This Dentist Explains Why Anesthesia Changed His Implant Practice Forever | Dr. Sean Keller

Welcome back to the Roots podcast
presented by Elite Anesthesia. Today
we've got Dr. Sean Keller from Smiles by
Design with us. Welcome, Dr. Keller.
We're excited to chat with you.
Oh, glad glad to be here, Sean.
We've also got James Prince with us.
He's our chief here uh in Seattle.
Yeah, man. This is great. We uh this is
meant to happen right here. So, I'm
excited about this podcast.
Dr. Keller, how long have you been
working with Elite?
Um it's been two three years now. Two
years. Three years.
Almost two years.
Yeah. Yeah. Almost two years.
Two years going on three.
Yeah. Nice.
Time flies.
Yeah. Yeah. Changes the game for me. I
love working with James and the rest of
the crew there.
Yeah, man.
Um it's just so much easier of a day
when when we use Elite.
dude. And it's literally some of my most
fun days, man. Like everything from the
moment I First of all, his energy
matches mine, man. Like he shows up,
he's pumped, man. Like he's got that
huge smile. walks in looking like
Wolverine. You know what I'm saying? And
like, yeah, we
feel like we should do this podcast
standing up.
I know, right? Like he he his music out.
Dude, we we were jamming out Michael
Jackson the other day.
I've been known to cut a little rug.
Yeah. No, we have we have a lot of fun
in there and I feel like I
super loosen up when I have um the
patients under anesthesia and I'm not
responsible for it. for many many years
um I would use um houseion benadryil and
or hion and um nitrous oral sedation
and um I mean for all fullmouth implant
and um I mean for all fullmouth implant procedures
it's um the only reason to do it is
because you're trying to be cheap and I
think it costs you a lot more in the
long run. Yeah.
Like the the little bit that Elite
charges for that is more than worth it
for the quality of care that you can
give um how much less stressful it is. I
mean, I do flat out do a way better job
and I'm going to have less problems with
the case later if the patient's not
moving and I'm not sitting there trying
to wash the vitals and it's safer,
better care, and ultimately it's cheaper
because I'm not paying to redo an
implant later or redo a suture or I mean
it and I go and I'm more productive
because I finish so much faster.
Every now and then there's a case that I
do where um for some reason it's you
know it's a little bit less cost on the
case. I'm like, "Oh man, you know, I
don't know if I can afford to add this."
and the patient's financing it and this
is the most they can get. So, I'm doing
it for that and I'm thinking maybe I
maybe I won't use a lead on this one.
And I almost always regret it. I can
tell you on those days I'm not singing
and dancing during the case then because
and dancing during the case then because I'm,
you know, dealing with dealing with the
disadvantage of um oral sedation.
Yeah. Yeah. Could you uh well we want to
talk to you about your practice, but
could you while we're on the while we're
on the topic, could you get into a
little bit of the economics maybe of I
mean what does that mean if you uh have
a patient that maybe has to come back a
few times like how how does that affect
the patient economically and maybe from
like a perception standpoint?
What what is an what does it when you
charge a patient for a big case like
this like what does an allex chart cost?
Is it is it 15 in arch, 20 in arch? 25
in arch, 30 in arch, 35 in arch. I've
seen it all over the place, right?
seen it all over the place, right? Um
and we I usually tell my patients
implants have a 98% success rate for
life. If you do if you don't load them
and it's a single implant and you do it
and it's a single implant and you do it perfectly,
um when you start immediately loading
them, that's going to drop to 95% if you
do it perfectly. That's one out of 20 is
going to fail. If you're doing a six on
six case, that's almost every other
patient's going to have a failed implant
on that. Now, what's going to happen if
that person's um coughing and moving
around and and starting towards the Hion
works for
an hour and a half, two hours before
they're starting to get to that agitated
state. And if you give them another one,
it makes it worse.
So, um and I know a double arch takes a
lot longer than that if you're doing it
Yeah. Um, and th those people are you're
going to not be as good and that failure
rate is going to go from every other
patient to almost every patient. And
sometimes, you know, if you did four to
six implants, if one of them fails, it
doesn't mean the whole case failed, but
that's a whole another day where you
have to do that. And
these people are they're traumatized.
They've already had probably one set of
dentistry fail in their mouth before and
this is their last shot. Like their
teeth have failed them. They've probably
had crowns fail them. and they've had
root canals failed, they probably had an
implant fail and now they're getting
this and if you have one of these fail,
it's really traumatic for them. Persons,
they're less likely to refer another
case. I
mean, you do this right for somebody,
when we do it right and we take great
care of somebody and it just goes
care of somebody and it just goes perfectly.
Um, they're going to send you everyone
they know that needs this,
Like birds of a feather flock together,
And and they they have people that
friends that need this and if you take
great care of them, they'll take great
care of you back.
Yeah. No, it's super good insight. I
reason I ask I I feel like dentistry
uh in general is kind of in this
transition period where a lot of our
general dentist population is moving
into the surgical world and anesthesia
is a hot topic because it's expensive
and you do have some options to be able
to do it on your own. Um, I think that a
lot of dentists are just kind of stuck
in the middle trying to decide how to
economically make it work and is it
worth it. Um, I think those who are
using us would say that it is. So, it's
it's good to hear your feedback on that.
It's worth it. And and when you when you
have it's I mean sometimes when you guys
just have the patient pay for it
separately, they they kind of get it.
You know, and for and for smaller
procedures, it's less like it's an
hourly thing and it's not that much.
