's not a business and I'm not promoting it all the time. I wish I would and I wish I could have 10 courses, right, but at the end of the day, I don't want to turn it into a business, right? Like I want to have fun, and you guys know we have fun, right?

Clark Damon:

yeah, we have, we have good fun, good drinks.

Soren Paape:

You know, friday night, we start at the bar at six o'clock and everybody can drink as much as they want and day two is a challenge.

Soren Paape:

I didn't make it the first time obviously your instructor here is not overdoing it, but everybody's having a good time and it's just, you get to meet so many cool people and I can't tell you how many times, how many days. I get a text from somebody in Oregon or somebody in Seattle or Colorado and it's hey, I got this case. What do you think? And it's very simple One guy, that one guy that took the course. I'm going to fly up and we're going to help him do some pterygoids and stuff like that.

Soren Paape:

We have some mentorships, and anybody who takes the course is always welcome to come in to the office in Fort Worth Mondays and Thursdays when we do surgery and learn as much as you want, and so it's a lot of fun. And so right now, those, those are two flagship which is all in four cadaver two days and then advanced zygoterragoid two days on cadaver.

Tyler Tolbert:

That's great.

Clark Damon:

Yeah, I want to say a couple of things. I learned so much at both of the courses. I think that Clark and Rick when he was there they did an excellent job with talking about a lot of the efficiencies that Tyler and I go over on the podcast a lot, and how to properly structure your team to perform these arches in an efficient manner so you don't have your patients under anesthesia for six to eight hours, and that's something I get a lot in Denver. Here we work with CRNAs a lot who travel around and they go to the different offices and there's a lot of general dentists that are doing these cases and they just aren't doing them in the most efficient manner and it's causing the patients to be under anesthesia for a really long period of time. It's causing the patients to, when you're in surgery for six hours a lot of times that healing after the fact is really difficult for those patients, and so learning good efficiencies and seeing them done on a cadaver, getting step-by-step how to do them, it helps a lot with surgery and it helps a lot for the doctors to continue doing this kind of surgery, because Clark is right that it is it's hard on your body and if you're doing a lot of these like you're going to get burnt out quick unless you get your team together and you get your structure for your surgeries together.

Clark Damon:

So today I also want to mention we talked about zygos and pterygoids, but they also, juan and Clark they go into trans sinus, they go into trans nasal A lot of the different approaches for if you reach this part of the mouth and this is something that I got from Juan and I loved it he talked about okay, when you're in the anterior, are we engaging the piriform rim? Are we engaging the transnasal? There's all these different approaches to these implants and how, if something doesn't stick, if you have soft bone, how can we use the next implant in our arsenal to load this case right away? Because we don't want these patients going away in a denture. That's not what they're paying upwards of $50,000, $60,000 for. We really want to have all of these different implants solutions under our belt so that way we can give them the best treatment possible. So, yeah, go ahead.

Soren Paape:

Yeah, one osteotomy in the maxillary interior. You can go floor of the nose, you can then go nasal crest, you can go lateral nasal or you can go transnasal. And that's really cool how, with one one essentially coronal entrance point, we can do all of that. And so you don't get all of this bone destruction where all of a sudden you look back and there's no alveolar bone left other than nasal cortex or whatever, because you've obliterated it. But it's.

Soren Paape:

It's a concept of feeling the bone and feeling your drills right. And if you want to make a change in your osteotomy or the direction that you're going to take your implant, the sooner you make that decision the better. Right, like you don't want to be going axially into the floor of the nose and you place your implant and you get 10 newton centimeters of torque even after penetrating the cortex, right, because then by the time you change to lateral nasal or nasal cortex, it can be much more difficult to really secure that right. So it's thinking about the bone and being able to be flexible, but be flexible early, and the sooner you make your changes the better.

Tyler Tolbert:

For sure. So I think that just to backpedal a little bit and give us a little bit more of a formulaic approach here, because I think it's very easy for us to go off into tangents about different techniques and how we think through different problems, let's scale back to an audience member is listening to this show. They've done some lower snaps, they've done some upper snaps and regretted it. They want to get into fixed care and what I'm hoping to do is for their very first arch. What should they be prepared for, what should they be looking for, what should they be avoiding and what are some of the principles and skills that they can go ahead and incorporate from the very start to set them up for an expedited path to success? What do you have for that Clark, starting really as soon as just case selection?

