Monday, July 28, 2014

Retirement

When I first began to practice dentistry, I knew little-to-nothing about the business aspect. Like many dentists, I learned the hard way. My first goal was getting out of debt, which took years. My school loans were low interest, so that was okay. But after a couple of years, I established a private practice in a state-of-the-art office with the help of large, high interest loans. I thought little about retirement. Actually, it was so far distant that I didn’t think about it at all.

Now it’s almost upon me and I wonder if I’m ready. I did open a couple of IRAs and 401(k)s once my wife and I stopped having kids. Although I managed to sock away a respectable nest egg, I come from an impoverished background and that leads me to feel a little less financially secure than I really am. Many of my non-dental peers are retiring with never-ending pension plans; my pension stops when the money runs out. So my knee-jerk reaction is to keep working “just a little longer.” That’s not necessarily a problem. I truly enjoy what I do and I love my patients; many of whom have become good friends over the years. I’ve watched their kids grow up, get married, and have kids of their own. It’s been a fun ride. However, following two back surgeries, my pace has changed. I see a physical trainer who has helped me. He advised that I relegate all major case work to the morning hours. Ten years ago, I would’ve never seen myself ‘slowing down.’

I guess there’s always Social Security, which could almost keep a roof over my head and food on the table if taxes and mandatory health insurance didn’t eat up most of it. Who knew that Medicare actually charges its seniors for services? I thought I was bankingmy FICA taxes for that throughout the years—apparently not.

Retirement does not necessarily mean that I have to stop participating in dentistry. Due to physical limitations, I’m no longer able to journey to distant lands to provide pro bono treatment to indigent people. Now I mentor younger dentists who wish to provide free treatment here and abroad. Consulting is something I can continue to do after I retire. I’ve also considered teaching and speaking in public schools on oral hygiene and nutrition, maybe writing articles or even a book. The possibilities are only limited by my imagination.

All of this is to say that if you’re starting out in practice or only a short way along the road, begin to prepare for retirement now. It may seem distant at this point, with so much else pressing in on you, but it gets closer every day.

Jim Rhea, DMD

Friday, July 25, 2014

Obsolete Dentistry, Part 2

In a previous blog, I listed some procedures that I either don’t perform anymore or perform a lot less. This time around, I’ll list some products that have come and gone during my career. I am not writing about products that served dentistry well and were later replaced by newer, better products. Rather, these are the products that disappeared and left us wondering what we thinking were in even trying them.

I think this is important is because we dentists are constantly bombarded with demands to purchase certain products. We constantly hear, “All the good dentists use product X. You want to be seen as a good dentist, right? So buy X.” We also hear, “The standard of care is to use product Y. Don’t you want to practice within the standard of care?”

Younger dentists, pay attention. Some products being pitched to you today may one day end up on my list of obsolete dentistry. Here are some of my favorites that have come and, fortunately, gone.

Caridex—I actually laughed when I heard this product explained to me. If Peridex is a good product for perio, then Caridex must be a great product for caries. It was designed to replace the dental handpiece in removing caries. How? You would simply use this magic liquid on the decayed tooth. It would dissolve the decay and leave sound tooth behind. I’m not joking. Then you simply restored the tooth. The only problem was that it didn’t work.

Air abrasion—I actually debated this one with a very well-know speaker during one of his lectures several years ago. He predicted that by 2005, air abrasion would have advanced the point where we would no longer be using handpieces. I almost choked on my lunch. Again, I protested. Oh well. I can’t wait until the year 2005 rolls around to see who was right.

Actisite—This one sounded good. It just didn’t work. In a stubborn perio pocket, you would pack a special cord treated with antibiotic and then seal it in with superglue - I mean - cyanoacrylate. You would never place superglue around someone’s tooth, would you, Doctor? The antibiotic would stay in place for 10 days and kill bacteria. The biggest downfall was that you couldn’t keep that cord in place for any significant length of time. It would keep coming out, even though superglue sticks to everything.

Electronic anesthesia—This was an effort to replace the dreaded anesthetic needle. You may have used a TENS (transcutaneous electrical nerve stimulation) unit in physical therapy or at home to relax some muscles. It works great for that purpose. You’ve seen these machines. They have pads that send electrical stimulation to those tight muscles. So why not put those pads on your face and numb tooth #30 for that RCT? The promise here is no needles and complete numbness. Even though your tooth wasn’t numb at least your face got a massage.

What crazy ideas will make my list in the future? I don’t know for sure, but I’m looking in your direction, Twitter.

Andy Alas, DDS

Thursday, July 24, 2014

I'm Back!