I mean, to me, it's I mean, it's and
it's less than it used to be,
too. Yeah. It's it's it's less expensive
and to me it's worth it. You finish
faster and it's done. And the peace of
mind like I can
walk in there, do it, and I walk out and
the whole rest of the day I'm
productive. I can do my consults. I'm
fresh and I can do my consults and exams
and more than make up for the cost that
I spent on it because I'm not stressed
out and wiped out.
And I feel like I can I mean, I can work
a lot longer in the week because I'm not
wiped out from dealing with everything.
Um, interestingly on that same topic, so
oral surgeons is a a whole another
category of of discussion we don't need
to get into, but um, in Utah, we
originally, so we've been in business
for since 2020.
Um, a little bit of push back from the
oral surgeon community um, having us
come in and work with them because they
do the same thing. They do their own
anesthesia and you understand it well.
Oh yeah. And uh you know fast forward a
couple years later and we actually have
the entire board of oral surgeons in
Utah works with us in some capacity
right and that's the reoccurring theme
right and that's the reoccurring theme is
you know for somebody super well trained
in anesthesia like an oral surgeon they
they do that often and so there are some
cases that don't stress them out but you
know even in the routine stuff the
patient population is getting sicker
it's getting heavier. getting more
difficult to deal with,
smoking more weed,
you name it. There are a lot of reasons
why patients are getting harder to
why patients are getting harder to sedate
and just interestingly, you know, 3
years down the road where we're working
literally with everyone, every oral
surgeon on the board in Utah.
Oh, I mean I mean I mean James and I did
a case um couple three weeks ago and um
the patient's health history, she didn't
tell us some of the recreational drugs
that she'd been taking. Turns out later
there was um fentanyl I think we found
out meth too and some other things that
they weren't telling us and um when he
had the
So that's the thing people don't realize
too is like this is a true chronic
condition right like if these people
could tell you the truth they would but
they can't. So, they've kind of, you
know, had to do whatever they had to do
to support their condition. And, um,
often it involves lying. And it's crazy.
As as much as I want them to be honest
with me because I'm giving them
anesthesia, they still can't be. And,
uh, often they're using a lot more than
they realize. And, man, when she showed
up, I mean, I don't know. He's I don't
know. Have you ever seen me sweat
before? Like, just getting the IV in. I
mean, I could say uh cool and calm under
pressure. It was it was tough and and
then at some point like her vein didn't
do everything we hoped it would and and
I'm halfway done with the procedure, but
it was nice knowing I had you there to
just handle that and you did like a
rockstar, so I could focus on the teeth
and I had an implant to do. It was, you
know, porcelain case, but um
we took great care of her, but I think
that could have gone the other way
without you there.
Absolutely. And you don't need as a
general dentist um we're held to the
same standard as um oral surgeons and
perodonists for implant work that we do.
And you don't need to have a case, you
know, one or two cases go the wrong way
and and you won't be doing those big
cases anymore.
right. And that's and you need to be
dialed in and focused on the dentistry
that you're doing and not worried about
this stuff.
this stuff. Absolutely.
The vitals and the anesthesia and and
everything else. So I can worry about
the teeth and you can worry about
keeping them alive.
And Dr. Keller does everything. Like I
mean I think what's really cool about
his practice is he's called us in for
some of these big implant like big cases
but he's also called us in for some
general dentistry cases. He kind of sees
everything from beginning to end and
we've worked together um just on some
really complex cases, some really
complex patients, man. And um you know
on that crazy case that that he just
spoke of, uh dude, he stayed there the
entire time. He stayed there during the
entire recovery. Um, I knew it was gonna
take us a long time to wake her up
because she had such drove her to the
put her down,
man. And he was there for an hour and a
half, like just with me, sitting at her
bedside recovering her. We were talking
to her, making sure she was comfortable,
like it took her a while to come out of
anesthesia, but I think it says
something about the care that he has for
the patients. Um, knowing they're
complex that he kind of sees it all the
way through the end.
Yeah. I mean, it's it's awesome work and
I feel the care from you, too. like
you're not you're you won't stay until
you're comfortable that they're ready to
go. Yeah.
I the the kind of I mean how I evolved
to given the kind of care that we do I
like I like to think we're known as um
when the person's told they don't have
any bone and this case can't be done for
any bone and this case can't be done for them.
Um like that's my my favorite ones is
where they're they've been seeing
multiple um implant surgeons and they
just say nope. And we're like no we can
do this. you know, with my um orca
training in in Guatemala and the um
learning with Rick Klein and Alex
Sebashinko down in Australia and um
Apparisho in Barcelona, these residences
we've done. We we can do the quad
zygoma, the transnasal, the vulmer, the
the terragoids.
Yeah, we did the other day.
Yeah. And it's um
You're here for the hard stuff.
Yeah. like, you know, I it's awesome
when somebody walks in and they just
have a mile of bone and you can put four
implants spread really wide, but most my
ones are little eggshell bone and you're
trying to find remote anchorage in
places and um and you don't want to be
um putting an implant
right here or two of them right here on
each side with that person moving at
each side with that person moving at all.
all. Yeah.
Like precise and that's Yeah. You just
want it to be perfect and precise and
you need to have elite anesthesia to do
that. And and to be honest, even when I
get one of these simple cases, I don't
want it to turn into one of those cases
101 15 years from now. And so even my
simple cases, I'm trying to overengineer
it so that it's just done one time and
done one time, right?
