Friday, November 21, 2014

Personal Loss

Committed concentration is required to excel in dentistry. Some practitioners—or some people in general—are able to concentrate fully in a chaotic atmosphere, while others need total, or near-total, quiet in order to focus. I’m one of the latter. I’ll joke and laugh with my patients until the actual treatment begins, when I need everything to be calm in my immediate space, with no extraneous distractions. My fun-loving and gregarious staff knows this and appreciates it.

The howling laughter from my hygiene room seems nonstop throughout the day. My hygienist is able to do her work while engaging in unrelated conversations. I might comment to a patient undergoing extensive rehabilitation, “Don’t you wish you were in Tami’s room right now?”

Whenever I walk into an operatory, I find my assistant chatting it up and distracting the patient from the upcoming treatment. However, she knows to cut it off when I begin my work. But as soon as that injection needle comes out, she and the patient pick up right where they left off. It creates a nice atmosphere.

But how does one focus when personal tragedy strikes and it becomes an internal distraction? Do we cancel our appointments, appointments that loyal patients may have waited months for? Will those patients understand? Where does our duty to our patients end and that to family and friends begin? Is there a clear demarcation? Probably not.

I recently came face-to-face with this dilemma. Last spring, my best friend, Ralph, was vacationing when he broke his No. 5 and No. 11 beneath the gingival crest. As soon as he got home that Sunday, I met him in the office, took impressions for a flipper, and suggested implants. Later, after extractions and healing, he had the implants placed.

When late summer came, Ralph and his wife were preparing for a European trip they’d previously planned; it coincided with the time when the implants were to be exposed. I discussed his case with the oral surgeon, who suggested the teeth could possibly be restored before the trip if I could get a lab to fabricate the abutments and crowns quickly. However, the surgeon also suggested that this might be rushing it. Ralph decided to wait, which seemed like the best move; he’d put up with the flipper until he returned from Europe.

By late September, the healing collars were in place. By early October, I took impressions of the analogs, keeping the flipper in service for “just a couple more weeks.” That’s when his wife, also a good friend and one of my wife’s best buddies, became seriously ill.

Ralph called me in desperation one night, needing a ride to the ER after his wife had been transported from their home via ambulance. My wife and I kept vigil in the ER with them until well after midnight. It was late, I was exhausted, and I began to consider the 20 patients I had to treat tomorrow—each one requiring my undivided attention. Thankfully, a mutual friend arrived to transport Ralph downtown after his wife was medevaced to George Washington University Hospital in Washington, D.C., for an emergency craniotomy.

Coffee helps, but there’s a limit. Do I cancel? No. I was not so tired that I couldn’t function and, despite my own emotional distractions, I had patients who might also have their own issues.

Ralph’s wife slowly began to recover, but unfortunately, she then lapsed into a coma. My best friend found out that his soul mate might soon die. That weekend, I restored his teeth, but it was incredibly difficult for me to concentrate while placing the abutments and crowns. When he stood up from the chair, his moist-eyed smile radiated beyond anything I had done for him. Is there anything more important than that? His wife passed away the following week and he was able to attend her memorial service without the distraction of an obnoxious flipper in the forefront. On her remembrance board is a stunning picture of her as a young woman, smiling broadly. I will always remember how Ralph looked lovingly at that photo.

As a member of the healing arts, I feel an obligation to people who may also be going through a “rough patch.” Honoring my obligations to them is paramount. They depend on me. And I’m sure you have patients with needs beyond anything you will ever know. They deserve our best.

Jim Rhea, DMD

Wednesday, November 19, 2014

Avoiding Endo

In dental school, I really enjoyed performing root canals. We had a wonderful endodontist on the clinic floor that helped me through some difficult cases, and pretty soon, I was starting to feel like an endo expert. (Dental students are so naïve!) I think I graduated with maybe 10 or 15 cases under my belt, a little more than our requirements asked from us. I even considered specialty training in endodontics at one point but, like most of us, I was eager to be done with school. Besides, what more did I need to know?

