Dr Robert “Tito” Norris: Creating Clinical Efficiencies and a Better Work-Life Balance

Alison Werner 0:05
Hello and welcome to the orthodontic products podcast. I’m your host Alison Werner. Today we’re kicking off our 2024 season with Dr. Robert Tito Norris. I had the privilege of profiling Dr. Norris for our September 2020 Cover Story of the magazine, which at the time coincided with the launch of the Norris 20/26 passive, self ligating bracket and wire system he developed with Dynaflex. And now we have him back to talk about the systems, products and technologies he has employed to achieve clinical excellence so efficiently, and how that translates into a better work life balance. Dr. Norris, thank you for joining me today.

Dr. Robert “Tito” Norris 0:37
Thanks for having me, Alison. I really appreciate it.

Alison Werner 0:39
Great. So for those in our audience who aren’t familiar with you, can you talk about how you got into orthodontics and your current practice? Sure,

Dr. Robert “Tito” Norris 0:48
well, I guess I gotta go all the way back to college. And first of all, I should probably say that I’m in treatment myself, right now I have MARPE and a nice little gap between my two front teeth, and I’m not enunciating as clearly as I might otherwise. I’ve gotta big old custom MARPE in the roof of my mouth. Okay, so back to back to college. I was studying mechanical engineering at UT Austin. And my whole life, I really wanted braces for the first time. I had job insurance and I had no money. And so I wouldn’t I got orthodontic treatment while I was in college. And just kind of sitting there in the chair, when I had this epiphany. It’s like, you know what, orthodontics is just a lot like engineering to the mouth. And there’s actually a person attached to it. And not only that, the person has, you know, has feelings, it has definite, definite emotions attached to their teeth, and their smile, and so forth. And I noticed myself as my tooth became straighter, just becoming more confident in myself and my smile. And to me, it was an amazing transformation. And the fact that I could use my engineering training and the ability to think in three dimensions and solve three dimensional puzzles, to apply it to this, this profession. So I made kind of an about face and I left the College of Engineering went into pre dent, and it was able to kind of quickly get those prereqs taken care of, and then you know, sort of like the rest of history, if you will. I have to say that when I was studying engineering, I mean, I could do it, I could force myself to do it. But I didn’t love it. And I’ll never forget, like my first week of dental school when the dental anatomy professor assigned us a book chapter to read. And then I read it. And I just was fascinated with the anatomy of the teeth and the fact that every tooth has a different function in the mouth and a different shape to perform that function. And so I ended up staying up all night, you know, up late, I read that whole book that night. And that had never happened to me in my educational career where I was just like really passionate about something. And from that point on dentistry, just and orthodontics was just no longer a chore. I mean, it was really, it was a pursuit of a passion that I still have to this day. And so you know, all through dental school all through orthodontic school, I just absolutely love studying this stuff and kind of pushing myself to learn more and stay on the leading edge of what’s out there. And and that that’s part of what led me to some of the things I’ve come up with over the years.

Alison Werner 3:31
Okay, and so you’re practicing at San Antonio.

Dr. Robert “Tito” Norris 3:36
That’s correct.

Alison Werner 3:37
Okay, so, um, what I want to talk, I know you have a very busy practice, you’re treating over 900 cases annually, you had mentioned, we had talked earlier, and you mentioned that. So I want to talk about how you create efficiencies in your office and the systems you’ve employed to treat, kind of with your visits while maintaining those, you know, those impeccable finishes that you want. So what is key to creating that treatment efficiency while maintaining excellent outcomes in your office?

