Ownership... Arghhh!

Good Friday to you. Hope you have had a great week.

My father and I are putting the final touches on the "hostile takeover." Some people will call it my buying him out. Things have been going pretty smoothly, but the minute details are maddening. My father and I have always done things a bit differently. A conversation between us might go something like this:

"Hey, you wanna buy the rest of the practice?"
"Uh, okay."
"Okay, done."
"Uh, okay."
"Okay, done."

Then a week later:
"How much do you want for the practice?"
"How about X?"
"Uh, okay."
"Okay, done."

This is really how two dudes do things. I don't recommend it, because now we have to start talking about things like medical insurance for "an employee." What if this? What if that? How about if you? I think you need a professional to handle all this.

One thing that I have started thinking about is trading. I am not saying I do this, but what if one of his friends comes into the office? Can he work on his friend for free? Can he trade services?

What if (and I am not saying this is a real situation) he had an optometrist friend from the military? Say they met at McCoy Air Force Base in 1971, and since then my dad and our family have received eye care and got a professional discount of 100%. His family has received dental care for the same professional discount here. He is on a 3 month recall here and I think my father and his wife get eye care. I went to him once in 15 years. I would consider him my eye doctor but I don't have any issues so I don't go. (I know, I know I should go more often.)

I found out about their agreement when his office didn't charge me as I left. I wrote him a really nice note and told my dad about the service I got at his office. My dad then told me their relationship."OOOOOHHHHHHHHH!!!" I said.

I took one of my kids there last week and was charged, as I expected. So now the question becomes: what happens when my dad no longer owns the business? Do I have to tell this guy who hasn't paid for a dental cleaning in 40 years that it is time to buck up? What about all the other "arrangements" my father has?

And that is just one thing. Now that I will own everything, I have to change the credit cards to my name. The office card that we have now has 350,000 sky miles that are mine. And do I give him a credit card? (Totally off the subject, but I had a patient that came in today that has 1.8 MILLION sky miles. Wow! He could go on a first class overseas flight with his wife over 150 times.)

What about his lab? I am partial to my lab (no pun intended). Mainly, my fixed lab. I don't think his lab is nearly as good as mine. My guy is local and is around the office all the time. And his work is really nice.

What about vacations? I guess he gets none because he is basically an independent contractor. See what I mean about the details? And that is only what I could think of off the top of my head. Disability? No. Is he is the bonus pool like the other staff members? What about if he starts to have a crappy attitude? What if he starts talking down to patients? Well, it is my practice now and I have to police everything. Do I send him to the schools? Uh, no. Do I send him to Rotary?

I think my head is going to blow off. Thanks for listening.

Have a great weekend,

john

My Crazy Weekend

Happy Wednesday. I am sorry about not doing a blog on Friday. I gave my second paid lecture in Tampa. I thought I might get a blog in, but my fingers were shaking so much that I couldn't even type.

I left my house at 7:30 a.m. to take my son to school and headed for Tampa right after. The GPS said it was a one hour and 38 minute ride. So I would get there at 10 or so. I had a lunch planned with the Kuraray folks at 11:30 a.m. anyway.

I was driving with the air on and could feel myself getting hot. The air was freezing but I was sweating. My hands were shaking on the drive. This was not going to be good. I had not been sleeping well either. I don't know why I was so nervous.

I got there early, so I sat in the lobby of the hotel and worked on my lecture. (Yeah, adding new stuff to your lecture 1 hour before game time is always good.) I got myself so worked up over this thing. I think it was because of all the science stuff I added to lecture. I borrowed some slides from Kuraray and 3M and I just didn't want to sound like an idiot talking about this stuff.

I also added some composite science. You know - the difference between microfill, microhybrid, nanofill and nanohybrid. I am still trying to convince myself that I understand all this. I am pretty confident in the dentistry, but the other stuff is pretty tough for me, especially because it is ever-changing (and I slept through that class in dental school). But if I am going to be an "expert," I have to know this.

Lunch went well. The lecture also went pretty well and there was a pretty good turnout. The Kuraray people were there but both of them had work to do; after the first half of the lecture, they stepped out to do work. Totally understandable.

But the first half of the lecture was the buildup to the good stuff. Kind of like when you have a salad and maybe some chicken, but you know this restaurant has great dessert. You are just trying to get to that hot lava cake with ice cream. Well, the second part of the lecture is all photos of teeth – my wheelhouse.

