Airway & TMJ: The Competitive Edge for Your Practice and Career

You have a new patient come in and you notice they have wear, they're bruxing. But you really notice the wear is kind of centered on canine to canine upper and lower and the back teeth still have really decent anatomy. That's really indicative of an airway problem. That patient is coming back and forth and grinding a betrusive trying to open that airway. So if you notice that, and then maybe you're a general dentist that likes to do, you know, crowns or veneers on front teeth, now you are able to not only treatment plan this restorative that will be great to restore their smile, but make sure that you're also looking at the airway and you're going to have better longevity of those crowns. Welcome to the Phil Klein Dental Podcast. Today's episode is all about expanding your expertise and setting yourself apart in your ever evolving world of dentistry. As a general dentist, you have the opportunity to transform your practice by subspecializing in airway and TMJ conditions, two critical areas that are often overlooked but deeply impact patient health. Not only will you be providing life-changing care to your community, but this shift in focus could redefine your career. bringing you a new level of professional satisfaction and fulfillment. Plus, understanding the nuances of sleep apnea and TMJ dysfunction can significantly improve the longevity and success of your dental work. So if you're looking for a way to differentiate yourself, enhance patient outcomes, and elevate your passion for dentistry, this episode is for you. Our guest today is Dr. Stephanie Vondrak. She owns and operates a private practice in Elkhorn, Nebraska. Dr. Vondrak is a prime example of how expanding a practice with specialized services in airway and TMJ disorders can elevate the standard of care across all phases of restorative dentistry. In doing so, she has not only enhanced patient outcomes, but also found immense fulfillment in her career. Dr. Vondrak will be joining us in a moment, but first, are you looking for an air-driven handpiece that rivals the power and torque of electric? Well, I have good news. It's finally here. It's called the TMAC-Z, and it's from NSK, a company we all know and trust as a world leader in dental handpieces. In addition to being lightweight and ergonomic, this revolutionary air-driven handpiece delivers unprecedented 44 watts of power, allowing it to cut through tough zirconia smoothly and quickly. In fact, the TMac-Z reduces overall cutting time by 30%. That means less share time, reducing the burden on you and your patient. Take a test drive of the TMAX Z air-driven handpiece from NSK. For a free 10-day trial, go to nskdental.com and find your local rep to inquire. Experience the power and excitement of the TMAX Z series. Dr. Vondrak, welcome to the show. Thank you for having me. We're very happy to have you on the show and thank you for your time. So your dental practice is considered a health-centered practice, very focused on the individual needs of the patient. Tell us about your approach and how it differs from the traditional treatment planning strategy that we learned in dental school. Sure. So, you know, when we're in dental school, they have so many things to teach us that it makes sense that the way that they have us learn to plan care is really individual teeth. You know, you're looking at problem focused. This tooth has a cavity. I'll fix this tooth. This tooth has a crack. I'll put a crown on it. But they don't really teach us how to look at the whole package or why things happen. So the way that I run my practice is I believe each person is an individual. And when they come in, they have different goals and needs. And so I try and look at the treatment planning from such a perspective of how can I see it in their future that they're healthier, that they have less problems. And we've treated those problems. We've treated them within a system that works really well. so typically do your patients know that you have a health-centered practice that focuses on the individual as you just explained or do they find out once they visit the office Yeah, that's a great question. It really happens both ways. I've been in practice for 21 years now. So I think there's a lot of word of mouth about how I do things in my office and that it's different. So if I have a referral from another patient, they kind of have an idea that it's going to be a different approach than what they've typically had. And that's why they're seeking me out. If it's a new patient that found me because they moved to the area, for example, then they're not going to know that. So some of it starts with the phone interview in which our front office person is kind of telling them about the exam and how it's going to. to go. But I always sit down with them at the beginning and talk to them as well. Like, hey, I'm so happy you're here. Do you have any concerns or goals? The patient will share that with me. And then in turn, I'll say, is it okay if I tell you a little bit about my practice? And that they always say yes. I haven't even said no at this point. So that opens the door for me to then. talk to them about what I do and how I can help them. And they know it's a very easygoing environment. I mean, I might suggest something that they're not interested in looking at, and that's totally fine. What I really believe is different about being health-centered, individualized, is that they get the choice. They have the opportunity to understand what's possible, and they choose what suits them best. So typically, Dr. Vondrak, the first visit includes getting a medical history, a dental history. x-rays