And that's why it's nice to have elite
for that.
Yeah, that's amazing feedback. We It's
It's hard for us to
and not everyone understands, you know,
it's I think the economic piece is a is
a big part of it and trying to get
through that. I mean the patient it's
they w they healing is better when they
haven't been hacking and coughing and
moving and stressed out. They're going
to heal better too. They're not going to
have as much bruising. It's going to be
um even if they don't remember it from
the houseion.
It's like their subconscious does.
We talk about a lot actually with nerve
We talk about a lot actually with nerve blocks.
Oh yeah.
Yeah. We call it a a ramp up where if
your sympathetic nervous system or any
pain response is is mitigated from the
beginning, you're actually able to
control that easier for a longer period
of time.
Um so just keeping that at bay from the
start is is uh is actually yeah really
really helpful.
really helpful. Yeah.
Did you have another anesthesia group
that you were using and then you
switched to oral sedation? Like how did
that happen?
Um I I I had a anesthesia guy that I
worked with um a couple times. He was
the um awesome guy, brother
anesthesiologist. Okay.
anesthesiologist. Okay. Um
it was really expensive though. I mean
it was and I mean it was it he's
actually anesthesiologist. It was um
awesome to work with him, but it was
awesome to work with him, but it was just
it was like seven grand or more or eight
or nine every time I used it. And when
you're you're trying to save the patient
every dollar you can. I mean, I would
say it was still worth it for the ones I
did it on, but at the end of that,
that's just a lot of cost. And um you
know, with more and more dentists doing
these procedures and them playing, I
don't I want to be known as more the
Nordstrom's that does this like
I don't want to be using the um cheapest
implant. I don't be known as the guy
that's using the cheapest implant that's
out there. Like why is it the cheapest?
Like why are there are there better ones
out there? Absolutely there are. Right.
There's ones that actually gain if you
use the Morse taper connection, it'll
actually gain a little bit of bone over
over time instead of slowly losing it.
Um, so to me, this is kind of like your
um don't buy the cheapest parachute that
you can find,
you can find, right?
All right. Like this is your this is
your last shot at your teeth
and and and you want quality. I want
somebody I want the patient to hold
still and and I'd rather um
if there's a place that does anesthesia
as well as you guys do and to me it's a
it's a good cost then I can spend the
extra money on better parts and and and
doing it the right way. You know better
better final teeth, better implants, you
know, all the parts that I use. I'm not
trying to use the cheapest stuff that's
out there. I want to use the best.
Yeah, I love that.
And it leaves me the room to do that
when I'm not dropping nine grand on
when I'm not dropping nine grand on anesthesia.
Got to be competitive. So, let's get
into your practice a little bit and
let's kind of start from the beginning.
Where where did you grow up?
So, I grew I was um born in um Seattle
and grew up in Kirkland
to start.
Right here, man.
Yeah. Like literally the the house I was
born in is um literally a block from my
house right now. I didn't even know
that. Yeah. I didn't even know that till
my um sister Michelle was showing her
the practice. Like, look at the building
I got. Like, it's going to be meant to
be the the implant center. Upstairs is
going to be the lab. downstairs will be
the clinic. And she's like, "You know
the house we were born?" And we walked
around and it was like right there.
The house is gone, but same yard. I
recognize the the tree a little bigger
recognize the the tree a little bigger now.
Um you can see where the rope used to be
for the tire swing.
Shut up. That's good.
Um and then but then um we kind of
outgrew it. My um went to um Holy Family
Catholic School, which is right up on
the hill there by um Lake Washington
the hill there by um Lake Washington Tech.
Was that like a secondary school or a
high school?
Cathol grade school.
Yeah. And then uh sixth grade um I think
my parents had their six kid then and so
we were just kind of outgrowing the
house there. So my dad um had this beach
cabin up on Kameo Island. So we um move
up there and it's um man tiny little
room and they had uh three more kids up
there. So we had um at one point we had
like triple bunk beds in one room.
It was like Yeah. All of us up there.
Where where are you at?
Uh number two. Second oldest. Four boy
uh four boys, five girls.
Sheesh. Our next door neighbor is um Dr.
Bolander. He was the head of the
prostidonic department at Udub.
prostidonic department at Udub. Oh.
And um I'd say we didn't make a good
impression on him. Uh some of the stuff
that we pulled out there just with four
boys, the the battles that we'd have
that would spill out into the yard and
out onto the beach.
Dude, you'd be so proud now.
I dressed up as um Santa Claus one year
and came out and we told all the kids to
look outside. So, I'm running across his
roof so they could see it out there. And
I slipped and fell and um land on his
wood pile and came out and I thought I
broke my back. And I'm out there
screaming and I and the kids are crying
cuz they're like, "Santa Claus just
died. We saw him fall." And I come in
later. Oh god. Can you take me can you
take me to the hospital? So yeah, there
was a hospital trip about once a week
with that many many kids there. Um but
anyway, it was fun growing up with the
brothers and then um went up to Western
for undergrad. Um I was a carpenter
in Belle.
Uh Bellingham.
Bellingham. Okay. We're in Belleview.
Yeah. Way way up north almost by the
border of Canada.
A nephew that went there.
Um yeah, it's a good school. My older
sister went there, too. And then um got
into dental school. I was uh probably a
carpenter for about 10 years. Like all
growing up from all through high school
and through uh going to Western. Yeah.