The Kuraray folks got to see me fumbling and bumbling, trying to talk science. They didn't get to see me really shine. But I still think they liked me. We talked about doing more stuff together. They have great products, so I think it is a good fit.

I was wearing a suit and could feel myself getting very hot. I started the lecture with, “Is it hot in here?" I knew I couldn't take off my jacket because I was sweating through my shirt. Gross, I know. The audience was freezing and I was full-on sweating. But at the end, nothing but relief. I don't know where the time went. "Oh my gosh. I am done. Thank God.”

There were a lot of good questions and a good discussion. I talked to people afterwards. They came up to me and told me I had done a great job. I could see a lot of speaker evals, and they were all straight fives.

Even though I was so-so on how I felt, I think they really liked the lecture. Even though the sponsors didn't see the second part of my lecture, they will get the evals and that is all that matters.

That’s two down and 248 to go (I estimated it would take 250 lectures for me to afford the Replica Cobra and the mountain home I want).

But that was only the beginning of my weekend. Friday night we had some people over. Saturday morning I ran 12 miles at 5:20 a.m. Then I had to be out the door at 8 a.m. to get my oldest to his lacrosse game. I left the lacrosse game early to get to my other son's baseball game that started at 10:30 a.m.

I had a friend from dental school in town; he asked if I wanted to play golf with him. I got the green light from the wife. Tee time was 1:30 p.m. I thought about it and realized I haven't played golf, (without a kid or without it being a charity scramble) for over 10 years. It was fun.

You think that is a long day? Not quite. See, on Thursday, someone asked if we could use 2 tickets to The Lion King, playing here in Orlando at 8 p.m. So, straight from golf to the shower, then to the bar for an appetizer and a beer, then the play (very nice second row seats). The Lion King was really good, but seeing The Lion King for free was even better.

Next day, up and at ‘em for church. After church was a charity kickball tourney I signed the family up for. Then back home for a couple of hours before our Bible study started. Then I ran 5.5 miles at about 9 p.m. And then I crashed on the couch.

Now, that is an eventful weekend. Good thing I have Monday off. This time of my life is so crazy. I love every minute of it.

(my 2-year-old with Noah's gear on)

Every day, it is something different. I am telling you, every day!!! It is crazy, but awesome.

Soon I will be able to play golf whenever I want. But not now. See you Friday, john

Gray

Greetings,

I was finishing up a root canal on a long-time patient of mine yesterday. After my usual post-op speech, I was walking out of the operatory and happened to catch a glimpse of myself in the mirror on the wall. I know I’m not going crazy, but I don’t remember having this huge patch of gray hair. It literally looks like someone hit me upside the head with a bag of flour. I’m not kidding. I didn’t look like this last week, I’m sure of it. This is all happening at a supersonic rate and I’m pretty sure who to blame it on — my kids.

I have all girls. That sentence alone should be enough to explain the hair. Trying to keep up with different boys is exhausting. Looking back, I could have avoided all this worry and stress by never potty training them. Think about it: supplying them with diapers for the rest of their lives is a small price to pay if I don’t have to fight off boys. I can’t think of a better deterrent than having to help “change” your date in the middle of a movie. I can just imagine the look on the boy’s face when I hand him a diaper bag and say, “Here, you are going to need this.” I would have never had to worry about finding diapers that fit; they go from stages to pull-ups to Depends. We can even go green and just hire a diaper service that delivers cloth ones! The landfill would appreciate it.

I will admit that the “driving lessons” added a little speckle of white on the old roof top, too. I don’t know how many more times I could have said, “Stop stop STOP STOP STOP STOP!”

Perhaps, it’s all part of life: slowly losing your gut lining to the point that prune juice is the only thing that will stay down. I mean, when you think of girls, you think of “sugar and spice and everything nice.” To be honest, it has been nice. I wouldn’t change having my girls for anything. There are a wide range of emotions I have gone through (and still go through); from “beaming with pride” to “what have I done wrong?” Even though they are totally different, they each add to my gray in their own lovely little way.

Bill Cosby once said, “Gray hair is God’s graffiti”. He must have gotten me when I wasn’t looking. (Or maybe I was looking.) Below, you can see the lightning bolt of gray on the right side of my head. I will probably look like a Q-tip by the time they get married, but I wouldn’t have it any other way.

Have a great week!