an intraoral exam and so forth i'm sure that all is included in what you're doing with your patients but you go beyond that so tell us in contrast to the traditional exam and information gathering that is needed in order to have a treatment plan tell us how your approach is different and feel free to use a clinical example to help us understand Sure. I love talking about this because I think that dentistry becomes a lot more fun when you're not just patching holes and you have the chance to really change people's lives and show them what you can do for them. So people come to my practice a couple of different ways. If it's a general dental type new patient, they have an exam with me first. It's about a 90 minute visit. It's usually about 30 to 40 minutes of my time, but we do a full set of interval photos, FMX, comprehensive exam. And I talk to them a lot about what's going on. I show them all the photos and give them kind of a tour of their mouth so that I'm not actually treatment planning chair side, but I'm kind of giving them an idea of what's going on. We do the full perio exam and we do the, I am the first one to do their probes, all of those kinds of things so that they know, hey, these are the things that I'm looking at. This is what looks great in your mouth. These are concerns that I have. if i have someone that's referred to me for tmj or craniofacial pain it's similar it's a 90 minute appointment at least 45 minutes of it i'm in the room and it's a very thorough exam we start by me drawing out the joints work explaining where the cartilage is explaining what a normal range of motion is and then evaluating them summarizing what i found in both cases we have a follow-up phone consultation about a week to two weeks later depending if i need like additional imaging for tmj on the day their phone consult i've emailed them their report which is called a review of findings and i have lots of templates so i put these together and they have pictures of their teeth pictures of what i recommend we go through it and then i schedule them from there how do you share the images the photos the x-rays etc remotely with the patient Um, so I have their images on their documents that I send them. So like, I don't send them every image that's taken, like if it's a CVCT, for example, but I'll take a screenshot of what I want them to see. And then that'll go on their document. And the review of findings that I send them can be three or four or five pages. Now, please keep in mind, I've created hundreds of these. So I have templates. So time-wise, I'm plugging in different pictures and fine-tuning their diagnosis, but it's not hours of work. dentist is listening to this and thinking that sounds like way too much. It's all about getting those systems aligned. And it's amazing to see the difference in your relationship with those patients when you take the time on the front end. You know, almost every patient can be a big case depending upon what they need or what they want. You're very focused on the TMJ in your practice, also airway. So I assume CBCT is used quite readily. What's the workflow regarding CBCT? a machine in your office you send it out So I have an imaging center that I use, so I don't have a CBCT here in my office. When I'm treating a TMJ patient, it depends on how or why they got referred to me. A lot of those referrals are from other doctors, whether it's an ENT or a chiropractor or another dentist. And so when they come in, I'm pretty much assessing if I think that disc, that cartilage is in the right position, or if it could be displaced or completely displaced. So depending on their medical history and their background, I'll either... use a panoramic if I see no degenerative joint disease, and I'll consider that good enough. Or if there's an airway concern, or I really want to see where that condyle is positioned in the fossa, then I can do a CBCT. If it's a really complicated case, then I send them to the hospital for an MRI. So depending upon where they are, I don't specifically pick the resolution or things when the imaging is being taken. I rely on a maxillofacial radiologist for that. But I have to have some image of what's going on before I can treatment plan it. So in the more than 20 years that you've been practicing clinically, now that you've taken a lot of continuing education and kind of sub-specialized in TMJ and airway problems, you must see a very tight connection between dental problems and the airway and dental problems and TMJ. So when you look at the patient with all your knowledge and continuing education behind you and experience, you see things that you would otherwise not see if you didn't have that training. Tell us about that. Yes, I do. And that's where for general dentists, what I think is really neat is to open your eyes to what's possible. And sometimes there's things that's going on that you don't realize what you're seeing, what that actually means is going on. So for example, you have a new patient come in and you notice they have wear, they're bruxing. But you really notice the wear is kind of centered on canine to canine, upper and lower, and the back teeth still have really decent anatomy. That's really indicative of an airway problem. that patient is coming back and forth and grinding up intrusive, trying to open that airway. So if you notice that, and then maybe you're a general dentist that likes to do, you know, crowns or veneers on front teeth, now you are able to not only treatment plan this restorative that will be great to restore their smile, but make sure that you're also looking at the airway and you're going to have better longevity of those crowns. You know, if there's sleep