Dr. Robert “Tito” Norris 4:05
FepwoI mean, I hate to boil it down to just one word, but it really is just one word and it’s systems. You’ve gotta have systems from from the, for the moment that the patient enters or calls the office, there’s a system to how we answer that phone. It’s a very systematic new patient examination because there’s a lot of lot of data that we’d have to collect in a new patient exam. And we look very thoroughly into things. What’s the position of their skeletal bones? What’s the what’s their airway situation, how they’re breathing? Are they sleeping, you know, we’re looking at them, facially. I love I love David Sarver’s, macro aesthetic, mini aesthetic micro aesthetic evaluation, so we incorporate that into the new patient exam. We incorporate Bill Robins core diagnostic process into the base exam. And I do have a partner and associate So we each have to have that systematic approach to the way that we assess and diagnose patients. Furthermore, we’ve had to have systems about, you know, how the braces are placed. And so indirect bonding has been kind of a hallmark, actually, I’ve been doing it since residency really helps, you know, that bracket accuracy, just getting gets his braces on just at the right positions. And that has been really, really helpful in terms of creating, you know, just just parity and equality in terms of our cases, because we all get to look through the same set of eyes that how those brackets should fit the teeth. And then, of course, you know, with the advent of a more accurate bracket, wire interface system, and the Norris system whereby we no longer have all the all the slop that we had, when we were doing an oh two bracket system, we now have a bracket that actually fits the wires that we like to use. So you know, part of that systematic treatment of a patient is to treat a patient using three or sometimes four, orthodontic archwires, right. So that just really reduces the number of thumbs in the pie there and really helps us maintain our consistency no matter who’s treating the patient, you know, we can we can start them very efficiently we can we know exactly what’s going to happen at the next appointment. All those appointments are very systematic, and, and the data really speaks for itself. And that is if you look at what’s published out there, through American Journal of orthodontics, and also JCO, you know, to get a good finish, the average is somewhere between 20 and 26 appointments, which is a lot. And so we’re recruiting patients in literally half of those numbers of appointments. Right now, our numbers are 12 appointments for teens and 13 appointments for adults. And so that is, that’s really key and to kind of keep an eye on the prize and look at how it’s like a game, right? And you’ve got to keep score, right? If you want to win the game, you got to be able to keep score. So we actually have a column within our EMR software, we happen to use too often. Where we have created a column where you have to fill in okay, this is appointment number one, this is appointment number two. So it’s pretty easy for us to go back and countless number of appointments, and we’re really focused on that in terms of, you know, how efficiently can we treat every single patient and, and get a great result, right? Because we have to have that go through another set of systems, another set of checklist, if you will, with before the patient get the braces off, you know, what’s their incisal display and repose? What’s does their smilearch like, where are the buccal corridors, how’s the occlusion? You know, all these little things, that we all have to go through the same checklist. And that is a system within our practice. And even after the braces come off, and we start looking at things such as you know, gingival margins, and we look at some of the micro aesthetic issues there, you know, it’s a coloration of the teeth simply changes some teeth and some buildups you know, all those things are once it gets a systematic approach to how we how we view things. We do have a number of aligner patients in our practice as well. And that is a fairly efficient way to go. But aligners just can’t do everything. So that’s what we got to embrace. We do a number of interdisciplinary treatments in particular, we we’ve kind of known for patients who are having airway issues. In fact, that’s why I’ve been treatment myself as I’ve developed sleep apnea. As I’ve turned 50, I kind of developed sleep apnea. And so now I’m, you know, treating myself and honestly, it’s the last 10 nights I’ve slept better to have in years and years is pretty amazing.

Alison Werner 8:55
Okay. So you mentioned those interdisciplinary cases. Can you talk at what how does the workflow change does the workload change anyway with those cases to maintain your standards?