Scott

I Can't Afford You

Hey everyone,

I hope things are going good for you. It has been crazy here. I am speaking on Friday, so I am so freaking out. I added some new material about the science of bonding and (I don't know if you know this), but I am not that scientific. So I have to learn this stuff and I am totally going out of my comfort zone. But then I move on down and talk about composites and realize I don't really talk about science here. That means I am going to have to learn this, too. I just want it to be great.

Anyway, it seems I forgot to put up the x-ray on Friday. I was talking about when to crown a cracked anterior. I told you that I won't consider it until I start seeing radiographic evidence of the crack. Well, look at this one.Pretty crazy, huh?

I met a very nice 65-year-old patient yesterday; we got along great. This patient came in for a new patient exam after having not been to a dentist for about 8 years. They had really nice teeth, with no decay and pretty good dental work in the past.

The last thing I do in my exam is a full perio probing. I was surprised to see that they had quite a few 6mm pockets. Turns out that in the past, they had lost both of their lower first molars. The upper first molars super erupted. So when the dentist went to restore the lower endutulous areas with bridges, the dentist also restored the upper first molars too. The dentist did root canals and then put crowns on them and did a very nice job. But all around all the dental work are 6mm pockets with bleeding.

I educate my patients on gum disease in the pre exam interview. I have a chart and I walk through the disease process to get them to understand their mouth. They are able to follow along with what I am going to do in the exam. By the end of the probing, if I have said, “Six, five, six, six, six, three, six, three,” the patient knows we have to talk.

I sat this patient up and we talked. I told them that I thought this was treatable non-surgically but that was going to take some work. I recommended a gross debridement and then two quads of root planing. This patient went up to the counter, made some appointments, and left.

They called about an hour later and said that they really liked the office but couldn't afford the work. This particular patient had dental insurance (but not very good insurance), and we guesstimated that they would pay a little less than half. So, out of pocket, a tad over $300.

This brought up much discussion in our morning huddle. I started to hear all the things the staff have been hearing. “Oh, I don't trust anyone to work in my mouth except Dr. Gammichia. But I get my cleanings at the clinic down the road." One patient got their x-rays at the insurance dentist and then got their cleaning here.

Here is my thing. We still have some work to do in the educating of patients. A cleaning is not a cleaning. But how would they know that? Is an oil change an oil change? Well, it is to me. And I know that it is not the same at every garage. Is a loaf of bread a loaf of bread? I think if you ask Merita and Country Hearth, they would say no. To me a loaf of bread is a loaf of bread. Probably terrible examples, but you get the idea.

My patients should know when the cleaning appointment is 60 minutes here but when they are rushed out of the clinic on their insurance in 15 minutes. That cleaning might consist of just a polish, or worse, having been cavitroned and then that’s it. It is what it is. So this patient is going to go to the dentist on "the list.” What will their mouth look like in four or six years? It will be a lot worse, and they will get shipped over to the clinic's perio surgeon. And that is going to cost a lot more than $300.

I know not everyone can afford the dentistry I can offer. I know that the economy is totally in the crapper. But I feel like I am fair. I have a service that is second to none (well, close to it), and we do work here that we are proud of. We get people better. Listen I am not crying a river. I have awesome patients that love me. And they tell me too (which makes my head really swell). I have a wonderful practice and love coming to work. I love my staff and I think they love me. Things are really good here But this is definitely an issue.

On the other hand, I had a patient came in today that works at an RV dealership here in Orlando. They sell RVs that range in price from $5,999 to $500,000. Guess how many they sell in a month. I have asked some patients that question today, and all the answers were all about the same. They all guessed somewhere between three and 10. The guy told me that in an average month they sell 100, with about 30% being of the larger, expensive kind. This was shocking to me. I can't sell 10 crowns a month to people that need them for their health, but they can sell 100 RVs a month?

What do you think? Are you hearing the same thing? Let me know.
john

Exit, Stage Left!

Remember that blog a couple of months ago about the associate that could be my grandfather that was working here? Just wanted to give an update on the semi-retired associate dentist that I was telling you about.

Well today was it; we informed him that it was the end of the road. It was not fun. I feel bad for him and his situation, but his practice style and philosophies were just too different and causing too much upheaval with the staff. Most of all, was the realization that even though were not doing the dentistry, our business could be held liable for any problems that arose. The practice owns the charts and the patient hands the money over to our business and they walk through our front door, so everything he does in some way reflects on us. That did it for me!