Endos in private practice are not like the ones I completed in dental school. As you all are well aware, time is a precious commodity when you are self-employed, and sitting there trying to search for canals in a second molar for hours was just not something I had the patience—or chair time—for. In addition, some of my earlier employment stints were in offices where other doctors actually laughed at me for trying to use a rubber dam (!!) or for worrying about filling all the canals properly. I realized I did not have the skills to complete root canals correctly in a short period of time. To make matters worse, the materials in some of these offices were so terrible that the rotary files—reused an infinite amount of times, of course—would have a tendency to separate, giving me minor panic attacks every time I picked up an instrument.

When I started working at my current office, I was able to decide how I wanted to proceed when my patients needed root canals. I wanted to do what was best for them and cause them the least amount of pain and discomfort. That is when I decided to refer all of my patients to an endodontist. I knew that a specialist would be able to perform the procedure in a fraction of the time, making the experience a lot more pleasant and tolerable for my patient, while yielding more predictable result. Sure, I probably could have invested some time in continuing education courses and gained more proficiency in this area, but it just so happened that I was not seeing a ton of endo in my practice anyway. Many of my patients are young with healthy teeth; for those who do need an endo, it’s usually to retreat an old poorly done root canal. I rarely saw “fresh” teeth that needed root canals.

Now, I know what you are thinking: How can none of my patients need root canals? I have thought about this as well. I try to be extremely conservative when restoring teeth. I know some dentists may tend to take a more proactive approach, since they do not want their patients calling them in the middle of the night, complaining of post-op pain. I always explain to my patients the pros and cons of trying to save the tooth and avoiding a root canal. There are many different kinds of patients. If you have a patient who would rather jump off the Brooklyn Bridge than experience post-op sensitivity, sure, you can offer them a preventative endo. However, I like to present my patients with every option. If it were up to me, I would prefer to do everything possible to avoid a root canal. This may be why so few of my patients actually need fresh endos, since I try to have that be my absolute last resort.

This is a patient I had a few weeks ago. This seemingly simple Class II case turned into an exposure, as the patient had ground down the tooth so much and there was extrusion. I do all of my restorative under isolation, either with a rubber dam or Isolite, to help prevent any contamination from saliva. I placed my favorite liner on the exposure and proceeded with the filling. I explained the situation to the patient and even gave her the information of my endodontist. She called me the next day complaining of pain, but she said that it was bearable. I advised her to try to wait it out. Either the tooth will heal itself, or the nerve will die, but isn’t it better to try to avoid having a root canal? Most patients agree with this philosophy. She ended up feeling better after a few days, and I continue to monitor this tooth at her recall visits.

These radiographs were taken one year apart. The patient had a mouth full of decay when I first saw him. A few teeth received permanent fillings, but some, like the one shown in the picture, were filled with glass ionomer (GI). There was too much decay to place the fillings right away, and I was not yet ready to create a more definitive treatment plan. Since he lived in a different state, I did not see him for over a year. When he returned, I removed the GI filling and placed a liner with a permanent restoration. We are still working on restoring his entire mouth, but so far so good with that tooth. Sure, he had to have that filling redone a few times—and still may need a root canal in the future—but I think he appreciates that I am doing everything I can to try to avoid it for as long as possible.

Hope everyone has a great week!

Lilya Horowitz, DDS 




Wednesday, November 12, 2014

THIS Is Why I Do Dentistry

If I polled all of you about what you like most about our profession, I’d likely get a variety of responses, including:
...every day is different
...I pick and choose which treatments I provide
...the predictable hours
...the money
...owning my own business

Don’t get me wrong, those are all viable reasons for loving a profession, and ours in general. However, there’s one thing that stands out most to me over my nearly five years as a practitioner—the people. Wow! I already have more stories than I could spend a week telling.

Believe it or not, I’m not wired as an extravert or someone who is recharged by social stimulation. It’s something I have to constantly work at, especially since I meet, greet, and small talk with close to 30 patients, not to mention my staff, on a daily basis.