So went to uh then I uh went to dental
school. I remember Dr. Bolander coming
out and um I I was he was telling me
from what he knew about us and how
rambunctious we were. I was like, "Yeah,
I think I want to get into dental
school." And he was like,
"Have a backup plan. Aim lower.
Don't tarnish my profession."
And I was like, "Oh man." So like, but
that, you know, kind of like uh drove me
to study a little harder. So got into
UDub, went went to dental school there.
um graduated and um man right when I got
out of school that's when um I I worked
I didn't have any dentists in the family
so I signed up for a tech agency and um
was doing like random jobs it was uh you
wake up and they say okay you're driving
to Pullman today there's a dentist went
down there so you're going to go work
there so for like three months I just
kind of drove around the state yeah some
sometimes I do hygiene jobs there
whatever it took to meet people and and
get busy um and then Uh what happened? I
I wound up working for Gentle Dental in
Everett for a little bit and great
people up there and um
kind of let me know that I didn't want
to do general dentistry. You know, when
when you work in the
corporate world, I that they had like
these numbers they had to meet and
everything was insurance based. So, you
know, I know how to do these
beautiful crowns and oh, you know, that
your insurance plan will cover a silver
filling. So, that's what you're doing
today. And you have to use this type of
amalgam. And I'm just like I just like
being told what to do and how to do it
was really tough for me.
was really tough for me. Yeah.
Yeah. And so I wanted to buy my own
practice. And then um 9/11 happened.
Yeah. And I remember, you know, remember
that morning waking up sitting there on
the couch and you're if you guys
Oh yeah. I think everybody remembers.
I was in grade school, but I do
Oh yeah. You're young, dude. I was in
Oh yeah. You're young, dude. I was in college.
Remember we first we first my brother my
brother Bo um also dentist. Yeah. And
then um my other brother Andy is also a
dentist. Like all
younger ones um Yeah, they're here. And
then my other brother, yeah, they all
had them all on together.
He was still in dental school. Yeah. So
I'm I'm he's getting ready to get in the
dental school
and I and um he's my roommate. The three
of us live together. Um and we're just
watching the news and we see the the
first plane
hits it. Like I wake up and it's already
happened and they're just like, "It's an
accident. What a random accident." And
we're watching news live and then the
second one hits
and we're just like
that's not an accident.
And that's before they cut it too and
you were seeing people fall. Yeah. I was
nuts seeing that.
So um but um you know economic effect is
So um but um you know economic effect is um
all these dentists that were about to
sell their practices because they
thought they could retire weren't
anymore. Yeah. So nothing was for sale.
There was like one practice that was any
worth looking at that was for sale and
it was um Smiles by Design in Redmond
Town Center and um most practices you
see there I mean that one was insanely
expensive. It was over a million dollars
which back in 2001 is 25 years ago.
Yeah, that's most of them were selling
for two or three and I just looked at it
and I was like, "Wow." Like there's it's
the only one for sale, but um I remember
seeing it had like um blue neon lights
in the sterilization room and I walked
in there and it was just the most posh
coolest place I'd ever seen and the Dr.
Rossi and Dr. Olsen were two um
instructors at the um Las Vegas
Institute for Advanced Dental Studies.
And it was just big cosmetic practice,
all veneers and neuromuscular dentistry
like that. The facial changes on people
after you do their teeth was insane to
me cuz all I done silver fillings and
PFM crowns before.
Oh, interesting.
You know, kind of what they taught at
UDub and you know, root canals and
um it was uh insane to see this practice
like that. And I I looked at it and they
were like, "You got to come in and like
just come. I'll pay you a week to work
here just to see what it's like." And I
was like, "All right, I'll you know, I
got nothing to lose. they'll try it out.
And I fell in love with the place and um
eventually I was able to get a loan for
it and buy it was in to me it was
insane. My dad was against it.
My accountant was against it.
Um but
went against division.
Yeah. And um and I got to admit even
after I got it, I found it hard to
believe some of the things that they
were saying. Like the whole idea with
neuromuscular dentistry, like the idea
that you could put a computer on
somebody and measure their muscles and
relax them and have the jaw position
change and then the way that you build
the veneers and the and the teeth to get
rid of headaches and migraines.
That was insane to me that that would
work. And I I honestly didn't believe
it. I said, "Can out of here and I'll do
just some veneers and the occasional um
implant, maybe the crown." I couldn't
wait to get their equipment out of there
after I bought it. But I they stuck
around for another year and kind of
taught me how to do it. And then I
started going to LVI and lived it,
breathed it, saw it, and it works. I I
believe it.
And so that got me into just doing these
um kind of bigger comprehensive cases
where you look at a lot more than just
the teeth.
And it was um I went I I attended LVI. I
went through the whole program twice
because it was just
fascinating to me. Yeah.
Oh, that's cool.
Yeah. Yeah. And it cost me 10 times what
dental school did going to it.
And then my um my brother um graduated
and joined me. So kind of doing that
together. And that was fun.
together. And that was fun. Um
so he joined you at Smiles by Design.
Yeah. Okay.
Yeah. And that was fun working with them
for a while. Eventually he he kind of
thought like, you know, I don't want to
work with big brother. I got to do my
own thing. So kind of do and it's it's
been fun, too. Yeah. So
um we all got the little want to do our
own thing in us a little bit.
Yep. Um, and then my other brother Andy
graduated and and he's doing it now,
too. And Brett is um like a master lab
technician, so he knows how to do he
actually does the work that we install.
So, it's kind of cool having him do
Some full family practice.