Soren Paape:

Yeah, let's just say zero. Zero to 10, zero to 20. Take a course first, right, like I can't tell you how many guys come to my course. And we go around the room and I'm like, okay, how many arches have y'all done? And they'll say five, six, seven, eight, nine, ten. Okay, great, what do you? What questions do you have?

Soren Paape:

and they're like oh, I've got a list of 100 questions. Okay, cool, I can answer all those. Where'd you get your training? And they're like nowhere. And I'm like you guys did 10 to 20 arches without any training, and which is mind-boggling to me.

Soren Paape:

First off, don't wing this. Wait. Take a course. Okay, I don't care to any number of courses if you're not going to take mine, but take a course first, okay, um, the way that you take courses and the way that you take education is sell the case, take the course and then line it up for literally that Thursday after you get back. Okay, so that way, you get back on Monday, you review your x-ray, you think of any questions, you call me, you call your instructor, you then call the implant company, you get your implants ordered and then you're ready to roll. Okay, so zero to 10,.

Soren Paape:

Some of the first things I think that you need to be ready for is have adequate implant stock on hand. That's number one, because you never know hey, you're new at this, right, you're not going to feel the bone like you should, so you're going to over prep. So you definitely need some 50 by 18s, some 50 by 16s, 50 by 13s. So you need rescue implants. Okay, if you don't understand the concept of what a rescue implant is. Don't proceed with surgery until.

Soren Paape:

The other thing sit down with your staff. Right thing sit down with your staff, right. Sit down with your assistants and say, okay, this is how things are going to work, these are the things that we are going to expect, these are going to be your responsibilities, these are going to be my responsibilities and these are all of the steps right. So my first arch, my first several arches. I wrote out every step right Incision, reflection trough, take out teeth. Five millimeters of alveoplasty, confirm with the prosthesis, posterior implant, anterior implant. I wrote everything down, I even wrote timing check screw channel access, check this torque. And I wrote down place 30 degree angled abutment torque to 20 newton centimeters. So be highly organized. And then the next thing is interest. You need to inspect yourself and you need to say do I complicate things for my staff just by my nature?

Soren Paape:

If so say how can I make their life easier? Okay, so then, how many instruments do you use? Like you should? Only for a maxilla, you should only need one forcep. Okay, a 150.

Soren Paape:

If you're calling for 88 R's, 88 L's, stuff like that, you're not going to be in the fixed game. Okay, trough the teeth, section the tooth, take out the root tips. Okay, very simple. And you need to be thinking okay, do we have the specialized equipment that can help us suture? Do we have nice long tissue forceps? Do we have Adson tissue forceps? Do we have Weterer retractors? Do we have Sweethearts? Do we have Oranger retractors, seldons, pritchards? Okay, those are all retractors that the doctor's not going to use, but it's a way that the assistant is going to help the doctor move quicker and be able to visualize things more and better.

Soren Paape:

And the other thing that I would say is don't do your cases guided, that's, I think in this early 10 to or 0 to 50, guided always comes up. If you're on Instagram for your education, you're going to hear multiple different ways of doing this and I will tell you. I saw something on Instagram the other day that said hey, we do guided because our temps are thinner and our finals are thinner. I'm like BS we do guided because our temps are thinner and our finals are thinner. I'm like BS every guided case never turned out the way I wanted it to and the guided cases turned out bigger.

Soren Paape:

And in addition to that, I was not flexible in my implant position and to me, I think, in general guided cases especially dentate, going from having to dentulate a patient and doing that guided just chalk it up on the board. In four years you're going to be redoing that arch. That's my opinion, I've seen it and I know why. Right, because you're typically not going to be able to reduce enough, you're not going to be able to cool your implant drills and cool the bone enough, and it's just not flexible. And I'm in some text groups and with with some of the best implant surgeons in the country and one of the things that we say is thou shall not guide until thou can free hand. Or what if, all of a sudden, an implant is like super buckle because of your guide? So thou shall not guide unless thou can free hand. And the other part of that phrase is if you can free hand, then why guide?