Dr. Robert “Tito” Norris 9:06
It does. Okay. So one of the things that is the hallmark of most of our interdisciplinary cases is that a lot of those cases are going to have wear on the teeth and basically, this is almost half our practice. 50% of our patients are adults. And those patients that have worn teeth, missing teeth, fractured teeth, whatever. The first step is, well when evaluated gingival architecture and see if they have APE altered passive erection, that’s usually the first step is to get them back to a periodontist, establish proper gingival architecture. Once we have that, then we can go ahead and send them to the dentist and have them build up those teeth so that now we’re dealing with basically virgin looking teeth they provisional buildups on those teeth, so that now we can use use that as a three dimensional blueprint for communication between us and the restorative dentist because eventually those teeth are going to be restored with you know, some long-term provisional, something of porcelain usually. But if they can do it in composite, or some other resin ahead of time, before they get the braces on that it really helps us because now we have an accurate incisal edge from which we can measure our bracket position. And it just helps the treatment go so much more efficiently. Furthermore, when you when you a lot of these patients have like anterior wear and maybe not quite as much posterior wear is but when you when you build up the teeth anteriorly you’re left with a kind of a little bit of a posterior open bite, because we’re gonna put them in some bite turbos and so. So you’re able to use extrusive mechanics, which are much faster than intrusive mechanics, because many, many dentists will say, hey, you know, intrude these teeth for me, in the talking about the maxillary anterior teeth, give them some restorative spaces, they can then go back and lengthen the teeth at the end of the treatment, we’d like to do it on the front end, where we just restore the teeth on the front end, and then we can extrude the posterior teeth into occlusion. And that’s a much more efficient way to treat these patients. And many of these patients finished in under under a year. Selecting the treatments that are that are most efficient and selecting an appliance it’s most efficient for each particular case.

Alison Werner 11:16
But then you have those systems in place where you have kind of that checklist to know what to go through so that you can maintain that efficiency as you’re going through even if the case is a little different or a little more complex.

Dr. Robert “Tito” Norris 11:27
Absolutely. And we’ve got different checklists for different types of patients. For instance, we’ve got a lot of what we do to cuspid substitution. So we have a number of patients who are missing maxillary lateral incisors. And in my practice, we simply don’t treatment plan implants, we always do customer substitution on these cases. So we have a very systematic checklist of what needs to happen step by step in order to produce a beautiful smile. And to do it in a systematic manner. And there’s certain times that we do each of these different steps and it’s everybody in the practice knows it and we sit down the assistants know what’s going to happen. And it really helps things run very smoothly.

Alison Werner 12:06
Can you talk a little bit about what it entailed to set up something like that a checklist or a system? Can you take an example of one checklist or system you’ve put in place? And what kind of thought process went into it? And what kind of data went into creating that?

Dr. Robert “Tito” Norris 12:21
Sure. So let’s just take the example we’re just talking about, let’s say cuspid substitution case patient was was missing their maxillary lateral incisors. Okay, so from the new patient exam, I mean, obviously, we want to the beginning point of the of the treatments where ultimately where do you want your maxillary incisors to fit in the face, the maxillary incisors are the central focus of the smile, okay. And in many of these cases, feel they need to be maybe even a little bit more forward than where they are right now. And so, you know, we before we even bond the case, we will go ahead and convert the cuspids to the laterals. And then we’ll basically use some coil springs to push those maxillary teeth into the correct position within their smile, but vertically, and then we look not only where they are, up and down, but also left and right and make sure we don’t have a cant going on. And also AP, we want to have the right smile projection of those teeth. Once we get that set, then the next step is for us to basically lock those teeth into place, we use something we call a y-bar. All right, and it looks like the letter Y goes the roof of the mouth. And it leverages off of two palatal tads. And this would be a system where you know, the assistant knows I mean, step one, they already know that we’re gonna be doing those, those cuspid conversions, okay, so they have everything set up for us to do the cuspid convergence. Step two, they know that we’re going to be pushing the teeth of the popcorns beans already ready. Step three, we know we’re going to be putting in the y bar. So we’ll have all that the TADs ready for us to insert that and the lab knows how to build the appliance and assistants actually deliver those appliances. And then, you know, when we’re protracting the posterior teeth, you know, the assistant knows that we gotta have buttons on all the four fives and sevens too, because we’re gonna protract for the facial to the lingual. So all of those little steps this this team knows the team knows every single step along the way. How do they know because we’ve done the training. Okay, so we have an in house, one of our lead clinical assistants is our is our clinical trainer. And so we reviewed these cases, and any new patient or any new employee basically goes through this training manual and knows these steps step by step by step. So there’s really no surprises here. And it just, we have such an amazing, talented team of people because we’ve we’ve brought them up that way we brought him through the farm league, and now they’re playing in the pros. And they I mean, when you’re a pro you don’t you don’t miss a step because you’ve done it so many times. You’ve practiced it so many times. And so now it’s game time and you know what needs to be done. Everything’s out, everything’s ready to roll. So when I sit down, you know, boom, they just hand me this, this, this and this and you you know, I’m out of there. It’s just, it’s just simply a matter of training, got to have those training. And that training has to be such systematic and different levels of expertise among the clinical assistants as well. And everybody has a little ladder or little little carrot to get to the next level, because that next level, obviously means better compensation for you when you master the clinical acumen that it takes to do some of these more complicated movements.

