OK simple question Why should we do more oral surgery.
Why should we do more extractions and keep them in house.
Well it's just a tremendous opportunity and security financially and as a business there's always a
demand for it.
It's never going away.
And it's something you can count on regardless of economic factors.
And what's happening in the outside world there's always a need for it.
So it's an opportunity for growth a profit center in the practice and a growth opportunity all around
the probability of courses is really there.
The price for the procedures in relation to the overhead.
When you compare it to what you charge for a crown that you have a lab fee for and possibly a second
visit and that sort of stuff it's really really profitable to do extractions.
I mean how much does an elevator cost how much does a set of forceps cost.
How many times do you use them.
There's just such little overhead.
And I'm going to teach you ways to get any truth out any truth in 10 minutes.
And so if you can do 10 surgical extractions in an hour a visit there's really few things that you can
do in your practice that are more profitable than that.
Another is time management and efficiency.
These things are really fast in relation to other dental procedures that have so many other fine details.
So you can really stack them up and you can book aggressively on your schedule and get a lot done.
And also this is a procedure that a lot of emergency patients will come in and something's broken.
Something's hurting and it's a great procedure for same day dentistry to work in.
On to your already busy book because you can drop them in anywhere especially if you know you're going
to get a tooth out in 10 minutes.
And there's just such amazing growth potential for this subset of dentistry because you can get into
so many other things it leads into other implant opportunities and removable and fixed opportunities
and as well as impact with teeth and more complicated or surgery aesthetic dentistry is not enough to
put that in there because everybody seems so focused on that and not trying to be obnoxious or trying
to brag.
But my practice is in the top 1 percent of production in the country with dental practices.
And it's not because I do amazing crowd bridge cases and these all alone for fix cases and all this
ascetic stuff that everybody's so excited about.
It's about bread and butter industry and it's about being able to do everything.
So here's a prime example of what I'm talking about.
This is a super easy case.
Very profitable.
In general the business can do this case.
I probably do that one if it was a complete upper denture would do all of those on top in one visit
and put in immediate danger in that day.
That's a wonderful procedure.
Probably go ahead and take those other two out on the bottom.
Need to go in and start working on a partial But you know this is the kind of stuff I'm talking about
that you just can't give away because it's just so easy and it's a tremendous value to the patient if
you can do these in-house.
Another thing that we have to talk about is credibility but what does the patient think when you have
to send them somewhere else.
And what is the local community think when they're talking about the procedures that you do.
And one of them says oh yeah well you know my daughter had their wisdom teeth done.
We've gotten to Dallas no problem and then the other person says well my dentist referred me to somebody
else because he couldn't do it.
Well it makes me look better whether I do it better or not.
Perception is reality and this is a real way to establish credibility as being a local expert and being
able to see the person from first visit all the way to win their treatment plan is totally complete.
And the last thing I talked about already a little bit is just control over the final result.
And and if you refer it out you're stuck with whatever comes back.
But if you're doing it yourself you have control over the bone and soft tissue and the time and the
speed and in your movable appliances are better you have much better control over your fixed restorations.
And of course your implants especially immediate implants and bone graphs and things like that are what
I learned in prison.
I did not go to prison.
I was not incarcerated.
I should say but when I wanted to get serious about oral surgery I decided the best place for me to
get good at it was to go to a local prison that had fifteen hundred inmates most of which had poor hygiene
and do all of their extractions and oral surgery.
A lot of that was impacted teeth broken teeth teeth that should have been extracted years and years
and years ago.
It was a complete mess.
But what I learned there is how to do a traumatic extractions.
And that's a buzz word right now that everybody is talking about.
But I mean really minimally invasive extractions on difficult teeth that most people would lay a big
flap remove a bunch of bone.
And I can tease these things out without a flap without any bone removal and they could leave that clinic
on 800 milligrams of ibuprofen and come back three days later and thanked me for taking out a horizontal
number 17 or four broken off bicuspid or whatever it was.
And I'm telling you that this is really really feasible to do without causing swelling without causing
bruising without having to suture everything.
And that's what I want to share with you today because I think most people are doing it too aggressive
because they're doing it the old way.
OK here we go.
So here's a real life.
I just I just picked.
I got into my computer at work and looked for 10 of very recent patients that had extraction.
So these are teeth that I did in my office all the show the teeth that we took out.
And what reason I wanted to show this is to tell you that all of these were done without a single flap
without a single suture without a single block without any fear.
We all are nerve block and I want to show you all of that as we go along.