Soren Paape:

Because all you're doing is you're inflating your costs. You are spending quite a bit of time designing and planning your guide and then having a meeting with the guide, support and coordinating three people, and then now your surgeries four weeks or five, six weeks down the road. Yeah, so guided is opinion. My recommendation is you just scratch that off the list, okay. I think in this early, early venture, one of the questions is as well what implant system should I use? The systems that you need is a single implant platform I can't tell you how important that is and you need a system that will grow with you. Okay, and you need to be able to say, hey, if I'm going to get into the fixed arch game, I need a professional system. So a professional system is one where the implant line has the same connection among all components, among all sizes, incorporates short implants, long implants, zygomatic implants, and has abutments that are smooth and nice and has all different types of sizes and stuff like that.

Tyler Tolbert:

If I could interject just for a moment, I think you're making some really excellent points and a couple of them even tie in together a little bit In terms of guided offerings, and you'll see a lot of this on Instagram, social media. I think that especially the realm of third-party guides it's such a productized thing and it's so easy to tell someone who hasn't done this you need to do a guide or you're not going to do this properly, right? If you want to do this properly, you need to use a guide and then you can start going freehand if you want. It's pitched as this lowering of the barrier to entry, and I think also that goes hand in hand with implant systems, and sometimes these things are even integrated together.

Tyler Tolbert:

You have to use the implant system that corresponds to the guide system, and a lot of those implant systems are not designed the way that you're talking about. They're not going to grow with you. They're very simplified, elementary systems that don't go into longer implants and are not going to have solutions for you when you're ready to do pterygoids and zygomatics and everything, and so it's almost as if there's this tendency of companies to productize that sort of person that's trying to get into this, and they end up going down a very expensive and frustrating road, only to find themselves back where they should have started, which was doing freehand with a system that could grow with them. So I really appreciate that point for sure.

Soren Paape:

Yeah, it's just, it's a learning curve and you have to have the knowledge and you have to have the experience. And you, you have to try it. Hey, I hate guides experience. And you, you have to try it. Hey, I hate guides. You know, I haven't done a guide in I don't know, maybe 2016 was the last time I even attempted a guide. So I've probably done 50, 60 guided cases and I'll tell you.

Soren Paape:

they were so frustrating, they were complicated and just getting the guide in there and getting it attached it was difficult. And then now you have your guided drills, which are even longer than your regular drills, and you're trying to get them all the way back there and trying to get the patient to open up wide enough.

Tyler Tolbert:

Yeah, with the offset, that doesn't work.

Soren Paape:

And so you know, because you're trying to maximize your AP spread, right, like hey, I can get this all the way back there. But then if you look at a lot of the guided cases, they're not on the mandible, they're not very far back right, they're a little more anterior because they know that you're going to have some trouble getting in there. And so there's. I agree, I think that we really have to be cognizant of the industry in general and that there's a lot of push. And I don't agree with full arch digital workflows across blanketed, right. I think that there's, that they work, there's some indications for them, but it is not a silver bullet, right.

Soren Paape:

I think you trade other problems for other things, right? And a lot of the stuff is pushed by implant companies wanting to sell photogrammetry and all this kind of stuff. Right, I think being able to say you know what I can do just as good, possibly better still, save money, still save costs, but use things differently. So I just think, at the end of the day, this would be something for the 500 or 250 arch person. It's okay to buck the trend, it's okay to just say no, I'm not going to agree to that. Just because you saw something on Instagram doesn't mean that, right, I think they said, like with the COVID shot, that you protect others. Okay, I don't know of any immunologist that actually believe in that right.

Clark Damon:

Vaccines protect yourself right.

Soren Paape:

We've heard of all types of stuff and guess what? It's okay to say you know what? No, I learned something right. And just because you learn it, don't forget it. Whenever you get pressured, you're going to get pressured by patients. This is another really big, important thing. I Don't forget it. Whenever you get pressured, you're going to get pressured by patients. This is another really big, important thing. I don't do FP1. I have no desire to do FP1. I would say it doesn't exist. I have no desire to do FP2. Guess what? If you're my patient, we're not going to do that. If you legitimately want that, I will refer you somewhere else and you can gladly go do that and somebody else can gladly do all that. But I'm not going to get talked into something that I don't agree with or maybe I can't do very well and I've never done a. What is that? Like a partial root bank thing.