It’s been an interesting journey through dental school and into private practice, learning to manage the clinical, as well as social/patient-management, aspects of dentistry. But it’s something I’ve fallen in love with, something that keeps me pouring that morning cup of joe and getting to work on time (which if you know me, actually NEVER happens) each and every day. The relationships I’ve built with patients have been such a blessing. I could talk about a number of people in particular, but since it’s so fresh in my mind (We finished today!), I thought I’d tell you a little about “Bob.”

Bob came to me on a Tuesday in November 2012. He had only a few teeth remaining and wanted “a whole new set.” He wasn’t just looking for teeth he took in and out, but ones that looked, felt, and functioned just like normal teeth. And not just that, but he wanted them like right then and there—so much so that we performed surgery just two days later. This is where Bob’s case got difficult—and where it got fun.

I love it when you go to one of those continuing education (CE) seminars in which the lecturing dentist or specialist shows the beautiful, picture-perfect esthetic cases to all those attending; it must be an instant ego boost for them. It’s the same idea with Facebook. You, I, and all our friends post the coolest, most impressive snippets of our lives for everyone to see. It’s awe-inspiring and depressing at the same time.

This story is not like that. For the better part of a year and a half, Bob and I have met at least two or three times per month, working on his esthetics case. During that time, we had a failed implant that had to be replaced, I went on vacation for a month, he traveled for work, and my lab dropped the ball when we were just about to finish the case, setting us back an additional few months. You get the picture.

This was no “ego boost, show it off to your peers at the local study club” kind of case. My assistants seriously had enough of me and my patient on multiple occasions. It was quite a learning experience and a case (and patient) that I’ll never forget. It wasn’t perfect; I could have changed 50 things about the case from start to finish. However, that’s not the point.

We persevered, gained a new appreciation for patience, and learned an absolute ton along the way. Through it all though, I made a friend. My staff made a friend. Bob made many friends. As crazy as it sounds, I’ll miss seeing Bob every week, being perplexed as to why the framework STILL DOESN’T FIT FOR THE TENTH TIME! Though I’m sure he won’t miss the hours spent in the chair—many of them snoring!

I wouldn’t trade these types of experiences for anything. Other dentists might tell you otherwise, but THIS is why I do dentistry!

Donald Murry III, DMD

Monday, November 10, 2014

A Day of Remembrance

I am the second youngest of 13 children, born and raised in Toronto. A member of a liberal, politically left-leaning family of Reform Jews, our household was filled with 13 siblings, all fiercely individual and unique, a zany group of people. It was a happy time for me.

At age 18, my father died suddenly. He was only 57. A successful salesman, but a failed business owner, he left behind a debt that was crippling. We lost everything, including our home and our cars. My mom had to start working for the first time in more than 40 years. We went from a five-bedroom house to a two-bedroom apartment. It was a tough time for me—and  for all of us.

I was ready to quit school—by now in my first year at the University of Toronto—to work to support my mother, but my siblings all were adamant that I find a way to stay in school. I was the first, and only, member of my family to have finished high school as an Ontario Scholar, with marks in every subject above 80 percent. I wanted to be a doctor and had the possibility of making that dream come true. So I stayed in school.

The first years were hard. I did not have the marks to get into medicine or dentistry. So I stayed in school and completed my master’s degree, with a focus on research in the field of cystic fibrosis. I earned some scholarships and I was finally accepted into everything I applied for—medicine, dentistry, and teachers college. I chose dentistry and was excited for my future.

But the dental school curriculum was a tough go. The time demands did not allow me to work and go to school, and there were no more scholarships, bursaries, or grants left. So I joined the Canadian Armed Forces.

A Jew in the Army is a very rare thing in Canada. There are probably more Canadian Jews in the Armed Forces in Israel than in Canada, but for me it was one of the best decisions I have ever made in my life (right up there with choosing dentistry as a career and asking Tina to become my wife…and she said, ‘yes’). As a result, I could study to become the dentist I wanted to be without the financial concerns. I graduated and was able to  practice dentistry without the accompanying business concerns. I would do it all over again without hesitation.