But this is real life.
This is the stuff I'm talking about and some you could probably get these out without a flap or without
sutures.
But some of these are teeth that people would immediately start flapping and drilling bone for.
And it's absolutely not necessary.
All of these teeth came out with no problem whatsoever.
OK.
So first things first before we actually start taking teeth out we got to talk about deal breakers.
We got to discuss medical history of course the dental history and the patient and their habits and
also social history.
But social I just mean the general demeanor of the person their reputation their hobbies and habits
and things outside of that which maybe recreational drugs or neglect apathy whatever it may be.
And the reason I spend a little time on social history is because I've made the mistake of seeing some
patients that I probably shouldn't have seen in the past.
And life is too short to have to deal with extra drama.
You don't have to do everybody.
And if they have a bad attitude or you know they're non-compliant or you know is just going to be a
pain to work with send them out.
That's the social history I'm talking about.
Don't do those people.
That's fine.
Let them go.
I had one girl that came in one day.
She was real nervous.
And she came in and we started getting ready to do the procedure and she started getting really really
excited.
She started convulsing and shaking and then she passed out.
And immediately went to put the monitor on because we hadn't even gotten that far yet.
And to get some oxygen going and she woke back up and she freaked out again and her blood pressure shot
through the roof.
And then she passed out again and this time she stopped breathing.
So we started positive pressure oxygen.
I started with an Ambo bag and I am pumping bagging this patient.
It took 18 minutes for EMT to get to my office.
Eighteen minutes is a terribly long time when someone is on the verge of dying as this girl was but
over that 18 minutes she would come back.
She would wake up.
I talked to her for a minute.
She would freak out again and she would crash again.
We eventually get her stabilized two days later.
I called her after several follow up calls and she was back home and asked her what happened then.
This is someone who is a known drug user someone who has a reputation of being so and she told me that
she was nervous.
So she took two volume before she came in for a visit.
I value my hand prescribe by him she had bought on the street she took two of those.
And right as she was coming into the office she felt like it wasn't working.
She was still too nervous and the drugs hadn't kicked in so she decided to use an illegal narcotics
and snort a line of cocaine then walk into my office.
So her body was fighting back and forth.
The rise from the cocaine to drop from from the anti-anxiety meds and she was all over the place.
And this is somebody who I knew from the start I probably shouldn't have done because it was always
trouble and always drama.
That's the example I use.
I know it's extreme but everybody's got some patients in their practice that you probably don't need
to do complicated stuff on.
Just consider it just for the hassle of it and the trust factor.
That's it.
We'll move on.
OK.
Let's talk about medical history some significant things we have to discuss right now.
Modern day bisphosphonates.
You know this is a hot topic right now mostly for women.
There's a list of some of the most common was there and the problem is that these these drugs cause
really poor bony healing sometimes complete destruction of bone and it won't heal at all.
And so the half life of some of these drugs is 10 years in some cases.
So the key factors in these are whether or not the person was on I.V. versus oral bisphosphonates how
long they were OWN those medicines because they absolutely do affect the the wound healing for extraction
size because the bone doesn't feel it fill in properly.
If they were an I.V. bisphosphonates for for any period of time sometimes even though all these need
have a console with the oral surgeon don't do these patients avoid the surgery at all costs do root
canals do whatever you got to do to keep teeth.
But these things can get really really messy.
The next thing we have to talk about is blood thinners anti-coagulants in this category we'd also have
to talk about blood disorders hemophilia things like that.
But bleeding is a major issue.
A lot of people are on these anti-coagulants Now some of the most popular of course are coumadin Plavix
and warfarin.
We have to take into consideration how involved procedures are going to be because we're going to have
more bleeding with these.
And the main thing we have to remember here is that if somebody is on it we never tell them to stop
taking it.
That's not our decision that has to be by their physician or cardiologist that prescribe the medicine.
We are a dentist.
We treat teeth.
We do not alter heart medication.
So if my this come off three times before.
It doesn't matter.
It's always worked before it doesn't matter.
Still do the medical console and let the prescribing doctor make the call and send you that in writing
so that you can put it in the chart and you can have the regiment that they recommended to do.
And usually that's going to be to stop it for a few days of course.
But some people can't stop because they're at risk of having a heart attack.
We're looking for an eye in our time of course of around one ideally and sometimes the physician will
recommend that they have a bleeding test to find that out if it's much more than that.