Most of the comments I got from the original piece about this issue said to “get rid of him immediately.” It just took us a little time to get there. Telling people that want to be here that we do not want them here is the part I hate about being a business owner. The bad part is that we hired an extra assistant to work with him; without him, we do not need her. She knew this could be coming, but I still feel bad. We are going to let her sub if someone is out and if a position ever comes open and she is available, we will give her a call. We are giving him a few weeks to wrap up cases and then it is done.

I hope that I am ever in the position that I have to work in my 80s. I am sure that bad things can happen, but that is have short-term and long-term disability out the yin yang to cover physical issues. I know one dentist that does not believe in insurance. I hate paying the premiums, but I would hate even more needing it and not having it.

We are saving for the future: 401k, used to do a Roth, a few other little things here and there. I probably should be doing more, but if I stay healthy, I should be able to work another 25 years and still retire before 65. I know that more issues will arise even after he is long gone, but we will have to put out the fires one by one. I see now why so many dentist partnerships break up. It is hard working with a dentist who just does things differently than you.

Well, I am not sure how we are going to handle bringing in another dentist in the future if one approaches us. But I know we have learned a lot from this little adventure.

Crack in the Amour

I totally forgot to talk to you about the Masters. I will do that and then I will talk to you about a case I did this week.

First of all, if you are a golfer, YOU HAVE TO GO to the Masters. Everyone says they would love to go. Just go, for crying out loud! It’s just money. This year I was given a ticket, but as you may know, I went about 4 years ago with my father and paid about $270 for a ticket. It was so worth it.

My father said, "I didn't think I would ever get to do this. Thank you so much for taking me." I guess his generation still thinks something like this is unattainable. Ours is the "Let’s do this" kind of generation.
If it costs, so what?

I am trying not to retire at 60 or 65. My plan is to retire a little every year (which is why my wife and I go on big trips). I don't want to wait to do something that is only $270. I realize that is a lot of money, but if you could have seen my dad’s face, you would understand.

Anyway, this year I got a ticket and my buddy bought one ($350). We drove up after church on Sunday. I stayed at a friend’s house that lives about 5 miles from Augusta National. Augusta is kind of a one-horse town but it comes alive for a week in the spring. The club is exclusive and the tickets are hard to get, but once you are in, it is easy. Parking is free. Sandwiches (palmetto cheese) are $1.50, and beers and cokes are $1. No, that is not a misprint.

One thing that gets you is the merchandise store. The only place to get Masters shirts and towels and tees and ball marker stuff is at the Masters. It is not that they charge a lot (most of the stuff is reasonable), but you just end up buying a bunch of stuff.

We got there at 7 a.m, and hadn't spent any money on anything other than gas. I left the merchandise tent at 7:30 a.m. and spent $500. That is also not a misprint. In my life I have spent $500 on clothes but... Two shirts for me, one for my wife, one for my dad, two t-shirts for a couple of friends, a hat and I got a pullover (which was really nice) and BOOM $500.

I just can't describe it. The elevation is unreal. The people are nice. The golfers are thrilled to be there and very friendly. The grass and the course are almost perfect. Remember, if you are a golfer, YOU HAVE TO GO. Doctor’s orders. Anyway, here are the photos.

There is only one way in and this is what it looked like at 7:55 a.m. They open at 8 a.m.

The madness that is the merchandise shop.

Lee Westwood at hole #3

Tiger and Mark O'Meara

The Big Oak by the club house

Hole #10, where Bubba Watson hit that miraculous shot to win the tourney.

This is Amen Corner: the green of #11 is on the right, famous #12 is in the middle, and the tee of #13 is way back on the left.

Now, the blog topic. I have a rash of central incisors that have had vertical cracks in them. In the last couple of months, I have actually recommended crowns to quite a few of these people. Now, you know how conservative I am. But these cracks have been palatable.

Usually when you see craze lines you run your explorer over them and they’re smooth. These really made me think the tooth was cracking in half. I could see the crack in the x-ray. I went back 4 years and looked at their bitewings; I could see the crack getting bigger.

This is a first for me. I have never prepped a central incisor because of this crack. I really felt like the vitality of this tooth was in danger. No symptoms but a huge crack in their front tooth.

I have a woman coming back in a couple of weeks. I recommended both the central be done and another one be done. I prepped this tooth yesterday, and much to my surprise, the crack continued. After I got the enamel off the facial, this allowed more light into the tooth and I could start to see the crack on the ling. So instead of a veneer, which I considered, I did a full coverage crown. You can see on this photo that the crack is still there in the prep.