But my service to my country taught me things I was not prepared for. Through my service in the Canadian Armed Forces, I learned about my country, and how World War I and II  helped shape us as a nation. I learned about how the members of the Forces treat each other like a large extended family. I learned about my great country by travelling all over it as part of the Forces, by training in remote locales, and by representing Canadians in a NATO exercise in Northern Norway as the Dental Detachment Commander for the Allied Command Europe (ACE) Mobile Force. I learned about my own physical limitations as I was pushed and tested beyond them; it  was a very humbling experience.

I served my country in peace time. I retired at the rank of Captain in the summer of 1990. There was a surplus of dentists in the forces at the time and I was offered a financial incentive to leave at the end of my contract, which I accepted. Then the First Gulf War occurred, and the world has never been the same since.

On Nov. 11, in Canada, we will observe the occasion of Remembrance Day—similar to Veterans Day as it is known in the U.S. In the wake of the October terrorist attacks on our soldiers on our home soil, the Canadian public is particularly interested in supporting our Canadian Armed Forces by participating in Remembrance Day ceremonies. At the 11th hour of the 11th day of the 11th month, we will remember with a minute of silence.

I am proud of my service to my country. I am proud of the sacrifices of the many men and women who have defended our freedoms. I am proud to continue to be a part of all of this through my association with the Calgary Highlanders, the Canadian Armed Forces Land Reserve Infantry unit. On Nov. 11, my family and I will remember.

That’s not a grind. It’s an honour.

Warm regards,


Larry Stanleigh, MSc, DDS, FADI, FICD, FACD

Friday, November 7, 2014

That Has My Signature on It...

I will tell you a story, and then I will tell you the moral of the story. 

I was a senior in undergrad at the University of Florida (I know, I know, our football team stinks. What can I say? We are a basketball school!). I was taking ceramics. Yes, I wanted an “easy A.”  

Much to my dismay, this ended up being a very time-consuming class. The teacher actually wanted us to work and get better at ceramics—the nerve!

I found myself at the ceramics lab at all hours of the evening. In this case, it was a Sunday night, past midnight, and I had just finished making my ashtray or something and I decided to walk through the senior lab as a short cut. 

I walked past an open trash can and inside was some finished and glazed pottery. The reason that particular piece of trash caught my eye was that it was so colorful. I did a double take and walked back to the trash can and inspected the work. (I guess to the casual observer I looked like George Costanza from Seinfeld eating the Danish out of the trash can—but I was a poor college student!). Well, what I found in the trash can were six chalice-like glasses and a matching pitcher. WHAT?!!! I had struck gold. This set was better than anything I had.  

So I started pulling the stuff out of the trash can and I heard a voice coming from one of the work rooms. A dude came out and told me that I couldn’t take that stuff. I looked around and said, “Someone was throwing this away and I think it is cool, so I am going to take it.”  He said, “No, you can’t! See, this is my work and I don’t want anyone to have it.”

Now you see, I was this dental school wannabe, not really belonging in this part of campus, so I didn’t really understand those artsy-fartsy types. He could probably tell from the dumb look on my face, so he continued:  “You see, if you look at the bottoms of all of those glasses, you will see my signature. Once I put my signature on something, it has to be work that I am proud of. If my signature is on it, well, that is my reputation. I put my signature on these pieces, and then I decided it was not up to the standards that I want out in the world.”

He continued, “Come on in here.”  Before we started walking, though, he smashed all six glasses and the pitcher into a billion pieces. I guess he was serious.

He took me to his studio in the back and pulled out six new glasses and a pitcher. He said, “This is what I did to practice. No signatures on the bottom. So you can take these.” I was thrilled and shocked at the same time. I was still a little taken aback by the smashed set in the trash can. I am sure I sounded a little like Bill and Ted when I replied excitedly, “Ah, dude, thanks.”