We need to adjust the plan and the speed of the treatment and we need to keep it more routine less invasive
and know that we're going to need to use pressure we're going to need to use sutures possibly gel phones
and other things like a collar plug or something to slow that bleeding down and to help stop that bleeding.
We've got to remember hard issues.
There's a lot of these that are affected by epinephrine which most of us inject with local anesthetic
every day.
So we have to consider these things.
Also we want to monitor blood pressure and oxygen levels on every patient that we're going to do extractions
on.
You may think that's extreme but you can actually save people's lives here because they're hypertensive
and don't even know it until you tell them that I put this on here because this is a nitroglycerin tap.
And some people keep bees in their pockets like their breath mints.
If somebody comes in your office and keeps these around that means they have episodes very frequently
we don't want to do those patients.
That goes without saying.
And it's good to have this in your office.
Nitroglycerin tablets.
These are sublingual tablets you put into the tone and dissolve that and aspirin are things that you
should have on hand of course in your emergency kit.
Well we're taking the medical history.
We're getting a list of their medications.
Unless you are a walking encyclopedia there's likely to be some things in that list that you don't recognize.
Look those up.
Figure out what they are what the contra indications are for what you're doing.
Lexicon has a great book The drug information handbook for dentistry that you can look by category or
by the drug name and list everything out.
There's also an app for your phone parties that does the same things.
And don't forget you see down here at the bottom don't forget natural remedies and herbal supplements
and drugs.
A lot of people are getting more into this holistic stuff and a lot of these things alter bleeding times
and blood flow and it's probably a good idea to look those up and possibly ask them to hold off on some
of those things if possible because they can affect things that happen in the cavity as well.
Don't discount those are very powerful other contraindications.
We're not going to take out teeth if there's radiation treatment in that area ongoing.
If there's any malignancy in the area near the teeth if there's a severe abscess an active abscess now
or if they have severe illness those people probably need to see be seen by in all surgery under general
sedation.
Moving on vital signs.
I just get an automatic blood pressure cuff for each of your arteries.
They're cheap.
These things are easy to use battery powered and take it on everybody that comes in.
You probably should do it on everybody anyway even if you're not doing extraction even for just doing
cleanings and route planes and things.
I'm telling you you'll be amazed at how many people are red flagged on this stuff and don't even know
how ill they are.
But you know this you know this is nothing new 120 over 80 is normal.
When you start getting above that you're considered pretty hypertensive.
And these are patients that may need to give a little nightshirts or something else to help calm them
down a little bit because stress is going to potentiate that and cause the blood pressure to go up more.
And we know we work in a stressful setting hypertensive is considered over 140 or 90.
And now we're getting into more dangerous stuff other than just nerves and and little high blood pressure
we can have episodes with these on these patients you should limit your epinephrine to two cartwheels.
And that's something we really have to think about.
I'm going to show you a way to get amazing profound anesthesia using way less than two carpools.
But on someone who's got high blood pressure we have to do that if they're 160 over 100 or greater.
You shouldn't do the treatment.
You should not take out teeth you shouldn't do anything.
You should refer them to their doctor for an evaluation.
Do palliative only do not use vasoconstrictor as an epinephrine.
Let the doctor make calls on whether their medicines need to be adjusted or whether or not they're healthy
enough to go through with whatever the procedure is.
But these people can get in bad trouble in your chair and you don't want any part of that monitor oxygen.
So with the pulse oximeter little finger clip that goes on to measure out to normal is 95 to 100.
Some people already own their own oxygen when they come in that's fine.
If they already own oxygen is probably a good idea to turn it up a little bit while they're in the office
and you're potentially stressing them.
All right.
Diabetes is type 1 insulin dependent.
You know that you ask somebody where is your sugar sugar usually.
And they say 120 ish.
There's a lot of issues and a lot of people don't really know where they are because they don't check
it.
So the question is should we test it in the office.
And the answer is absolutely yes.
These little monitors you could go to your pharmacy and get one for free.
Most likely again you don't have to have one at every opportunity.
But having one in the office and some test strips train your assistants how to do this easy stuff it
only takes 10 seconds.
And the thing that we hear is it's better sweet and sour.
If they're a little high that's OK.
But if they're really low that's a red flag and could be trouble.
And if they've taken their insulin and have not eaten a meal it could be trouble for them to have insulin
shock and to have trouble there.
The great thing is is if they're low it's really easy to get them back up with just a little bit of
carbohydrates or some sugar.
Most people keep cake icing or something like that in the office.
Coca-Cola.