Alison Werner 15:28
Now, a key component of great outcomes and efficiencies is the products and technologies you employ. And as you mentioned, you have developed several orthodontic products over time that do just that. So can you talk about the products and technologies that are key to you getting the facial aesthetics and finishes you want, when you’re treating patients in your practice?

Dr. Robert “Tito” Norris 15:46
Well, I think that’s a great question. I mean, you know, obviously, the Norris bracket has been, you know, the hallmark of our practice here for the last seven years. And in the whole thing, it’s all about finishing. And for the first time, we actually have a bracket that fits the wires that we like to use, most people finish it in 19/25 wire, and with a 20 slot bracket, you can get a really nice torque control of these teeth and great rotational control. So it’s just really control and finishing what it’s all about, you know, when I’ve talked about those efficiency numbers, in terms of, you know, 12 or 13 appointments, you know, we don’t, we don’t make up that ground in the first two or three appointments make up that ground in the end in the finishing appointments. Because the teeth move, you know, you put a little bend in the wire and the tooth goes exactly where you want that to be because there’s no slop in the system. The system is a very tight, it’s the difference between, like driving like an old farm truck with a bunch of slack and the steering wheel versus driving like a Formula One race car, where because exactly where you need to be. So in a way, this has made us better orthodontists because it’s made us better bracket positioners. And we’ve got to be extremely accurate with our, with our bracket positioning. So you know, first and foremost, it’s just, you know, that system right there, the smaller 020 bracket system fitting in 19/25 wire, that’s the biggest thing in our practice, okay. Beyond that, I mean, we obviously we love in ART spring, it helps to, you know, control that torque a little a little more on the interior teeth, it’s very, we love the CS springs for class three patients. We love the motion appliance for early you know, kind of class two type of stuff. And yeah, those are those are mostly, you know, other other other things, you know, like for instance we’ve got a handpiece, multiple handpieces every chair, you know, with light, we’ve got great lighting, we’ve got suction, we have great air, I mean, it’s just easy when you sit down, everything’s right there, you don’t have to ever get up and get anything. Okay. Ergonomically, you know, we did a whole thing when I built the office in terms of ergonomics, and I wanted every assistant to have everything. So we have a lot of duplicity at each chair. No one ever has to get up to get a plier. You don’t pick it up at the wire, you don’t have to get up to get anything, because every unit is self contained there.

Alison Werner 18:03
So it’s not just about having the products in the moment of, you know, applying the braces or moving a wire, I think it’s having everything in place, from the instruments to the chair to just be able to get going right then in there.

Dr. Robert “Tito” Norris 18:19
Execute. Okay, execute right there. And there’s no delays. So it’s yeah, that’s a that’s a that’s a, I think I recently saw a patient in a friend of mines office, I’m not going to mention it, but oh, my gosh, you know, the burs were over there, and the handpieces were over there. And it was just like a madhouse trying to get what I needed down into this one room with this one patient. And, you know, and I realized, yeah, you know, it’s an investment to have all those things, you know, it’s have everything in each of your treatment rooms, I get it, but it’s a one time expense. And once you’d have those things, you know, they’re going to be there for years and years to come. And you’re going to save on, you know, just simply time. I mean, that’s your most valuable asset. And so, you know, I mean, it’s sort of like, what is it pennywise pound foolish or something like that. And so I’m more than willing to make those investments to for the ergonomic efficiencies that we get out of it, as well.

Alison Werner 19:20
Yeah. Well, I was my next question was going to be how does this efficiency tie into profitability? And you kind of talked about there about making that investment up front with your office design and, you know, making sure you have the resources to accommodate all those patients to begin with. But can you talk a little bit more about how these efficiencies within your treatment have helped with profitability?