I went home and showed all my roommates. They thought I had robbed a bank. This stuff was nice. We went straight to the kitchen and threw away some plastic cups to make room for our new set.

That was the story. 

I have no idea where that pottery is today, but this story stayed with me 25 years later. That clay-molding dude in 1990 is still teaching me today. 

Have you ever stopped to think about how many times a day you are letting your stuff, with your signature on it, out into this world? I know you and I are a lot the same. We are busy in our days. We are finishing up a procedure and, at the same time, two hygienists are waiting for a recall check, the next patient is here, and the composite resin you did has your thumb print on it from the placement. It will do, but it is not signature-worthy.  

Have you ever told someone, “I am going to let you go, but if you ever go to another dentist please never tell him/her who did it?”  Or, have you ever thought about telling a patient that?
I have. Seriously, I have actually told people this. It is my inner ceramist talking.  

Have you ever been finishing up a resin, one you are trying to make really nice, and your assistant is looking at you with an expression that says, “What the @#$% are you doing?”

Your reputation is building, whether you want it to or not. Every day your art has your signature on it and you are letting it out into this world. We all do it. We do a crown that is the wrong color. We do a composite restoration with no contact. We do an anterior composite and that @#$%ing grey line shows at the margin right across the mesial of a central incisor. What do you do? Well, I guess that is different for all of us.  

At the end of the procedure, I sit with the patient and tell him or her that this work is unacceptable to me. I tell the patient, “To you it might look good. To you it might be okay, but I am not happy with it.” I say this knowing that I have to reschedule this patient and he or she is going to be upset. If there is a crown involved, I know my lab guy is going to be upset, too. I know that I am now going to lose money.  

But, after all is said and done, the patient is going to respect you. Your lab guy is going to respect you. And, most importantly, you are going to be happy that this masterpiece will have your signature on it.

Not to belabor a point, but I have made it known to my staff that nothing leaves my office without my stamp of approval.

You know the person who broke a tooth and you don’t have the time to do a crown, so you did a build-up? Has that person not come back? Heck yeah. Your signature is on it—or your thumb print. Two years later that patient goes to another dentist with a broken build-up. 

The point here is that I don’t get dirty looks from my staff anymore, because they know that nothing leaves the office without looking good. I am a little OCD when it comes to this, too. I have been known to put anatomy in IRM before. I know, I know—I need help.  

So I’d like to say, thanks ceramic dude, for the glasses and the pitcher, but also thank you for teaching me about pride and reputation. Twenty-five years later, I am really glad I took that route home.  

John Gammichia, DMD, FAGD









Wednesday, November 5, 2014

The Big Time

I never would have realized when I was asked to begin blogging for The Daily Grind what an amazing opportunity this would be. When this venture began, it was what I thought would be a chance for me to test the waters of the blogging world. I have never considered myself a “writer.” In fact, I despised writing assignments my entire life. I now recognize it wasn’t that I didn’t enjoy writing, it was that I didn’t care for my previous subject matters.

Now I have the freedom to discuss what really matters to me, from writing about my passion for the AGD, continuing education (CE), and Fellowship, to dealing with treatment failures, patient dental plans, and my appreciation of the staff who makes me who I am. I’ve touched on many subjects in my short time here and, nonetheless, I never would have expected to be invited to have one of my previous blogs published in AGD Impact, nor did I think I would be invited to write a wrap-up article for the magazine on the AGD 2014 Annual Meeting & Exhibits in Detroit.

Admittedly, I am thrilled to be a voice of our professional organization, but you can imagine my surprise when a freelance writer contacted me—the little girl from Port Huron, Mich., who used to run around the woods playing make-believe by herself just to stay entertained—to participate in a story that the writer was preparing for Reader’s Digest.