Yeah. Yeah. So, I realized with these
big porcelain um big reconstructive
cases, if people have had this bad bite
and things are hitting the wrong way for
long enough, um they start losing teeth.
And sometimes a bridge is appropriate,
but sometimes you can't. And so I kind
of got into implants, but with this um
holistic approach that we do, the um
titanium implants weren't weren't always
weren't always the best choice. And I've
been hearing about these uh non-metal
implants like the zirconia implants
coming out of Spain and Switzerland. And
so I um the internet I think the
internet was just coming out around then
too. Like I remember downloading like
too. Like I remember downloading like 2002.
Yeah. getting an email about this
ceramic implant and I'm sitting there
waiting for it to download like
as the picture's going the whole thing's
white I think. Is it going to be gray at
the bottom? And the whole thing's white.
Wow. It's sacodia. Like I was like yes.
Like we white white implants. We don't
have to have that gray metal in there.
But I remember the email downloading so
slow. Was that Yeah. Early internet
Windows 98.
Yeah. It was Yeah. It was Yeah.
dialup, man.
Yeah. So the yeah the the email came in
and then I uh emailed the guy back and
he's like yeah well I said can you send
me some? And it's like I mean obviously
you can't use them. They're not FDA
approved yet but you can play with them
a little bit. So got a few of them and
um as soon as they got FDA approved I
was um I had I had the first shipment
coming in
and so um started placing these um white
zirconia implants and um they're
freaking awesome man. like to me to me
um I usually don't use them for the big
crazy full arch cases cuz that remote
anchorage stuff they can't make them
long enough to go back there but if
you're missing a single tooth they're
you're missing a single tooth they're awesome
so kind of got into the implant world
who makes those
um there's now there's a few of them
back then it was um Sarah but now
there's um uh uh Strawman bought the
noble they have the noble pearl one they
call them but they were called Z system
before that
um um
sounds familiar
yeah there there's like four of them now
there's even one trying to do it where
they um do a CAT scan of the of a moler
and then they get an STL file from that.
So it's actually shaped exactly like the
tooth and they mill that and you pull
the tooth and then you tap one that's
already shaped like that into the spot
right in there
like it's shaped exactly like the tooth
like it's shaped exactly like the tooth was.
Yeah. So that that they're doing those
in um Switzerland right now called
bioimplant. They want me to donate money
so they can get FDA approved. Apparently
getting FDA approved um isn't it's more
about just getting a million bucks
Just pay for it.
Pay you just buy it.
So they just try we gota we just got to
get enough money to go approved. Oh
so you you
bought Smiles by Design
and didn't inherit you bought this
practice went to Las Vegas Institute. Is
that right?
Yeah. And it's it's kind of um it was
known as like uh one of the there
weren't a lot of cosmetic schools out
there like it back then like now veneers
you can watch a YouTube video you know
everybody's got a video or school on it
but back then um veneers weren't really
that popular or a thing.
And so um that was that there was maybe
them and Panky and the Hornbrook
Institute a couple of them around the
country but that to me that was um the
best one like actually had an institute.
It wasn't some guy's um practice with a
room on the side.
Right. Um and so and it and it was
Vegas, too.
Vegas, too. Yeah.
Um so, uh who doesn't want to go there
for, you know, weekend? Maybe that's why
I had to take the school twice because
you're only there half the time.
No, it was it I mean, it was um buying
Smiles by Design and um and being able
to hang out with two of the instructors
there, Dr. Rossi and Dr. Olsen, was um
life-changing for me. I I would have not
believed some of the stuff that they
were doing there. like the um some of
the pictures they had on their wall as
you walk through the practice of the
facial changes like somebody with um
like a receded chin and a weak chin and
it looked like they had like a class
three jaw surgery to fix it. But um I
went and looked at them all they had was
the um back teeth redone in porcelain to
bring it in the right spot. As your as
your teeth wear down and you and then it
kind of pushes your jaw back and then
your jaw muscles bulge out and the
diagastric gets overworked. when you um
tense the jaw and put the EMGs on there
and read it and get it in the right
spot. We do it with an orthotic first
and then once it's there then we build
it up with porcelain and um I mean it
was just watching them do it again and
again and again and again and then
seeing um seven eight years of patients
who had been through this and hearing
their story like I was getting migraines
and neck pain and um breaking teeth all
the time and these guys put in the
orthotic and restored me and I've been
good for you know seven eight years.
Just the testimonial I was like wow I
gota I got to figure this out. M
and so that you know started doing it
and built my way up and um now I
the practice was doing that and then you
were you guys replacing implants as well
and then did it have a general dentistry
component also or was it like purely
component also or was it like purely cosmetic?
I mean I get to me it was um that it to
me that is general dentistry now.
I guess like when somebody comes in and
they've got um a bunch of plastic
fillings everywhere I can't help but
look at everything else you see going
on. like if
like if you know if they get one cavity
I guess the less you know the more
normal your patients appear appear
and so if they you know I almost
everybody I no it's almost nobody has a
perfect bite and the way things fit so
if somebody I don't generally people
don't come to me because they have a
don't come to me because they have a cavity
they usually come I'm getting headaches
migraines or I'm missing teeth and you
know and I hurt you and know my goal is
not to just slam one if
if the if you're missing a tooth and and
the tooth on each side has collapsed
into it and the top tooth has come down.