Here is the picture of the tooth before prepping. Looking at this photo, I know that the other central is definitely in danger of the same thing. I told the patient this. But there is no radiographic crack yet.


I didn't know what to tell this patient. I didn't know if I should tell her that this tooth could possibly act up. I don't know if this tooth is going to need endo in the future. didn't know if this was the ultimate treatment. Does it matter if I do an all-porcelain crown or should I use PFM?

Crazy, but I am going to look at these cracks a lot different now. I still don't think I am going to treat every one of them, but I think if I can see the crack on the x-ray, I definitely am going to start planting the crown seed.

Do you guys see a lot of this? Have you seen someone that has lost a central because of this? Let me know.

Have a great weekend.
john

Now, I Need Your Help

Hey all,

Hope everyone had a great Easter. I went to Miami and spent Easter with my wife's family (who I consider my family). We had a great time. One thing though: no one in my family likes golf. I sat in the living room and watched The Master's all by myself. It was awesome. Too bad I didn't have anyone to share it with.
Their thing is baseball, so I can say I watched a ton of baseball.

Listen, I reread my last post and I think I might have misrepresented Triodent a little. Here is the thing: Triodent is getting bigger. They had something like 10 reps in the USA. One of the ways they were getting the word out about their products was by supporting lecturers (like me). And it worked; their products are doing very well. Recently they have come into an agreement with Ultradent to distribute their products. Seems like a win-win.

Now, on to the topic de jour. I want to ask some advice. You know dentists are basically on islands. Things like this help, but for the most part, most of us are doing things on our own. So, I don't know what is normal sometimes.

For instance, you take a tooth out and 4 weeks later there is a bone spicule sticking out of the patient’s gums. You go in there and take it out. Do you charge for something like this? Or, better yet, what if they have a dry socket? Not your fault. But next thing you know, you are changing dressing two, maybe three, times. All of this I do for free. But I have to tell you that I can't remember the last time someone came to me with a dry socket. It must have been over 6 years ago.

How about this? You do a deep filling. The tooth starts to hurt, so you relieve the occlusion (free). Then the tooth doesn't stop hurting. IT is throbbing and very tender to the touch. Uh oh. This bad boy needs a root canal. So you do the root canal and there are no problems there. Do you charge for the access filling?

Some of you would then recommend a crown (I think that if it was small enough to do a filling, just because it has an access filling doesn't mean it needs a crown, but we won't get into that). Do you charge for the build-up to fill in the hole left by the root canal? What if you do a crown and the same thing happens? Do you charge to fill the access hole?

What if you do a denture? We all know that there are two types of people that get dentures. The first type is the patient that you deliver the denture to, but then never see again (I have just read about this patient in books). The second type is the patient you deliver the denture to, and then this happens:

You ask if there are any high spots or areas that might be rubbing. The patient says that everything feels great. But, a week later, they are back. You do some adjustments and then the patient says, "That feels great. Thanks for everything. You are the best."

A week later, they are back. You do some adjustments and then the patient says, "That feels great. Thanks for everything. You are the best."

A week later, they are back. You do some adjustments and then the patient says, "That feels great. Thanks for everything. You are the best."

A week later, they are back. You do some adjustments and then the patient says, "That feels great. Thanks for everything. You are the best."

Here is the thing. My father says that 3 adjustments come with a new denture. Fine. But when do you tell the patient this? Before the denture is made? All you are doing is telling them that things may not be perfect, but give us three times to fix it. How about after you deliver the denture? Or do you tell them 3 adjustments are on the house after the second adjustment? Then it looks to the patient like you think he is crazy.

How about things like a baby tooth? If I have to take a tooth out on a 5 year old and it has big time root structure, that is easy. I charge them full $100. If the tooth is wiggling there and the parent wants you to take it out before it is naturally going to come out (even though you tell them that the thing is like a week away from coming out), what do you charge for that? If you go in there, put a 2x2 around it and take it out with your fingers, do you still charge $100? I think this is unfair and I guarantee they are going to think that, too. I think even $75 might be too much. I mean, the mom didn't even get a chance to sit down in the reception chair when the kid comes out.

I don't know. I know I am a wuss when it comes to valuing myself. What are you guys doing? I know I asked a lot of questions, but the more you answer, the better I (and other readers) will become.