I was skeptical at first, thinking that maybe this was some sort of scam, because, really, my thought was, how does the magazine even know about me? Well, it was from here, on this platform, that freelance writer Nancy Kalish came across my blog entries and felt that I had something worthwhile to share. I did some background checking to confirm her status and, in fact, she was who she claimed to be. So I told her I was in. I stated that I would be more than happy to participate in her article, though still, in the back of my mind, I was thinking this wasn’t ever going to make it to publication.

We discussed the story, and then, via email, she sent me the questions she wanted me to answer. That was in May of this year. She told me that it wouldn’t likely make publication until the fall and that was it. I heard nothing and forgot about the article, until a few weeks ago when a distant cousin posted to my Facebook timeline, stating that he saw my quotes and name in Reader’s Digest. WHAT??!!! Oh my goodness, I was ecstatic and surprised! I really hadn’t a clue that it was finished and in circulation.

I promptly called my friend who I knew subscribed to the magazine and made her check her mail; she confirmed it for me. I immediately had to buy every copy available at our local bookstore. The reality for me was that I was in a national publication, and I was the only DDS who participated! I was happy and honored to represent my profession. I would have proudly exclaimed my association with the AGD if I had been given the opportunity, but that attribute was not included in the writer’s list of questions.

So, as I reminder, take those chances, push yourself—believe that you can and will meet the goals that you never even realized were a part of your future.

If you would like to read the article—you may even have it in your reception area—it is the cover story for the November 2014 issue. You also can find it online.

As a member of the Michigan AGD board of directors, I was encouraged to share this exciting news with the AGD. 

Thank you again to the AGD for providing me with my previous opportunities, as well as any upcoming ones! I encourage everyone to become involved, in something, at some level—don’t let your life pass you by.

Colleen DeLacy, the little blonde girl from Port Huron, Mich., that aspired to be a dentist—and did it! 

Colleen B. DeLacy, DDS, FAGD



Monday, November 3, 2014

We Don’t Slip

I recently attended a continuing education class about oral surgery with speaker Karl R. Koerner, DDS. It was a great class and I really enjoyed it. One thing he said really stuck with me. He was very thorough about describing all of the potential errors that can occur during treatment and showed cases where such things did go wrong. One dentist “slipped” and cut the facial artery during an extraction. The bleeding stopped at the site with pressure; however, the blood found a new place to go and ended up causing a Ludwig’s angina. The patient took legal action against the dentist. Dr. Koerner said, when describing that case, “This is why we don’t slip.”

That sentence stuck with me. Teeth are slippery, especially when they are covered in plaque, blood, and saliva. We are using a lot of pressure with our instruments and it seems inevitable that, from time to time, minor (and major) things are going to happen. I have been thinking about what he said and I have been trying to implement a few of the techniques he showed to us to ensure that slips don’t happen. It seems the more skilled you are and the more practice you have, the chances of “slipping” decrease, but to say “never” seems bold.  There are things we all can do to be more confident and minimize risks.
  1. Use the proper instrument for the right area of the mouth. When you are trying to use an instrument that doesn’t fit the space, the chances of bumping adjacent teeth or sliding off the tooth is much greater. Dr. Koerner demonstrated some narrow beaked forceps that he prefers in certain situations.
  2. Luxators and elevators are different and should be used accordingly. This is something I am guilty of not following; luxators go apically and elevators go interproximally.
  3. Take your time and think through what you are doing. The hygienists are waiting on you for exams and your next two patients are in the waiting room. Still, take a deep breath and really think through your procedure—it can make a big difference.
  4. Don’t be afraid of flaps and sectioning. If you aren’t getting movement, it is time to make things easier on yourself and take some interseptal bone. I saw a technique in which you collapse the roots into the socket after using a No. 700 bur to remove part of the tooth all the way around.
  5. Patient selection is key. Patients who are taking blood thinners and who have complex medical histories can be managed, but if you haven’t had the training, it might be best to refer until you get the proper training on how to manage these patients.
We all are human and we will never be able to able to practice without any risk, but the more we learn, the more we can take steps to improve and minimize risk whenever possible.


Sarah Meyer, DDS

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