Um just placing an implant in there is
not going to fix that. Like now the
whole jaw has shifted from that and
you're going to need an implant every
two three years the rest of your life or
a root canal or you're going to lose
bone and cause paradonal disease from
the way the bite is. So I'm looking at
yes maybe you do need an implant there
but we got to get your jaw in the right
spot and build everything the right way
it was. when you start when you start
knowing more and asking more, you know,
you know, I notice that you're missing a
tooth right there, but I look at your um
cone beam scan and that joint is
impacted and and and it's clicking. Do
you get headaches very often or
migraines? Yeah. You know, now I think
about it, more of like a sinus headache
like this. Hm. Does the lateral
terragoid attach to the back of your
senoid bone which could cause a sinus
headache there? And do you get pain
coming down right here? Yeah. Are these
fingers a little numb? Yeah. So, let's
um before we do that, while this
implant's healing, why don't we just
throw an orthotic in there and put that
joint in the right spot and see if some
of that gets better,
you know? And so, that that kind of led
to that. And as I met more and more
complex cases that needed more and more
implants, um then it started then this
all on X thing started to come out
because I'd meet people that needed, you
know, there were enough bad teeth that
they either needed a denture or an
implant retain denture. Mhm.
And so, but I still didn't really use
anesthesia that much yet.
anesthesia that much yet. Yeah.
You know, for for like a fullmouth and
but it was not I would say there were
hard days.
Yeah. The days where I was
What what years were these
uh like 2000, you know, as I as I I kind
of watched them and helped them and did
the more general type stuff in 2001
through three and four. But as I
started, you know, my veneer cases got
bigger and turned into fullmouth cases
and um started placing implants. It was
like 2002 did the implants, but it's
usually just one or two. So I
I try to just survive off the oral
sedation then.
But by about 200
seven or eight is when I started getting
into the more complex ones and that's
when I started using the
anesthesiologist, but it was just so
expensive. That was a big hangup for me
And there's only one of them.
Yeah. There's like not many. Yeah,
that's why you can charge so much,
right? When
Yeah. I mean, yeah, I mean, and and the
Yeah, it was it was insanely expensive
then, but I mean, it was like it was
nice to not have to think about it, but
um you're always trying to provide the
best possible experience and safety for
your patient. And how can you argue that
it's not
a better experience and safer for the
patient to have somebody else taking
care of the vitals and doing that?
Like, it's like these complex cases,
Like, it's like these complex cases, they're
they're hard.
They're real surgeries.
Yeah. It's a it's not like yeah you're
you're flopping there's nerves there's
bone there's sinuses there's
it's a human right there and and and
having more people that know what
they're doing a part of that you know
when when you look at like a cardiac
surgery there what eight people around
surgery there what eight people around there
doing that and and we're working on
you know these all x cases you're you've
got their face open
we we've said it a few times that these
oral surgery cases all x cases are some
of the craziest surgeries that I've ever
been a part of
you know are four to six, even eight
hours long. There's a lot of blood,
there's a lot of teeth, there's a lot of
bone, there's a lot of
I mean, when you're doing like a femur
replacement, they use general for that.
Oh, yeah.
And you don't there's not right there.
The brain's far away from it. There's
not an airway right there.
Um, you don't see what it looks like
afterwards. With this, you're going to
see it, you know, and then there's um
you're not packing sugar around it and
seeing how that acts. But this, you
know, the next day they're going to be,
you know, drinking sugary things and
that's going to affect infection rates.
You know, so it's
it feels like
as dentistry moves, we kind of talked
about it earlier, but as as dentistry
moves and is transitioning into more of
a surgical world than it's been in the
past, anesthesia is just an absolutely
necessary part of that. And there's some
drag and, you know, everyone being able
to adopt it or being willing to adopt
it. There's also not been a lot of
availability of the anesthesia itself. I
mean, we we've been around for five
years as a company. We've been here for
little less than two.
little less than two. Yep.
I mean, we we're adding providers at a
rapid rate right now trying to keep up
with demand. So, it's just interesting
to see dentistry as a whole evolving
into that world. And I I think it's
created a lot of trauma throughout the
years of patients who are probably
should have been sedated but didn't have
the opportunity to be and uh yeah and a
lot of surgeries that could have had
better outcomes if the patient was
better outcomes if the patient was asleep.
Couldn't agree more, Sean. And and not
not to bring up uh um when things do go
wrong, but I' I've um I've heard stories
about um dentists having um losing their
license over that one case that goes
bad. Yeah.
And this is a pretty major surgery. And
and I can guarantee you when when that
does happen to somebody, the chances of
happening are a lot less when you when
you have somebody else taking care of
this part. Somebody who's trained,
dialed in, and that's all they're
looking at. And um I've worked with you
on a ton of cases. And um
I mean I' I'd trust you with my life
from what I've seen.
from what I've seen. Absolutely.
You like if I knew I had to go under,
I'd feel totally comfortable with you
looking at my vitals for whatever I had
looking at my vitals for whatever I had done.
Absolutely. And I mean, I think that's
the that's the biggest thing, man.
Ketamine in there.
Ketamine in there. Yeah.
You know, start with that joking.
What we fail to realize is that the
experience does matter. Like everything
from the moment we walk in um how we
return, all that stuff matters, man. And
um I think one of the biggest reasons
why dental anxiety is what it is is
because there was a time before
anesthesia and then there's now. And
then like I mean I one of the biggest
reasons why I went in anesthesia is cuz
I got my wisdom teeth out under local.