obstructions going on, that'll shorten someone's lifetime. So it's really great to make them smile good. It's really great if they can smile longer and have a longer life. You know, one of the things that I think is neat is just to kind of see what's out there. So using the clinical example that you just talked about, canine to canine wear, upper and lower, posterior teeth look pretty good. So you're suspecting an airway issue with the grinding, that protrusive movement at night. What's the next step to confirm that? And if and when you confirm it? What's the treatment plan? Sure. So in my office, I developed a little tool and it's called PACT and it stands for Plaque Airway Total Calculations. And so if we do some of these community education courses, we've talked about it, something that I can provide doctors, but it's a little laminated sheet that has different pictures of things that are going on. So it's my screening tool. So if I see that there's three of the five. possible airway obstructions happening in that patient, or even two of the five in an adult, I'll say, hey, I recommend a home sleep study. Now, I have home sleep studies in my office, so I can just have them purchase one here. Or sometimes a patient wants to use a home sleep study through their physician because of medical insurance or something. I'm fine either way. I just make sure that the results get sent to me. Because what I found is that when this home sleep study is done, a physician rarely spends time explaining it. They're just automatically sent for a CPAP. And that's why people get nervous about being screened. So if I let them know, hey, you're not going to be on a CPAP unless it's really severe. There's things that we can talk about and we can do. Patients are more willing to get tested. So I have a screening tool. And then if that's going on, I want to test them before I do the restorative work. I might still do the restorative work and not make their sleep their sleep appliance until afterwards because they fit very specifically, depending upon how bad it is. But now you've really helped that patient. They've got their smile back and you're protecting those veneers when they sleep because they're not going to brux on them. And their airways staying open. So it's super cool all the way around. So let's assume you get the test results back and it clearly shows there is an airway issue, but not severe enough to warrant a CPAP, which is good. The patient returns to your office. And at that point in time, I know that you utilize appliances quite readily and effectively with your patients. Tell us about that. Sure. So the typical way of looking at a sleep appliance is they're called mandibular advancement devices. So when patients were treated with a CPAP machine for airway, essentially it's a pneumatic splint. The air is being forced down and the air is what's holding the soft tissues apart so there's no obstructions, okay? With a sleep appliance, you're mechanically holding the mandible forward so the soft tissue doesn't collapse on itself. If you look at the research, a mandibular advancement device is going to be effective as long as they have mild to moderate sleep apnea. Once they get into the severe range, you're not going to be able to bring those obstructions down into a healthy level necessarily. So the way that I look at it is I get my study back, which will show me how many events on average per hour. And if you have between five and 15, it's mild apnea between 15 and 30 moderate over 30 severe. What you'll also find is that some people don't actually obstruct to have apnea, but they have something called upper airway resistance syndrome, which means they're kind of almost waking up multiple hours. That's completely ignored by the medical community. Those patients typically are in pretty decent shape, but just are tired all the time. and they don't understand why they're tired all the time, I treat them the same. I make an appliance for both of them because even though they aren't actually fully obstructing yet, none of us feel good when we're waking up all night long. And we remember back to when we had infants, right? It's no fun when you're getting up constantly. So that's what those appliances are. Okay, so that appliance is placed even in a patient that doesn't have an obstructive problem. Well, if they're diagnosed with upper airway resistance syndrome, that means they're having, that's also shown on a sleep study. And what they're having is respiratory-related RERAS, R-E-A-R-A. And what causes that? It's similar. It's just that the soft tissue is collapsing, but not enough to completely close off the airway. So it's still interrupting the sleep cycle. So it is obstructive to some extent, but mildly. I see. But mildly, and because it's not linked to the same number of comorbidities as apnea, it's often overlooked. We'll be getting right back to Dr. Vondrak in a moment. 