Hello. My name is John Gammichia, DMD, FAGD, and I am going to be joining the bloggers on The Daily Grind. It is kind of weird for me to say that, and some of you might even know who I am. I was the original blogger on The Daily Grind. I was on the AGD’s Technology Council about a decade ago. We were sitting in a room, thinking about new technologies, and we spoke of starting a blog. Next thing I knew, I was posting on this blog two to three times a week for almost four years (no, that is not a typo). That adds up to more than 1,000 posts. I decided to take a break because things were changing. I needed to be more focused at work and I have aspirations of doing some lecturing (and, oh my gosh, does this take a lot of time).

For those of you that don't know me, I am a proud 1995 grad of THE University of Florida College of Dentistry, and I practice in Orlando, Fla. I am married to my college sweetheart and have four children, ages 15, 13, 10 and 4. I have a fricking great life. My job gives me time to do other things I really like to do. I get to coach my kids in multiple sports. I have time to serve at my church. My hobbies include all Gator sports (basketball is my favorite) and running marathons. I love dentistry and have a great passion for it. That’s enough about me.

Like I said, I am trying to get a lecturing thing going. My favorite thing to talk about is posterior composites. In my journey (that sounds corny, doesn't it?), I have come across a ton of products that I don't think the masses know about. I joined a group of dentists (called Catapult) that reviews products and gets sent a bunch of info, and we have teleconferences about products and whatnot. So, between the group and what companies are coming to me with, I get to see a lot of products.

I am finding that the ins and outs of the materials are really fascinating. Research and the business of selling stuff move at the speed of light. Companies are trying to get product out and science is trying to research it, all going on behind the scenes of what we are doing every day. I subscribe to Operative Dentistry magazine (wow, this just sounds geeky) and I feel it is on the cutting edge of this. I feel like I am part of the process and it is pretty cool.

Today I want to tell you about a product that I am using that might be useful to you. I feel that talking about the nuts and bolts of dentistry is where I might find my niche in this blog. When I lecture, I find there are a number of dentists who are intrigued by the new products I mention. But these are things I have been using for years. Sometimes we get so much information from study clubs, mail-outs and magazines that we get a bit of "paralysis by analysis". We just continue to do the same thing. I’m not saying that this is all bad; if it works, you don't always have to change. Or maybe you learned so much in school and you are so busy jumping through all the hoops that the minutia of the differences are in the generations of bonding agents don’t seem relevant.

I began my posterior composite life right out of dental school. I saw a guy named Ray Bertolotti, DDS, PhD, in 1995, and he changed my life. I started doing posterior composites exclusively and was using an etch-and-rinse system (that is the new lingo for a 4th generation etch, prime and bond system). About 12 years ago, I started using a 2-step self-etching bonding system, Kuraray's Clearfil SE Bond (this would be considered a 6th generation).

I was fat and happy for a long time, but I couldn't shake my desire to etch the enamel. So it wasn't long before I went to a selective etch technique. That is, etching the enamel AND using a self etching bonding system. I did this for awhile and things were going great. I would try other things along the way, but I always went back to this.

Then another tweak that stuck for a long time was disinfecting my preps before bonding with chlorhexidine. They found that chlorhexidine disinfects and acts as an MMP inhibitor. MMPs are proteinases that are released during the etching process that have been proven to be the culprit of dentin bond breakdown over time. Chlorhexidine was found to inhibit MMPs, making the bond stronger for a longer time. There are other products that are MMP inhibitors also.

Then companies started latching on to this knowledge. Kuraray put an MMP inhibitor in the primer. Are you kidding me? The "gold standard" of self-etching primers just got better! So now they have a product that is like SE Bond on steroids. It is called Clearfil SE Protect. It has MMP inhibitors in the primer, but it also has fluoride in the bonding agent. It forms a great long-lasting bond and the dentin is being fortified by the bonding agent.

I am still selectively etching, but I get everything I want out of Clearfil SE Protect. And with this product, I can do things like this this:

I am so glad to be back.

John Gammichia, DMD, FAGD

Monday, July 21, 2014

It's Just a Tooth - Remove It

I really want to share with you all the awesomeness that was #AGD2014 Annual Meeting & Exhibits in Detroit! But alas, you’ll have to wait to see in it next month's AGD Impact. But I can tell you firsthand that, it was GREAT! I’m looking forward to the Golden Opportunity awaiting me in San Francisco!