Tyler Tolbert:

I don't know how does that not?

Soren Paape:

turn into an abscess and a root tip.

Tyler Tolbert:

Socket shield right Partial extraction therapy.

Soren Paape:

That's just a root bank. Like you see these guys root bank this stuff. Like how does that does what happens? I've seen root tips galore and they're all infected. I don't know, maybe somebody just needs to tell me Like the partial extraction therapy, like I get it in sense right, hey, like the PDL is going to stay there, it's going to supply the buckle plate, that's fine if you want to do number eight implant, but I'm not about to do a fixed full arch case with all these socket shields and root banks. Does it work? I don't know, it doesn't equate to me that it works right, but at the end of the day I'm not going to get talked into that because I don't think I could do that patient a good service, right? Also, too, just know, hey, I'm not going to get talked into this.

Soren Paape:

The other thing that we talk about and this applies to zero to a thousand you get a patient that's got pretty severe periodontal disease. You have to indentulate them, okay. So if you tell me they only have 25 grand, great, do a free maxillary denture and do a lower permanent. Identulate them. Please, do not keep periodontally involved teeth. And then you need to look at the occlusion. What does it typically look like. It looks like a rollercoaster. How are you going to provide them a beautiful arch when the opposing dentition is just all over the place? Looks like a roller coaster. Really, think that kind of stuff through.

Soren Paape:

Be able to say no, but kindly, and educate them as to why. Right, if you live in Texas, this was one thing I learned early on, in 14, 15, yeah, I think it was 14, I opened a practice up in Amarillo. It was a cowboy town and I grew up here. I should know this. But I'd see these men and I'd say, no, I can't do that. That's not good enough for them, right? And these are just men that are going to ask a thousand questions. They will say, okay, why not this way, why not that way, why not this, why not that? And so out of my career. I got frustrated and I was like, why don't they just believe me? They don't. It's their job not to believe you. They'll believe the assistant before they believe you, but it's being able to educate them as to why and ultimately, what is the true cost of them keeping their teeth.

Soren Paape:

I will go into consults all the time and I'll have a pano and they'll say hey, doc, I want lower, all on four, but I want to keep my upper six teeth. Like, ok, great, you know, we can do that. Here's fifteen thousand dollars for a sinus lift on the right side and three implants here. And then, ok, let's do another fifteen thousand for another sinus lift and three implants here. And then, okay, let's do another 15,000 for another sinus lift and three implants here. Okay, so you're going to spend 30 grand for the upper and look like you need to go see the dentist because we haven't even touched the front six teeth, right? So let me say, okay, so that's six crowns. My associate can do those. Two grand a piece, 12 grand, so 42 for the top plus your 22, five for the lower.

Soren Paape:

And I tell them if you really want to keep your teeth, we can do that. But as the trouble is, after you cut teeth, how many times does it turn into a root canal? And then they're back in the chair, same spot, right? Again. It's just about education, and so once you put it on paper and you just start just writing out these fees, patients are like oh yeah, let's just rip out these six teeth and it'll save me a bunch of time, energy, money, and just rip out these six teeth and it'll save me a bunch of time, energy, money and effort, and I love that, because now they're educated and you weren't put into a position where you talked them into it.

Soren Paape:

They agreed with you and said, yes, that's a good idea, so it was their idea to do it. So you did not talk them into it.

Clark Damon:

You educated them and then, in addition, now you're not pinned up against a wall doing stuff that you don't think is really a great idea yeah, yeah, absolutely, that's all it's about, um, the zero to 20 arch space, uh, and just to recap, I think some of those are one go away from the whole, uh, as many implants as possible, right? There's still a lot of people out there that don't even recognize that. So I agree with you 100% Four in the front. And it's really easy, like I try to tell my patients the same thing where I say I prefer to do six implants on every case that I can, and the reason I do that is to reduce cantilevers, to reduce forces on these back implants with large cantilevers. But I always try to clarify that doesn't mean six implants up in the front, because there's still people that are doing that. It means four in the front. Get something in the back, try to get rid of that cantilever. I thought that was a great point. Another really good point is just try not to go down the guided train, and by not going down the guided train it does mean that you should be going to some sort of course. Is try not to go down the guided train, and by not going down the guided train it does mean that you should be going to some sort of course to figure out the best way to do these cases without a guide and what anatomical landmarks to use in order to avoid using the guide and still be able to do surgery predictably for all of your patients, tyler and I, when we talk about these things, we talk about them so quickly. It's because we do this day in, day out and we've already went to all of these courses in order to properly place these implants in the correct directions to avoid the sinuses on the posterior implants, avoid your foramen on the lowers, know exactly how much reduction to take off on these cases.