And I remember asking him like what's
the anesthe uh what's the anesthetic
plan? And he was like we're just going
to numb you up and hold you down.
And I was like wait that's the plan?
Like that's legit the plan? And they
were like yeah we'll just I'll just be
as fast as I can. And I remember feeling
everything and I and I heard the drill
and I felt like the pressure and I you
know I saw him he had the hammer and he
was like cracking my tooth and and and
and when I left it it it changed me like
I was immediately more fearful and the
result of that shows the pathway of why
people have fullblown mouth implants
because I got a cavity um I don't know
maybe maybe a year later and I didn't
tell my mom and I started having all
this cold sensitivity ity and I didn't
say anything and I didn't say anything
cuz I didn't want to go back to the
dentist and I was like maybe I'll just
go away. I'm going just take some
Tylenol like you know and then it turned
into a root canal and when I went back
to my general uh dentist she was like
why didn't you say anything and I was
like dude I was so fearful like I just I
thought that was going to happen again
and she was like oh my gosh I'm so
sorry. So like it one thing can lead to
a next the the next and uh and and you
can see where anesthesia can come in and
really play a pivotal role as far as
just making the experience more
palatable. I think one of the cool parts
about your practice is you've created
this tool belt and I think when people
when all they have is the all-on four
solution then that's what they offer
because that's what they have. But you
kind of have this holistic approach
where you can look and treat in many
different directions and you'll offer
that accordingly, man. And I I I love
that. Like that's that's the type of
practice that I'd want to send my mom
I can't tell you how many people I've
got a lady right now that just came in
and she said, "I'm I'm done with my
teeth, right? Like they've um betrayed
me and I want them out and um I'm ready
for this. I'm all on four, all on X,
whatever it is." And um I've convinced
her that that's not she's got a bite
problem and that's what's wrecking the
teeth. and I think we can do three
implants in the back and restore it with
porcelain and keep her teeth. It's what
I would do in my mouth. And I believe
well she goes, "Well, what if I spend
all this money on this and um then I
need this in 10 years anyway." I'm like,
I'll give you the the guarantee on this
as long as I'm practicing, you know, I'm
going to I'm going to manage this this I
believe that strongly in this, right?
That that this is going to last for you
that the problem is you shouldn't, you
know, there is a time when there when
people do need the implants.
Yeah. Um and and and if there's four or
five teeth left and they're in really
bad shape, yeah, don't try to hang on
to, you know, a lonely island out there
in the middle. Um but but there's a lot
of this I think this procedure is done
too often.
I think I think many times it's a bite
issue and an implant here, an implant
there, and and build up the back teeth
in a strong way. There's um we have some
really cool ways to get the jaw in the
right spot. And um I think you'll get
10, 20, 30 more years out of your teeth
the way you could with very little
problems. And who knows what technology
we'll have in two decades.
To me, it's like and so a lot of these
um all on four cases
um the way they hit it's going to slowly
cause a little bit of a forward head
posture and um possibly even the
digastric. I I mean I've had I'm I'm
aiming for optimum facial changes as we
do this and um I noticed that when I put
EMGs on the muscles if I leave it high
in the preolar area the massitors bulge
in the preolar area the massitors bulge out
and even the diagastric is kind of
tensing right here and that's where the
double chin look can come from is that
muscle but as soon as I get hitting them
I'm on first and second mer these
muscles relax and start to thin out your
jawline and cheekbone over the ear will
start to look more prominent and this
will suck up as you're hitting on your
mers all on forest can't hit there. Is
that a problem? Yes. But in some people,
can they have implants back that far?
That big sinus and there's no bone, the
nerve is close on the bottom. It's it's
hard to say. Um, you know, with the
advent of um new materials in sinus
lifting or the terragoid implant or
sometimes if there's a molar there, we
can get one in the palar root. I'm doing
everything I can to get those back
implants. I want to overengineer every
case. I'm not just trying to get four
implants in a set of 12 teeth in there.
I want the back as solid as I can so I
can get the jaw in the right spot, open
the airway, support the face, support
the joints, and um straighten their
spine up.
spine up. Um
it's it's interesting. Um being in the
TMJ world, we we know that if um if the
jaw goes off, that throws the neck out.
That'll throw your shoulder girdle out
and your hip girdle and um this can
affect the whole body.
And so I Yeah.
Just hearing you describe that, I mean,
it's it's pretty intricate surgery in
and of itself. And to hear the
implications of making sure that that
procedure is done well
uh is pretty extensive all the way down
back up about it now.
Yeah, dude. I love that.
Yeah. And I I mean to bring this back
full circle, but I just I can't even
imagine trying to do something that
precise on a moving target.
Oh, absolutely. And the and the more um
I mean I'm I I saw a couple of gray
hairs in my beard. um couple weeks ago
and uh either I'm getting older or I'm a
and uh either I'm getting older or I'm a wizard
and I know I'm not getting any older. So
uh so uh as I get older um I the energy
to to to to do one of these cases when
they're not sedated, it's not good for
your heart. It's not good for your back.
Like I want to get in there on a I would
say on a on a upper lower six on six
implant case if I'm trying to do oral on
that. That's going to be six plus hours
no matter what.
With um elite anesthesia um and the
actual it's going to be 90 minutes for
the top and probably 60 for the bottom.
Yeah. Wow.
Almost cut in half.
Almost cut in half. Yeah,
dude. And it's cool too, man. I think
one of the things I actually love
working with is like providers that have
been there kind of since the beginning.