Today, I had what Oprah calls an “Ah-ha moment.” That is to say, I was walking along with a friend during my hometown parade and I sarcastically said I should have brought business cards because I saw a lot of people IN NEED! As we continued to walk and talk, my friend questioned me about whether or not I accept the adult dental Medicaid plan provided under the Affordable Care Act. I simply said, “Yes, I do. But it’s VERY limited.”

Before anyone ostracizes me for taking PPOs, children's Medicaid and “insurance” at all, hear me out. My partner and I work really hard and although we do hate seeing the end-of-day adjustments, there are a significant number of patients that we HELP! We get them (with the plans’ help) into the office and present treatment to restore their oral health. Some find a way to pay the additional needs and some work within the confinements of their plan. For many in my area, this is the only way they can receive ANY necessary treatment. Also, we get a chance to educate and inform them.

Now, would I love to do 100% resin/porcelain? Of course. But, OMG, wait for it… I place amalgam! I know! (I feel like I just shared the dirtiest tale ever!) I believe there is always a time and place. If my patient can’t do the appropriate full coverage and I know I can’t appropriately isolate and restore in resin, then amalgam it is.

It isn’t always about reimbursement. We have been placing posterior composites at a downgraded fee for years in order to provide minimally-invasive, appropriate dental care to our patients.

While thinking about the limited plans, I feel that patients were given a bait and switch. Having been without benefits for many years, they were handed Willy Wonka’s Golden Ticket. They walk into the office beaming saying, “I’ve got dental insurance now and I am ready to have my work done!”

Unfortunately, then, you haveto sit them down (or, if you’re lucky like me, the treatment coordinator breaks the bad news) and explain that yes, although they have dental benefits, those benefits are limited. Sadly, breaking the news that a tooth is infected and needs an RCT is usually met with, “Does my insurance cover that?” When the answer is no, most will choose to have it pulled because “it’s only a tooth.”

It saddens me that in my young career I am already experiencing the frustrations of the red tape politics that is dental benefits.

Colleen B. DeLacy, DDS, FAGD

Friday, July 18, 2014

Young Buck, Meet Old Stag

The title refers to my father and I, so as long as he doesn’t read my blog, I’m golden!

I wanted to spend a few minutes of your time discussing how valuable a mentor has been for me in my dental career, with the hope that everyone will see the benefit in gaining such real world experiential knowledge.

All too often, I think we, as dentists, want to just do it our own way. We feel like we’re competing with our peers for the same patients and don’t want to share strategies with the enemy. We feel like we’re the greatest implant surgeon to ever walk this Earth, and that we have written the textbook on patient communication and case presentation (as I slowly raise my hand in admittance). I think this causes many of us to miss potentially game-changing relationships with mentors during our careers.

I went to a great dental school, where I feel they did their best at preparing me for the practice of dentistry. But its academia—there are politics, guidelines, rules of engagement. It’s just not the real world. Great learning experiences for sure, but not every day dentistry. The dean said to me, “Placing one or two implants as an undergrad under the supervision of the oral surgery residents won’t benefit you in the least,” and it still irks me. Oh man, if you could have taken my pulse rate during that first implant surgery in real life. I honestly am happy I didn’t faint onto the patient. I was sweating so much that I had to change my scrubs. It would have been nice to have an experienced resident (mentor) by my side for that one. This is where dad comes in.

I get the privilege of working alongside my father, as well as my mom, brother and sister-in-law, in my practice. I’ve been practicing for a little over four years now, and feel like I’m just getting into my “groove.” That point where you start to feel comfortable with the procedures, materials, day-to-day grind, and crazy patient questions-- yea those questions! It’s a fun and exciting place to finally be, but there’s always work to be done and valuable information to absorb from our mentors and peers.

I consider Dad my AGD instructor. He took me under his wing, showed me the ropes, answered my crazy questions, and even bailed me out midway through an extraction or two early on in my career. Not everyone has the chance to work with a close family member, but there are plenty of well-versed dentists in your community that are ready and willing to share their wealth of knowledge.

We know the absolute basics to get through daily dentistry when we come out of school—the rest is up to us to learn on our own. Or, better yet, alongside someone who has been through it, and already made the same mistakes. Do yourself a favor and find a dental mentor!

Donald Murry, DMD



Check out this AGD Podcast on the Value of Mentorship!

Wednesday, July 16, 2014

Employee Agreements

In the May 2014 issue of AGD Impact, Dr. Don Deems had a great article about how to take responsibility for employee behavior. It’s a great article and has some really great steps on avoiding the pitfalls of teams falling apart and how, as the leader of your team, you can create an environment that is fulfilling and positive. Of the many points he made, one that was mentioned was employee agreements. He did not expound much on this particular topic (no room in a one-page article), but this point resonated well with me.