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So whether you're taking... your first step into digital dentistry or you're looking to add additional equipment, check out Shining 3D Dental's complete digital dental portfolio. To learn more, visit shining3ddental.com. I don't make the appliances in my office. I resource them out. So there's different labs that I work with. I really like the Moses appliance, probably is my favorite, but there's a ton of different sleep appliances. out there. So you can get trained on those. The biggest thing why you have to look at TMJ and airway together is you just kind of want to do some screening because you're going to move the mandible forward to make sure they don't have a really bad TMJ issue before you crank their jaw forward with an appliance at night. Yeah, that was my next question. Can you cause a new problem with the temporomandibular joint by bringing their mandible forward? So you're alleviating the obstruction, they're sleeping better. Your restorative work is going to have more legs because they're not destroying it as they sleep. But the joint is now changed. The relationship inside the joint has changed with the mandible being brought forward. What happens there? How do you prevent that from causing a problem? That's a good question. So if you look at the literature, you're almost always going to get some changes in the bite long term. So when the mandibles advance forward for seven, eight hours at night, you're going to get some changes. And I tell patients that up front, that's very important. Now there's some massaging techniques you can do to like the masseters in the morning, warm heat. There's something called an AM aligner, which is like a little wax wafer of their MIP position. And they can kind of work their teeth into those grooves each morning to kind of bring their mandible back. But the only time you're really going to cause a TMJ issue is if there was probably some sort of big underlying problem and then you cranked them super far forward, super fast. So, you know, through Moses training, for example, they really teach you how to take the bite in such a way as that's probably not going to happen. But you have to be able to screen. Is there a system in place where you gradually bring their mandible forward or does the lab decide? This is the device they need, and their mandible, the first night they use it, gets moved forward to eliminate the obstruction, and it's not a gradual process. Really, that's up to the discretion of the doctor. The doctor's deciding how far the jaw is coming forward. So most of the time, it depends on how bad their apnea is. You know, if they're in the high levels of moderate, then, and they don't... They don't seem to have a TMJ problem. I'm going to bring their mandible forward pretty far because they need to breathe. That's what's affecting their longevity. How do you determine how far to bring the mandible forward? There's different techniques for how you can take the bite. So you essentially put them into a gauge where you can move the lower jaw forward and back. And I do about 80% of their maximum protrusive distance. is the most I will move someone forward. If I'm nervous or I'm concerned that maybe I don't want to go that far that fast, you can start a little bit further back and then titrate, move them forward as time goes on. There's another appliance called Proceris, and it has like little bands that go in between the upper and the lower jaw, or there's something called an EMA that's the same way. You can start with a shorter band, and then as they're not, maybe they're still snoring, but they're feeling better, switch to a bigger one. So you have a process of titrating and moving. What I do is sleep therapy package. I essentially charge for... my exam and my scan and the appliance, and then two or three follow-ups to make sure that we're getting to where their symptoms are correct. I can then talk about things like sleep hygiene. There's things like nasal release that I can refer them to for opening up the nasal passages. There's other adjuncts I can offer to try and get them as healthy as I can in my office. And how long after they start that appliance do they see improvements in their sleep patterns where they're feeling better? they're noticing, hey, I've actually, or their bed partner is noticing that they're getting through the night without getting up. That's so funny you mentioned that. The main reason I see sleep patients is because I see a man whose wife doesn't want to stay with him in the bedroom anymore because of snoring. That's almost always it. And it's hysterical because they really don't care if they're better or not. They just want to be able to not sleep in any room bedroom. But anyway, yeah. So I usually see them three weeks after they get their appliance and I have a subjective kind of questionnaire that I've created for them to circle where they are on their symptoms. And then depending upon what's going on, I might say, okay, hey, let's talk about this or let's talk about that to help fine tune where they're at. But usually after three weeks, they're noticing improvements. Yeah. So you're like saved how many marriages do you think in your career? I don't know, but it's pretty funny because, you know, I'll get to the end of these studies and I'm like, okay, I'd love to do a follow-up sleep study and see what your actual numbers are. And the men are always like, nah, I'm good. She let me back in the bedroom. I don't need to know where the numbers are. I'm like, yeah, but this would be really great. And your doctor would love to see it. And they're like, no, I'm good. So I always try, but that's typically what happens. So how much continuing education did you have to go through to become a dentist who really is somewhat of an expert, I would say? in getting to the root of the problem with some of these issues, not only sleep, but also the condition of the oral cavity. Because as you mentioned earlier, you do restore the teeth first, and then you make the appliance for obvious reasons. But if you don't make the appliance, and many dentists are not, you're in this infinite loop of dental repair, correct? Right. That's right. So, you know, I'm one of those people that just loves to learn. And probably a lot of the people that tune into your show and are listening to these podcasts, you know, they fall down that rabbit hole in dental where it's like you learn one thing and then you