Clark Damon:

I think it's a good idea to, here and there, have a reduction guide. I don't know what your thoughts are about that, Clark, but nowadays I'm doing a lot more digital cases, so I'm using existing dentition as my reduction guide. However, I do think it's a good idea to have a. You can just use a replicated denture, cut it off at 15 millimeters from the incisal edge of the teeth and then you can even add in a lingual trough in order to have a like a multi-unit guide, and what this enables you to do is it gives you the reduction, it gives you positioning for your multi-unit placement. So the access is and that's how you actually get thinner prosthetics right. You want a good access that comes out right behind the teeth. So I think that's a great thing to have from zero to 20.

Clark Damon:

And then I do think a couple of good things to go over that would still fit in this space here from zero to 20 are what are absolute contraindications? What patients do you say no to, no matter what? And then also complication management. So a lot of doctors that are in this zero to 20 arch space they're a little bit nervous to get into it because what happens when they get a patient that's bleeding and they can't stop the bleed? I think going over a couple of these things would be really useful for some people to get a little more comfortable taking on these cases in the 0 to 20 range, because it might give them an idea of what to look for and what not to be scared of.

Soren Paape:

Yeah, I would say absolute contraindications. I would say two pack a day. Smokers. I would also say if they're on some type of bisphosphonate, if they've had head or neck cancer, radiation to the jaws We'll get into later. We'll get into how I treat patients who have had bisphosphonates. I do, even if they're taking Prolia, but we'll get into that. But this is definitely not something that they should do. I would say if they're on Coumadin, do not do the ARCH. Just managing that is difficult. Same thing with Plavix and aspirin. Obviously all those patients need to be off those type of drugs. But just there's some significant special considerations. Probably I would stay away from your kidney kidney failure class three or stage three. Obviously dialysis stay away from your dialysis patient. If a patient has like a sickle cell, especially if they actually have the sickle cell trait, don't do that. What are their medical issues?

Soren Paape:

A1C above eight, heck no. Really really, if you want to be, I would say, this area, you want to be even more conservative, so I'd probably say A1Cs, your cutoff would be 7.5. Bruxers, if you get a farmer a male farmer in and like his jaws are as big as your biceps and he has just worn his teeth down, don't do that. Somebody where you know. Just the bone is like ultra thin.

Tyler Tolbert:

No, Jorge Mosquera is someone that actually messaged the podcast today and he was asking specifically about these questions, specifically about contraindications with oral and IV bisphosphonates. He also mentioned SSRIs and PPIs. Are those absolute or relative contraindications for you?

Soren Paape:

No, they're not. You know SSRIs or PPIs? No, we're fine on those. Yeah, If you want, I can. It's hard to answer the IV bisphosphonates because it's just yeah it is it's loaded?

Soren Paape:

Well, okay, I would say contraindication is IV bisphosphonates across the board. I just think if you've done over 15, 1500 arches, then sure text me, I can talk you through how I handle Prolia. Okay, my absolute never, ever is a so meta, I won't touch you, there's not enough money in the world. Is another one that's really ex jiva, ricola, some prolia, they're all the same drug, dino sumab, they're just done in different dosages. So Prolia is every six months, recolast is every three and Xgeva is every one to every two. Typically XGiva is given for multiple myeloma patients and those are patients who are having bone troubles and that to me is just no-go as far as my protocol, if somebody is on, say, boniva, okay to me, even if they've been on Boniva for, let's say, two years. The Amos has a white paper and it guides you through all of this to some extent. A little more specificity would be nice. But even if they've been on it two years, even one year, I still want to do a three-month drug holiday. I understand half-liveses and I understand all that, but I want I have seen CTX values change and actually go up after a drug holiday.