Thanks. Have a great Thursday.

john

Popcorn and Wine

Greetings,

I hope everyone is happy and healthy as we speed through 2012. For those of you who read my “Big Valley” blog, a quick update: we have running water! There is still a lot of construction to do, but being able to flush a toilet is something I never thought I would take for granted.

I have had stomach issues for years. I have been to every GI doctor you can think of. I have had every prodding and poking test they can come up with. I am usually given some sort of acid reducer and told to relax because most of this is being brought on by stress. Well, that could very well be. I do tend to hold things in, so it made sense that stress would be a factor in my stomach problems. As time went by, the whole “gluten” sensitivity issue was brought to my attention, and thinking back, I could really associate my stomach pains to eating a meal with bread or pasta, etc.

About a year ago, I decided to try the gluten- free diet. Believe it or not, I felt really good. The pains were not nearly as bad, so I thought I was on to something. =I was very strict (or at least I thought I was) about my gluten intake. I would have a gluten- free chocolate protein bar every morning with my coffee, or a gluten- free whey protein shake. Sometimes I would have scrambled eggs and bacon, being very careful not to have any bread. Anyone who has had these pains knows exactly what I’m talking about. It’s almost debilitating. Staying up all night or sleeping on the couch. This gets to be tiring after years and years. I couldn’t figure out why I was still miserable if I was eliminating all the gluten from my diet.

Recently I decided to take a blood test that would determine if, in fact, I was sensitive to wheat and gluten. The results were more than shocking. Of course, (which I could have told them) anything with wheat and gluten came back as a high reaction. But, here is the list of all the other things I can never eat again for THE REST OF MY LIFE:

Eggs
Milk
Whey
Chocolate
ALL dairy
Asparagus
Green peppers
Pork
Almonds
Yeast (No beer? Are you kidding me?)
Cod
Crab
Avocados
Kidney beans
Coffee
Honey
Sugar

I will let your brains absorb that for a minute and see if you come up with the same thing I do. I think most of you figured it out. My diet now consists of popcorn and wine. They are the only two things NOT on the list! I have been going to the movies more, which is kind of fun (Hunger Games was good). Ok, it’s not that bad, but close. It’s been about 10 days now and I have been really good at not having any of those foods. Believe it or not, I have not had one stomach problem. I guess from now on, I will have to determine if a bad stomachache is worth eating or drinking something I shouldn’t. I will have to choose wisely.

Have a great week and think of me when you go to the movies.

Scott

OSHA

Is it just me or did Easter come up pretty fast? People are calling and asking if we are open today and I am wondering why they would be asking that. Duh! It’s Good Friday. Life has been so crazy that I have forgotten to look at the calendar. Usually the house is decorated and there is plenty of notice from my wife and staff, but apparently it has been the same for them.

There are a couple of things going on in the lecture front. I didn't know if it was out yet, but Triodent (the ones that are sponsoring my lecture) have basically sold their USA distribution to Ultradent. So Triodent is now Ultradent. They said to me that as of May 1st, they couldn't honor any of their commitments.

I called Ultradent and asked them if they plan to honor Triodent’s commitments. And basically they said no. They politely said that they have to see me first. I can understand that, but it still stinks. Uh, well, I had about 6 lectures planned that they were supposed to pay me for. If I have to do a couple of lectures for free then so be it; I need the experience anyway.

But another trail got hot while all this was happening. Kuraray (whom I tried to start a relationship with before because I use their products every day) called me. Turns out they might want to sponsor me. They are sending their clinical director from Arizona and regional director from Atlanta to come see me speak in Tampa in a couple of weeks. And they want to have lunch. Uh oh. Oh my gosh - the pressure. I don't know if I am any good yet, considering I have given the lecture once. Well I have been working pretty hard on the lecture lately. I will let you know how it goes.

Today I want to talk to you about my experience with OSHA. I am going to come out and say it: I have been bad. I think you are supposed to have a staff member in charge of doing ALL things OSHA. In the last 5 years, we have had some staff turnover. People have retired, people who were part-time needed full-time. Now that the smoke has cleared, we began to realize that we have not done the things we need to do in a loooooonnnnnngggggg time. We called in a consultant (a past OSHA employee) to come into our office and get us back up to snuff before the hammer comes down on us.