learn the next thing. And that brings you to the next thing. And so my journey started with the Panky Institute a long time ago. And I would just, I'd meet interesting people that would be doing things at their practices that were really cool. And then I'd go on to the next thing. With TMJ and Airway, I did a program, a mini residency program over a year with the American Academy of Craniofacial Pain. And there's also the American Academy of Craniofacial Dental Sleep Medicine. So I did both of those. And it was a lot of work. I had to fly down to Dallas every couple months and take tests and do all these things. I learned so much about how all of that works. It was really instrumental in kind of shaping where I went with my practice. From there, I worked with the Clinical Foundation of Orthopedics and Orthodontics to understand how does the face grow? Why do I see the same types of patterns of how these maxillas are shaped in all of my TMJ patients? And so then I started to understand how growth is. And now I do a lot more orthodontics and craniofacial growth stuff. So 80% of what I do is either... this kind of comprehensive treating these issues or treating kids to help avoid them from happening later. Yeah, which is a great, yeah, it's a great service to your patients, without a doubt. So how did you make yourself known to other dentists to refer you these cases? And I assume GPs are referring you cases that apply to this? Yeah, some GPs refer me cases. It's interesting, you know, Dentists are interesting because a lot of times they get nervous about, you know, their restorative work being done. So I'm always happy to get someone stable, even if I balance their bite with composite at the end of a splint and let them do the crowns. So, you know, I make that known to patients if they end up in my office for general dental, if they have a different general dentist near me. But I did a lot of speaking over the years. So pre-COVID, it was a very different world when it came to speaking. And so there'd be lots of events that I get invited to to just talk about what I do. Or I think patients would find me and then show up in their general dental office with this splint, and the doctor would say, well, what is this? How does this work? And then we could talk from there. What you mentioned earlier seems like it could be an issue where if a GP refers you a case, there's a certain percentage of those patients that are going to say, wow, Dr. Vondrak, I love coming here. Could you just do the rest of my dental work? So that is a concern, I would assume. from the gp standpoint well what's interesting to me is it's only a concern and i don't know how this is going to sound but i'm just going to say it anyway if you're a really good dentist it's not a problem you know the problem is if i see someone whose dental work is really failing and in poor condition and i've talked to other specialists you know endodontists and oral surgeons who get these referrals and these patients' mouths are not healthy. And then the patient asks them what they think. And you're kind of in a spot there. So if I show them an intro photo and it's got a huge amalgam that's cracked and breaking down, that's not been treatment planned, they're like, well, can you fix it? Like, well, you can talk to your dentist. And if they're like, no, I'd rather have you do it. At that point, I feel like it's a good service to provide. But I have a lot of doctors out there that are great dentists that just don't want to do TMJ work. Then I get them stable and I'm like, here you go. Enjoy. You can get all these crowns done and nothing's going to happen. And they're usually thrilled with that. Today's episode is sponsored by Sunstar, makers of gum products. Gum's premium line of interdental cleaners, soft picks and toothbrushes offers innovative, easy to use solutions for better oral care. Introduce your patients to gum, the tools they need to maintain healthier smiles. Learn more today by visiting sunstargum.com. With your education and what you've pursued in your practice, you know, you're kind of like a specialist, even though you're still a general dentist. You are specializing in TMJ and airway. So when you see a patient, you're seeing things that you just would not have seen at all before or even focused on without the education that you've had. Could you make a few recommendations to the typical general dentist? about what they should be looking for when that patient sits down in their office for the first time and they're going through that initial exam, that would highlight the fact that this patient possibly has TMJ disorders, they might have airway obstructions. What can you offer the general dentist to give them that insight when they first see that patient? Absolutely. So something like the straightforward solutions that we kind of talk about here. When you're doing your comprehensive exam, you want to be able to look at just a couple of straightforward things. If the patient can open straight, you know, everyone probably looks at the joints for a second. Look at their actual path of movement. If when they open, it's making an S pattern, then, or if they're deflecting, they're going just to one side. If they're deflecting to one side, avoid that. That could mean a disc displacement that's not reducing, that's staying locked out of place. You go to do a crown or something, you could open up a whole can of worms. If it's making kind of a funny S-shaped pattern, you see that all the time, there's probably a little something going on. I don't know that it means you absolutely can't do the dental work. I think you probably can. But then you can have a really good conversation ahead