More than 20 years ago, after I bought my practice from Dr. Roy Rasmussen (who, at 89 years of age, is still healthy, of sound mind and mostly sound body, continues to be an inspiration for me), I ran into the usual problems that we encounter so often. The receptionists were complaining about the assistants, the assistants were complaining about the hygienists and the hygienists were complaining about everyone. And they each told everyone, except the person they should have been talking to, that they were unhappy. It did not happen every day, but it happened with enough regularity to keep the office from reaching its potential, which hurt me financially.

I worked with a business coach and he pointed me to some wonderful training he had received from Tony Robbins, the man who brought us the “Personal Power” and “Get the Edge” personal improvement systems. There is one section that talks about an employee agreement. It is both simple and powerful.

Simply put, if Sally has a problem with Josephine, she does not tell Anne. Sally has to talk to Josephine directly. And Anne has to agree that if Sally does come to her with a complaint about Josephine, Anne is to direct Sally to talk to Josephine. That’s it. We all simply agree (regardless of position within the office) that Person A must talk to Person B and that Person C, if approached about Person B, must send Person A back to Person B without comment, but simply to support.

It all boils down to communication and relationships. I don’t expect my team to be best friends and socialize on a personal level outside the office. I do, however, expect them to be comfortable enough to sit down, face-to-face, in a private, supportive environment, and discuss like adults the issues that we are having with each other. It is simple, it is powerful and it has lead to peace in my office for many years. I now have team members (I don’t have staff, I have team members) who have been with me for 15, even 20, years. At first, I needed to be a neutral third party, sitting as an observer, to ensure the conversation remained civil and adult; that soon dropped as expected adult behavior reigned and became commonplace. The blame train ended.

Another important aspect in helping the employee agreements to be effective was personality testing and the information we learned about each other from this testing. I’ll discuss that in my next blog.

In the meantime, if you have not implemented the employee agreement in your office, try that now. And let me know how well it works for your teams.

Warm regards,

Larry Stanleigh, DDS

Monday, July 14, 2014

If I Knew Then What I Know Now

I recently read a great article titled, “If I Were 22: Embrace Your Ignorance.” The article is written by a Harvard graduate. He is looking back to when he was 22 and thought he knew everything, before he learned the hard way that he did not. I can relate to that feeling. I am 29 years old and one year out from dental school. I have been working in a private practice since July. The article rings true with what I’ve experienced over the past year.

After graduating dental school, I didn’t realize everything I didn’t know. I believed I was ready to step into the role as dentist, manager, and boss. As my one year mark approaches, I find myself looking back and thinking about what I would have changed or done differently if only I’d know this or asked that before starting. That’s the problem with hindsight: it’s 20/20. Since a lot of dental students are getting ready to graduate and begin their careers, I would like to take this opportunity to pass on some of the things I’ve learned over the past year.

I am not yet an expert in dentistry, and I don’t know if I ever will be. What I lack in clinical experience I try to make up for with patient care. Dental school teaches you the basics of prepping a tooth or making a partial, but there is a ton of on-the-job training that can only come with experience, and it all comes back to treatment planning.

CE is awesome! Take as much as you can to help fill in the gaps and get better. Read through the posts on Dentaltown, take courses, shadow other dentists/specialists in your area, and attend your dental society meetings.

I’ve realized that you never do the same thing twice in dentistry. Every time I think it’s just another crown, filling, or extraction, the circumstance, the mouths, or the people change. That’s why we have all heard the phrase, “We are practicing dentistry.” The moment you start to be overly confident or try to cut corners, it will back fire. Get proficient at doing everything the right way, and then try to improve your speed or technique.

Don’t be afraid to say you don’t know. Just make sure you go look up the answer. That’s why there are reference books. Keep them in your office and review them as often as you need. Google is also very helpful.

Finally, ask questions from everyone and treat everyone as a mentor. When I started working, people just assumed I knew everything about everything. We learn a lot in dental school, but classes and clinicals are no substitute for years of practice. So, ask your hygienists, front office, and office manager as many questions as you can. You can even shadow them for a day or two to learn about what they face every day. It is important to become knowledgeable in all the parts that make up a dental office, not just the dentistry.

As dentists, we are in a profession where we are surrounded with our successes and failures. This can be frustrating, whether you are a new graduate or a seasoned dentist. So maybe the best piece of advice I have is to remember that we are in a profession of life-long learning: there is always something new to learn.

Grant Glauser, DDS

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