A couple of things about this. This guy makes every infraction sound like a "they can shut you down" infraction. This office is 30 years old, and we have had the same electric plugs for 30 years. He wants us to change 30 regular plugs to GFI plugs because they are within 6 feet of water. We had to buy log books. We have to have paper employee files. We have to have everyone's immunizations on record and, according to him, they have to be under lock and key (and if you don't have the actual paper from the doctor you have to sign a form saying you swear to have the right immunization). We have to have an emergency exit route drawn up and posted. We all have to have completed a class so we know all this and we have to sign something saying that we all know where the log books are. We are apparently using the wrong kind of sharps containers (they have to be clear). We have to know who manufactures our red bags and their phone number and put it in the log book so OSHA knows we are using the right kind. All of the soap and cleaning supplies have to be labeled with a MSDS tag.

There has to be an eye washing station. We have one, but the caps covering the things are gone. He said we have to replace the caps. First question: Why? Second question: How the heck are we going to find caps for an eye washing station?

This little update is going to cost us over $2,000. I mean, changing 30 GFI plugs is going to be expensive. We had to buy all the appropriate log books. I have to pay for everyone to have the OSHA class. Arghhh!!!

I know OSHA is important. I know they are trying to make me safer and I know that I should be up to date on all this. But man, can they nick pick you to death. I can see how this would make some dentists say, “Just forget it .We’ll worry about it if they come.” My father has been doing this for 41 years and has never seen an OSHA rep (knock on wood).

And just when we are in the middle of all this, the fire chief comes around and starts inspecting our place for fire safety. We have to have a new sign out front to tell the firemen about the building. We have to change two EXIT signs that are not working properly. And we have two extinguishers that are almost out of date.

When I got into this business, all I wanted to do was help people. They never told me about this stuff in dental school.

Anyone have any "I'm going to shut you down" OSHA stories? Come on, misery loves company.

I hope you all have a blessed Easter.
john


Remember the reason for the season. Easter is a day where we celebrate Jesus dying for our sins (on Friday) and then rising from the dead (Sunday), essentially defeating death and opening up the gates of heaven for us. It is a great day in the Christian world (and, of course, there is lots of candy). It is the most meaningful holiday of the calendar for me. If you have any questions about Easter or want to contact me about anything, I am always available at Jgammichia@aol.com.

Adhesives: The Game

Hey all,

Sorry about Friday. My editor told me in advance to send the blog to a different email, and I didn't. So I sent this blog into cyberspace only for it not to be seen until after the weekend. My fault.

The sting of last weekend’s loss is still dull, but it is going away. I think watching the games being played is going to make it worse again. We should be there. I told my friend that watching basketball this weekend is like seeing your old girlfriend with some other guy at a dance. BUT I did get Masters tickets (just Monday's practice round). I am so excited. Hopefully the azaleas in full bloom will make me forget about the pain in my heart.

I will tell you about my Masters experience on Friday, but here is a tease.



I am not reading as fast lately. I am so busy wearing all my hats that I don't have that much time to read. But I did finish the book Samson and the Pirate Monks. It was okay. It is about this pastor of a church who was addicted to sex and pornography. He spent over $300,000 on prostitutes and porn. The book is more about his recovery than his addiction. I think it would have been better if he detailed his addiction. Society nowadays wants all the dirt.

I am now reading The Boy that Came Back from Heaven, a book is about a father and son. They were in a car accident and the boy was hurt badly (his head separated from his spinal cord). The doctors told the parents that no one has ever survived these injuries. I think the story is going to be that he survives and he talks about his time in Heaven. I have heard so many people talking about it and someone finally gave it to me, so I picked it up. I will let you know.

Okay, where were we? I have all this new knowledge of the science behind the new generations of adhesives. And like most things that are new to me, I usually bounce them off the experts. I usually go to two or three different places. I go to one of the top guys at the University of Florida College of Dentistry Biomaterials department. I go to REALITY and ask the question on their expert forum. And I go to Clinicians Report.

So Clearfil SE Protect? I went to CR and looked up the last adhesive study:

Fourth generation bond strength..................Dentin 39 and Enamel 34MPa
The best 6th generation (Peak)...................Dentin 50 and Enamel 46 (Wow!)
SE Bond..........................................Dentin 47 and Enamel 38
SE Protect.......................................Dentin 25 and Enamel 30 (Hmmm)

I wrote to the author of the article and I asked him how he felt about giving up half the bond strength just to add the bromide in the solution. He told me that he talked to Kuraray (manufacturer of Clearfil) and they said that they have a problem with the way CR did their study. So now who do you believe? Do you believe the manufacturer or do you believe the independent study?