Soren Paape:

Whether or not you think CTX means anything or not and is clinically relevant. There's not a lot of literature to back that up, but you got to think hey, if you ever get thrown into a court of law, what are they going to be asking you? Doctor, did you know about this CTX test? Did you know that Carl Misch, who a lot of people bought the book from, really advocates this test? Do you not think that would have been pertinent to you? Do you not think that would have been helpful? You can't say no, right, so again you back yourself into a corner. Right, so again you back yourself into a corner. Hey, doctor, do you not think maybe doing a three month drug holiday before surgery and then after would have been beneficial? Maybe, right, but again. So I think there's a difference in what we can say from a literature standpoint, and then I think there's another stance where I think we need to be looking from a medical, legal standpoint.

Soren Paape:

So like I want to eliminate any arrow that somebody could come after us for, but it's also just taking all of the giving it your best shot right. Let's have all of our ducks in a row, let's line up as many helpful things as we can so that our chances of success are higher. And then the other thing that I do is I always send a medical consult. I do not call it a clearance. Okay, we do not have that verbiage. Our medical colleagues do not give us the chance to say yes or no. That is on us and that is our responsibility. However, we do want their consultation in obtaining knowledge that they specifically have related to their specialty. That also helps if things were ever to turn legal. And so I did not put them on the drug right, and so that's a good thing. I do not put my patients on Coumadin. I do not put my patients on Plavix and aspirin. That's their doctors, and so their doctors need to take them off and their doctors need to be the ones to give us the green light on that. So I also ask the physician for a medical consultation for a three-month drug holiday before and after and we had a case, maybe I don't know, six months ago, where the patient was like I just took my first dose of Boniva. That's like a one-off thing that I've never had happen and I was like, okay, fine, one dose of Boniva is not going to do anything. I think we did her surgery a month or two after. She just did not have the incorporation of the toxicity and of that drug into the bone. But I would say just being safe, rug into the bone, but I would say just being safe.

Soren Paape:

If they, if it's over a year, for sure I would do the test. I'd do the three month drug holiday before and after surgery and medical consultation. I typically like doing the CTX test at consultation because I want to see how that changes over time over the three months, and so typically we'll do it at consultation. Ctx I'll do it at two months and then I'll do it a week before surgery. Now, for under 100 arches, maybe even under 200, I would say look if they have been. On the likelihood, the literature shows that there's an increased risk with oral bisphosphonates of now it's Meronge after surgery and so probably avoid those. I think that that's not going to be predictable. Right, we are in the predictability phase, right so.

Clark Damon:

I would avoid that, but to answer your listener's question.

Soren Paape:

There it is. That's what I would avoid that, but to answer your listeners question.

Tyler Tolbert:

There it is. That's what I would do. I do have to throw one more in there. Do you have any opinions on the use of hyperbaric dives, pentoxyphiline, vitamin E regimens? Any of these things are floating around for prevention.

Soren Paape:

I don't think those prevent from range or bronze okay whichever one you want to call it.

Soren Paape:

Yeah so pentoxyphiline, hyperbaric. There is debate within the literature, as this is for head and neck radiation receiving patients right. So for your patient who has received, who's had squamous cell, carcinoma floor of the mouth and the mandible has received over 5,000 centigrade of radiation, that's the line in the sand that you get into high risk for BRONCH or, sorry, for ORN at that point. And there's some debate as to whether or not hyperbaric is as effective as something as simple as vitamin E and pentoxifilene.

Soren Paape:

Because there are some significant side effects of hyperbaric One. It's expensive, it's time off work, you have to go do 30 dives before your surgery and then 10 after, and that's a challenge for a lot of patients and luckily Medicare will cover that. Typically those are the patients that have received head and neck radiation for the most part, but that's where for radiation-rece receiving patients, that's where hyperbaric vitamin E and pentoxifilin come in.

Soren Paape:

If you want to be absolutely safe avoid all areas of the mandible or maxilla that have received a radiation dose of above 6,000 centigrade, and I would do. What we do for our patients is both vitamin E, pentoxifiline and hyperbaric. And again it's just kind of throw in the kitchen sink at a big problem before it exists. However, those only very special people should be treating those types of patients, and so I would say avoid those at all costs.