Dr. Robert “Tito” Norris 19:41
Well, sure, um, you know, the thing is, listen, every case should we’ve kind of broken down to how many appointments did I did it take me to finish that case? Okay. So if it took you let’s just take an example. Let’s say $5,000 case, and took you 10 appointments, okay, that’s $500 per case, right? So the same case $5000 case, if it took you 20 appointments to treat that case, well, then you made $250 per visit. All right? So the efficiency and the profitability is pretty obvious the least number of appointments is making more profitable. And yes, we all care about profit and so forth. But I’m, I’m just at this point in my career, I’m more interested about time. Okay. So I mean, imagine we have roughly 2000 patients in treatment, right? And we’re able to treat those patients with half the number of appointments that we might otherwise treat, or they might be treated in another office. So, so what I mean, what does that what does that mean? I mean, that’s, that’s, that’s 1000s of appointments that we’ve saved. And so what do you want to do with that time? For me, that’s more of a life balance type of question. And, you know, I, I love what I do. I love orthodontics, but I also love a lot of other things. You know, I love travel, I love skiing, I love my family. You know, it’s it’s nice to have that sort of, you know, ability to have some time off to sharpen the saw to go to meetings to do other things. I don’t feel like I’m just, you know, always at the office, because I’m not.

Alison Werner 21:10
Okay, well, that was gonna lead into my next my next question is actually going to be about the fact that you know, you do lecture frequently you do conduct in office courses. So I’m guessing these fewer appointments, which frees up that time is allowing you to do those things. So can you talk about that work and kind of the topics that excite you that you enjoy lecturing on?

Dr. Robert “Tito” Norris 21:29
Well, there’s no way that I would be able to do all the other things that I do. I mean, I’m a competitive swimmer. I lift weights three days a week, I go surfing on the weekends, you know, I take 15 weeks off every year, you know, whether it’s in meetings, or lecturing, or whatever. And there’s just there’s absolutely no way I can do that stuff, if you know, if I weren’t extremely efficient at the office. And that’s the only way that’s ever going to happen. And so when I give the courses, you know, when one of the things I mean, obviously, I’d love to talk about efficiencies, I like to teach people how to be efficient, not only like how to place the brackets on the teeth, but the systems and how to use for your archwires and all those kinds of things. What excites me most I mean, honestly, I love interdisciplinary care. And I have for a long time, I think it’s, it’s, I think it’s next level orthodontics, I think you have to think quite a bit on some of these cases. And, and some of these can be the most rewarding cases, when you’re really changing someone’s life if they’ve got, you know, missing teeth, worn teeth, and they live like this. And they feel like they’re almost invisible. And you give them this new big brilliant smile. And they just I mean, they’re in tears, they just they feel self confident rather than, you know, self conscious, you can really change someone’s someone’s life. But I think as I look at at the future of orthodontics and what’s what’s on the horizon, what’s what’s happening, I think the biggest area for growth is going to be in the area of airway friendly orthodontics. And I don’t want to beat people over the head with this, but my practice has changed dramatically in the last 10 years. And, you know, we’re helping people in ways that we’ve never been able to help them before. And, you know, patients come in, and we go through a whole exam, and you know, they just came to straighten their teeth, and they end up you know, improving their airway and they’re sleeping better, they’re breathing better, and their life has completely changed, you know, whether it’s children or whether it’s adults. You know, now we have those technologies to to help everybody. Basically, I’m kind of living proof right here with my MARPE going on. I’m 57 years old, I’m very hard headed, and I got a skeletal split of my maxilla. And I basically resolved my sleep apnea here in a relatively short period of time. That was unheard of when I graduated from residency 30 years ago. And that we would be you know, not just straightening teeth, but really helping people live better lives, live longer. I mean, just simply speaking, you know, if you can resolve someone’s sleep apnea, you’ve given them 10 years to their life. That’s phenomenal. Yeah, I mean, what’s your most precious valuable asset it’s time and time and time you’ve given 10 more years of life. So you know, for those who have not gotten on the I want to say bandwagon but who have not gotten educated themselves in terms of the benefits of a MARPE or a custom MARPE dun procedures, sharpe procedures, those kinds of things. If we’re not looking at airway, you’re never going to find it in dentists are in a very dentists and orthodontists are in a very unique position to recognize early signs of airway problems. Everything anything from just like snoring to tooth grinding, okay, open bites, tongue thrusts, all these kinds of things can have to tie into that the airway component So that’s one of my favorite lectures to give. And they tend to be very eye opening for a lot of patients, and they go back and they look at their patients with a different, totally different way. And and now that we have all this all these new tools at our disposal, I mean, orthodontics has been through a major overhaul here just fairly recently.