I did call my contact at Kuraray (don't I sound so high society?) to get an idea of how Kuraray feels about the above. How does one company get one result and one company get another? He said he was going to call me about it.

Then I wrote my researcher in Gainesville and asked him what he knows about MMPs and how he feels about putting bromides or CHX in the solution. He said, “"Whether or not MMP means anything, I am not so sure. For example, in a recent study from Leuven, they could not detect any MMP when Clearfil SE was used, but found it after the use of Optibond FL. Personally, I am far from convinced that it plays any role at all. The reason is simply that Gwinnet did some studies where he had removed all collagen by use of collagenase, and the bond strength was as good as with collagen. I personally believe that one of the keys is to get an intimate contact between the primer and the hard dentin surface and then get rid of moisture before the resin is placed and cured. Under such conditions you form tons of van der Waal bonds. If water to any greater extent can reach that region, the van der Waal bonds may fail."

Oh man, now he is saying that collagen might not be the deal at all. So do we listen to the company, the independent study, or the researcher? Confused yet?

Listen, me and you are the same. We sit back and do our work. We are dentists. We want to do good work and do the best we can for our patients. There is no way we can get involved in all the research and all the back and forth that is obviously going on in the product manufacturing side. And if you do try to learn everything, you can see that your head will spin right off.

This is almost like a game. But who is the referee? Who is going to tell me THE TRUTH? I don't know, but I will keep working on the answer. And I am hoping it is not MONEY.

Have a great week.
john

Shades and Cosmetics

Spring is here. Everything in north central Florida is neon green. The weather is nice enough to break a sweat in shorts and a tank top, so we must jump in the pool to cool off. Hope that does not make any of our northern readers to upset.

Let's talk about shades and cosmetics. I have a case on a very sweet girl I am trying to get nailed down on No. 7. Let me go over the history of this tooth and how we got to where we are today.

This tale starts about three years ago when “Susie Q” walks in the door with No. 7 fractured just above the attached gingiva. The tooth had previous endo with a build up and no post from an unknown provider. The tooth/crown and buildup had fractured. We go over the options and decide a post and crown would be needed, though somewhat guarded due to the limited ferrule effect.

Everything goes well, at least for about three years. Then she comes back one day with the root fractured No. 7. Now, after a lengthy discussion, we decide an implant was best since three-fourths have had very little restorative work. My office refers her to an implant place and everything goes well. After initial healing, we place a temporary to help soft tissue development. After a few months everything is going well and we start the restoration process. The patient has thick biotype tissue and everything is healing well. We end up using a Atlantis custom abutment with a layered zirconia crown.

Now the fun begins. No, it is not the dreaded black triangles of death! But, the shade and cosmetics of the crown is driving the patient and me crazy. After about six shade checks, multiple photos, the lab sending a ceramist over for a shade match, and the patient traveling about 75 miles to the lab for an in lab shade match—we get it.

Before she goes to the lab, I tell her to look at everything, the shade, phonetics ... I mean everything! I tell her not to leave the lab until she is totally happy with the crown. She returns from the lab and everyone agrees the color is great, finally. It is cemented and everyone thinks it looks great.

Well, that does not last long. A few phone calls later, the patient decides she needs me to look at it. She now thinks that it is on crooked and the contour is not right. She has gotten herself worked up in such a emotional mess over the weekend about it. “Susie Q” says her family thinks it looks great and they all like it. However, she is just not sure if she likes it! There is a little too much roundness to the facial and the incisal edge is a tad to flared.

I tell her that there is only so much I can do to change it, and that all the shading is on the surface so the color could be effected if I adjust it. Reluctantly, I break the glaze and adjust the crown. I make a few changes to the labial and line angles and she thinks it looks better. I am not sure how she will feel in a few days, but at least now she seems happy.

I get a case like this every few years, and it is always a single anterior on a female. I always tell them before we start that one of the more difficult things for a dentist to do is match a single anterior front tooth! I warn them it could possibly take several shade checks and visits to get it right. I want to warn them and set their expectations before beginning so it does not look like I am a bumbling idiot every time we have to send it back. This crown takes the cake. It has been the most difficult one in a while.

I know there are all kinds of gadgets out there for shade matching. We look at them in natural light with neutral backgrounds, all that text book stuff. Sometimes the human/emotional factor will override everything. I want to make my patients happy; however, chasing perfection with a patient can make you go crazy at times—especially when it seems perfection is a moving target.

Have a good week!

J.J.