of time. Like, hey, Mrs. Jones, I noticed this pattern of movement, so I'm going to really be watching your TMJ joints. Or maybe we make you a bite guard first when we're done and just see if that's enough. And if it's not, I could always refer you. So that's like a great way to do it. Would symptoms be... associated with those movements would they say sometimes yeah Sometimes, sometimes not. So they might say, no, I have no problem, but you're watching an erupted path of movement. You can also measure how wide they open. That's really easy to do. I use a little triangular ruler. You can find it on Amazon. It literally looks like a triangle. It says TMJ in the center. They should open 50 to 52 millimeters as a normal opening. Maybe in a really small petite woman, maybe it's 48 or something. But if you have an idea that they can get to maximum opening, then probably they don't have a big TMJ problem. That's a really easy screening tool. I would also say real quick that I wouldn't hesitate to put somebody in a bite guard just to see. It's just that they have to know that that's the introductory level of what we're taught in dental school. And if it doesn't work, that's okay. That just tells us the problem's more complex. So that way the general dentist doesn't have to eliminate doing their bite guards. They work for some people. But just as long as the patient knows, like this is more of a blanket, like Band-Aid kind of approach. Some of them, that's all they need. Some of them need more. um with airway you want to find out like if they screening tools look at the inclination of their upper incisors if they're what we call division two which means the incisal angle is tipped back towards the roof of their mouth there's been pressure on those tmjs for a long time okay because their mandible grew right up probably to the inside of those front teeth they probably have a deep bite I'd be a little careful about doing a crown on 2, 31, 18, you know, because you might mess with the bite a little bit there. If they have a very vaulted palate, there could likely be an airway issue. If you see a lot of erosion, erosion happens when the acid is pulled up out of the stomach during one of those obstructions trying to breathe all night long. And then they brux on the acid and wear the teeth down. So those are all like screening things that you could have in your normal conference of exam. They don't take a long time to look at. inclination of teeth, acid erosion, things like that. Yeah, I mean, that's like a good detective. There's a show on Amazon Prime called Elementary. I don't know if anybody's watched it, but his name on the show is Sherlock Holmes, but he's a brilliant deducer of what actually happened at the scene of the crime. And when you look in the mouth, you're noticing these things very quickly because you're looking for them, you understand them. Even if a dentist doesn't plan to do any of the work to try to fix the problem, it's really important to identify that the problem exists, right? That's what I think. I mean, I think it's amazing if a lot of general dentists notice things where they think, you know, I don't know how to treat airway yet, but I think there's an airway problem. There's likely a dentist in that city or town that does it. If not, they're a physician. is usually thrilled to get a sleep study on these patients because the physician is probably noticing other things that were not that could mean a potential sleep obstruction. So I've never had a physician say, no, I won't do a home sleep study for this patient. Everyone has done one. So even if you get that done and they get on a CPAP, you've helped that person so much. So I really encourage dentists to see what's possible and look for more because we have such an ability to make such an impact on people's lives. So do you think that the physician kind of default? to CPAP more so than they should before they give more conservative approaches a chance, such as the device that you described? 100%, unfortunately. Yeah, that is a bummer because, you know, I'm not practicing. I'm an endodontist retired. But if I was practicing and I noticed that there's a good chance this patient has an airway obstruction based on some of the things you just mentioned to look for, I would be hesitant, a little reticent to send them out to a physician who's going to... order a CPAP right away. And then this patient has to have this for the next 25, 30 years. It would be better for me to send it out to someone like you, who I know is more conservative and would try something that is not quite as radical as a CPAP, which could be much more comfortable for the patient and work just as well. So that's why I think what you're doing is so important, Dr. Vondrak. And I think it's important for dentists to identify other dentists that understand the types of pathology involved here. and how to treat it before necessarily sending it out to a physician who's going to default to a CPAP. Well, and I think that, you know, I've had some amazing mentors in my life. And when I was first practicing, there was a dentist in town where I would take the study models. I would mount them. I would go and say, what am I seeing? Can you help me? I want to do more. And I would learn that way. So I'm always very open to sharing things that I know with other doctors that want to learn. And so I would encourage people that are listening that if there's things like that that they want to know, don't hesitate to reach out or look for mentors within your community that might be interested in helping. Because we do have just an amazing opportunity that, you know, most patients see their dentist much more than they see