Alison Werner 25:19
Yeah. I know. Before working on orthodontics magazine, I actually did work on a sleep medicine museum or magazine. So I’m actually curious, have you incorporated questions about sleep habits and breathing into your patient evaluations?

Dr. Robert “Tito” Norris 25:39
Absolutely. That’s a seminal part of it. In fact, the Chervine Sleep questionnaire is its diagnostic. It’s actually, for instance, remember, when you were a general dentist, like if someone brought to you, like a, like a bitewing X ray, and it had a, you know, it looked like a cavity, a caries lesion on there. I mean, you were pretty much committed to it, you couldn’t ignore it, right? Like, you would have to treat that cavity or at least inform the patient that you have a cavity that needs to be treated, or it could turn into a root canal, or you could lose a tooth. Well, the Chervine sleep questionnaire, which is part of what we do, you know, for kiddos, and we have another one for adults, it is a validated instrument. In other words, you know, if if someone answers, you know, eight or more on that Chervine sleep questionnaire, you can send that to an ENT, and they can’t ignore it. For years and years and years, I was trying to do more airway stuff, and if sending these patients to these local ENTs. And there was a well, yeah, they have class three tonsils, but you know, I’ve seen bigger, insurance isn’t going to cover it unless they’ve had so many infections. Meanwhile, you know, the poor child is not sleeping, not thriving, they’re struggling, they’re they’re mouth breathing. It’s, it’s really, it’s really been a shame that we haven’t had the support, but once you kind of educate your colleagues and align them and show them what you can do, and how they can help as well. It’s really, really great to have that interdisciplinary team on board with everything.

Alison Werner 27:08
Going back to your lecturing and everything, and you’re in-office half his courses. Do you have anything coming up in the next few months?

Dr. Robert “Tito” Norris 27:15
Absolutely. Well, there’s there’s two courses coming up. One is next month, that’s going to be in Scottsdale, and I’m lecturing with Chad Foster there. And that’s going to be focused really more on orthodontic aesthetics and finishing. And that’s, a course, that we’ve given several times. And the feedback that we’ve gotten has been has been really, really positive, very eye opening for a lot of people. He’s got some really, really great stuff to share. And of course, we both make some contributions there. And then we do an in house course twice a year, every May, and every October. And those can be found on the Dynaflex website, if you just open up dynaflex.com and it’ll pop up right there. Yeah, once you’re up to date in office course, and we cover everything from indirect bonding MARPE even systems within the practice, you know how to answer the phone? We do. Yeah, I mean, we actually is very much involved in taking excellent records. You know, Disney level service, team building training, you know, all is a pretty comprehensive thing. And then we go through airway we get through interdisciplinary care, cuspid substitution, solar transplantations. It’s more of a hands on type of thing.

Alison Werner 28:33
So Excellent. Well, Dr Norris thank you so much for speaking me today. I really enjoyed our conversation and I hope our audience finds everything you had to say really helpful, because I think it was.

Dr. Robert “Tito” Norris 28:45
Thank you so much Alison. It’s been a pleasure.

Alison Werner 28:48
Great, great. Yes. Great to see you again, too. Okay, take care. As always, thank you for joining us. Be sure to subscribe to the orthodontic products podcast to keep up with the latest episodes. And be sure to check out orthodontic products online.com to keep up with the latest industry news. Until next time, take care.