Like this dude, he's one of the first in
Seattle to start doing implants. Like
everybody kind of knows Dr. Keller. So,
he's kind of seen just the change. And I
remember one day I left my power cord uh
for my monitor um in his surgical room
and he had just started using Elite
Anesthesia, so he wasn't fully using us
yet. And I I stopped back the next day
and he was doing a procedure and I
walked in and he was like, "Thank God
you're here." And I was like, "Oh no,
I'm just here to pick up my power cord."
And he was like, "Oh my god, we need you
so much." Like like something something
like you know. And he immediately had
that appreciation, man. Like, dude, I
actually and his staff is the same way.
They're like, "Dude, we love when you're
here." And I was like, "Dude, I love
being here." And he's like, "All right,
we're gonna start calling you more
often." And we've been working with him
even more and more ever since. But it's
kind of cool to have that juxtaposition
where you've literally seen both sides
of it. And um that appreciation's there,
man. It's great working with you. And
they always are able to handle
themselves well cuz they're they've been
working on moving patients for so long
that when they get a steel patient, man,
they're able to do some really precise
work and work super fast. And I remember
he was able to do a consult one day and
he's like, I've never been able to do a
consult on a surgical day.
A surgical day.
I mean, I my general way that I used to
do it, I can't remember one of these um
practice management places to teach you
how to take, you know, run a good
business and take better care of your
patients. and he says,
you know, get your um work done in the
morning and then, you know, put on your
tie and your nice um nice outfit for the
afternoon to meet people and and you can
get in that emotional state. But when I
if I do one of those cases in the
morning and I got a consult or two in
the afternoon, I'm a different man. If
like your chances of connecting with
somebody who's about to have their teeth
taken out, Yeah.
How's that going to go when you're
How's that going to go when you're wiped?
You're not going to you're not going to
be able to connect with them and have
them feel comfortable with you. But
somebody who used Elite comes in there
fresh, they can sit there and and
connect with this patient, actually have
a chance to help them understand to get
the care that they need.
They need if they're in there, they need
this. And if you're not at the top of
your game, then you're not going to be
able to um you're going to miss
something or you're going to blow some
they might say something that was hard
on them and you're not going to be able
to help them feel better about that if
you're wiped out.
you're wiped out. Yeah.
Makes a huge difference.
Makes a huge difference. Yeah.
It's awesome guys more.
It's awesome guys more. Yeah.
I love I I was I was laughing thinking
about um some of the cases of when um
back I've had associates over the years
um and some of the and using oral
um and some of the and using oral sedation.
Oh, it's Yeah, it's it's um you never
know how um with with oral how it's
going to act. Sometimes it doesn't seem
to do anything.
You know, you give them two pills and
it's been an hour and a half. All right,
can I give him another one? All right,
it's been an hour and a half. Let's
let's do one more. Yeah.
Beauty IV,
what are you doing in the meantime?
what are you doing in the meantime? Um,
like while you're waiting for it to kick
in, are you just kind of like kind of
burning the candle?
I I I usually like I'm just kind of
sitting in there in the room like you
know, you got you got to keep an eye on
them during that. So, like I'll be
sitting in there like just kind of
looking at the vitals and um doing
notes, looking at the case. But, you
know, after an hour and a half, like
then you want to it's time to start. The
part they're going to remember the most
is probably the numbing,
you know, and so we use the wand and a
lot of topical and the want, you know,
and I'll use some endo ice to kind of
cool the area before I numb it. But, um,
sometimes they'll still remember that
part. Like, it's, you know, it's not
there's there's times when I've done
oral and you ask them, I say, "Hey, how
much do you remember from yesterday?"
Everything. Oh wow.
That and and is that person
gonna send you everyone they know
after even you can do the most amazing
job, the most amazing veneers that just
look so natural. You know, I spent top
dollar on the lab and I spent a lot of
times on the provisionals making sure
they're perfect and you can do
everything perfect, but if their memory
is that that was tough, um that they're
not going to want to send.
It's not a good experience for them.
Yeah. And and if you're going to do
complete dentistry, that's not a half
hour billing. Yeah,
you know, it's a long time to sit in a
chair and and I'm reminded every time I
have to sit in the chair, I remember if
I have to get like a um my back was
really tight to hear what you say.
No, I took my tooth the other day and I
called you and I was like, "Oh man, what
was I doing?" "Oh man, I bit down onto
the fork and like I had already knocked
it out a little bit from like mountain
biking and I bit down." I was like, "Dr.
Keller," I was like, "Dude, I chipped my
tooth." And he was like, "Yeah." And he
was like, "All right, man. Like, I'm out
of town this weekend or something
something." I was like, "Oh, man." And
like and and immediately I was like,
man, is this going to hurt? Like I was
kind of already thinking about like, you
know, man, do I need sedation? Should I
call my buddy? Yeah. Like, should I call
my buddy? Yeah. Like
I remember saying that. Chip probably
looks good. You're a good-looking guy.
Chip probably looks good. Like you
probably look tougher. You told me I
I probably look tougher, man. Like watch
the kids will listen to you now. Like
just leave it.
I've been through some stuff.
I've been through some stuff. Forks.
As my wife, I was like, "Do I look
tougher?" She's like, "You look like an
idiot." And I was like, "Okay, never
mind. Yeah, he I got in a fight and he
caught me with his Super Bowl ring.
Right. Right there.
Well, uh, Dr. Keller, it's been awesome.
Great conversation. James Prince.