their physician. So if we can identify these things. Yeah. Do you go to physicians and let them know what you do and say, hey. you know, and confirm with them that if it's mild to moderate on that sleep test, we don't have to go to CPAP. We can use these devices. Is that something you do where you reach out to physicians? Because I don't think a lot of physicians are particularly up on dental devices that could help them with these obstructions. Sure. So I have in the past, I've done lunch and learns and things like this. With my credentials, I'm on some lists. that physicians have now of doctors that have credentials to treat sleep and TMD. And word travels that way because physicians, you know, their initial appointment with a new patient is usually 15 minutes. I need an hour and a half to look at the mouth and they have 15 minutes to look at the body. It's crazy. So they can only do what they can do. But word of mouth tends to travel quite quickly when patients are being compliant and they're getting better. And so I do. I talk to people all the time and people ask me questions. And just having interactions like this and conversations like this really generates a lot of those types of referrals. And right now I get referrals from doctors I've never met. I don't know who they are, but it must have been they talked to a different doctor who said, oh, hey, send him to Dr. Vondrak. So word of mouth just kind of tends to travel. And you say that you plan for a 90-minute visit. That's a lot of time. If the patient shows up, it's okay. But what happens in those cases where you get a last-minute cancellation, you just blocked off 90 minutes? That kind of kills your productivity for the day. Sure. So that really comes down to your front office person. I mean, that initial phone call is really important to kind of let them know what it's all about. My TMJ and my new patient appointment are 90 minutes, not all doctor time. So I might be dovetailing to a different room for something during part of that 90 minute appointment. My initial sleep consult is not that because if they're coming from a physician and they just want a sleep appliance, it's a 30 minute consultation. I do charge for it, but it's. only 30 minutes so that one's just a little bit different with the tmj by the time they're willing to come in it's also you know a cash price and it's you know a little expensive so most people by the time they commit to doing that are going to show up in my office. People that just want to try a bite guard aren't going to go to those lengths, right? These are people that are super uncomfortable that have a big problem that are coming to see me. So that's, you know, I don't have a huge problem with people not showing, but how your front office talks to those patients really makes a difference. Right. But the typical patient that comes in that is not aware that they have either a TMJ issue or an airway, how long is that first visit in your office? My initial new patient visit is still about 90 minutes. Oh, it still is? Wow. Yeah. And so for my general dental patient, because we're doing the FMX, the full set of interval photos, we're talking to them. Now it's probably only about 30 to 40 minutes doctor time, but we're getting all this history and all this information. So we have kind of a little template of how my front office person will explain the appointment because they may or may not get their teeth cleaned that day. It's going to depend on what all they need because they might need scaling and replaning. Initially, that's all explained up front and talked about and we're excited to see them and we're looking at all these things for them. They know. So we don't a lot of times have cancellations with that because I book out a good six weeks or so. They're not going to be able to get back in easily. So it's all how the front office kind of prepares them to help avoid that from happening. So you work in Nebraska. an area called Elkhorn, which is really part of Omaha. Fairly populated, I would say. So there's plenty of dentists there. So it's important really for you to differentiate yourself as a dentist. And I assume your subspecialty in airway and TMJ has really helped you with that. So it's very populated. So I see people from all over. But Elkhorn, I mean, I'm within... three minutes drive time of technically Omaha. So I live in Omaha, which is five minutes from here, but I practice in Elkhorn. So we do have a lot of dentists in Omaha. There's two dental schools in Nebraska, which is a lot for a small state. So we have a lot of graduating dentists every year. So differentiating yourself and learning these things has really been how I've grown my practice. I love it. It fulfills me, but also it's been a way to grow and create an environment to where I can be booked out six weeks because people are coming for something different. They're not just coming because of an insurance plan. As we wrap up this podcast, Dr. Vondruck, and it's been really enlightening, you covered so many important points, really detailed stuff, which is great to have on this podcast discussion. Any closing thoughts? What I've been able to establish here in Elkhorn could have a bigger reach and doctors can feel really fulfilled in what they do because we have such an amazing opportunity and dentistry can be tough day to day. So if we have things where we can see more and do more and feel great, then we're going to love what we do. Great discussion. Thank you so much, Dr. Vondrak. And hats off to you for what you're doing with your career and the services you're providing to your community. Hope to have you on a future program soon. Thank you. I appreciate the opportunity.