Call 911

I am feeling so much better. I was so sick when I wrote Wednesday’s blog that I was begging for the day to be over. By about 2:30 p.m., I started to sweat while working. About 20 minutes later, it was like a miracle. I was feeling so much better.

I had already had made a doctor’s appointment for the next morning. I went to my appointment anyway and was feeling pretty good by the time I got there. She gave me a Z-pack because she thought I might be harvesting a post-viral bacterial infection. My glands were still swollen and I was still having pain on swallowing. A day and a half later, I feel like a million bucks. It makes me not take feeling well for granted.

Today, I was having a normal day. Got patients coming and going. Some were actually walking in. A man walked into my room and he was swollen on the lower left side. He told me that he hadn't slept at all last night. We took an x-ray and then I started talking to him about his medical history. He has had three strokes. He is on an antiplatelet medication, aspirin, and about 4 other meds for his heart. Oh, and he is 56 years old.

Looking at the x-ray, he has a molar crown that has history of a root canal and crown with through and through decay and abscess all around both roots. The tooth needed to come out. This guy, although not in good shape medically, is having a dental problem that could possibly make his fragile health even worse.

I looked in his mouth and pushed around looking for spontaneous bleeding. Things looked okay. I wanted to get this tooth out, so I told my assistant I wanted topical. She looked at me and said out loud, "Where do I sign to say that I am not responsible?"

"Shut up and stop telling me what to do." I numbed him up and realized he had lost his color. I asked him if he was okay. I started to talk to him to make sure he was responding to me. We were having a conversation. I started to numb the tissue around the tooth. He told me that he has always hated the dentist and always gets nervous around needles. He asked to sit up, and this is the time I thought I might be in trouble.

He was sitting up and we were still having a conversation. But for safety’s sake, I called out to the reception area and had his wife come back. She was a trooper; she had obviously been down this road before with him. She started talking to him and he started to fade. He was sitting up and passing out at the same time. She said, "I think you better make that call." WHAT!!!????

I said as calmly I as could, "You mean call 911?"

And she said, as calmly as she could, "No, I mean call Domino's pizza and get some lunch while my husband is here dying in your chair."

No, she didn't say that. She said, "Yes, call 911."

While I was talking to the operator, he had come to and started feeling better. He was saying all the things that dudes say when they pass out. "Did I pass out? Are you going to make me go to the hospital?"

He really was fine and he was talking, but I still put in him in the Trendelenburg position and had him breathe oxygen until help arrived.

The guys came in and did their tests. They hooked up an EKG machine and blood pressure cuff and did their exam. Heart was good; blood pressure was little high but okay. Then they asked him what he wanted to do. He looked at me and asked me if I wanted to go ahead and finish. I said, "No fricking way."

The paramedic said, "Everything looks okay, I would recommend you going to the Primary Care physician when you get a chance. But for now let’s have you just stand up and see what happens." He stood up and, about 3 minutes later, he started to fall over. We made him sit down and the paramedic changed his tune. "I think you should go ahead and ride in bus to the hospital." They brought the chair in and wheeled him out.

I guess if you are going to have an emergency, this is the kind to have. You don’t want the kind that require CPR. Or the kind where lawyers have to get involved in later. Having the guy talking and laughing on his way out is definitely the way to go.

Just a great way to end a really crummy week. Now I have a good reason to hit the sauce tonight (I am not going to tell you how the AGD feels about drinking your stress away. I make that up by the way).

Have you had this happen to you? Anything crazy? Tell me, tell me.

Have a great weekend.
john

I'm Sick of It

Hey all,

Hope everything is well. I just watched Despicable Me this weekend. Now, that is a good movie. I didn't think it was going to be good, but it is. I really liked it. I finally finished reading The Book Thief. It was a huge success you know, "National Best Seller." I didn't think it was that good.

I have just started reading Samson and the Pirate Monks. This book is about a pastor from Tennessee who was a sex addict. He claims he spent over $300,000 on porn and prostitutes, all while holding a job as a senior pastor. It is about his addiction and his walk to recovery. He was a guest speaker at our church, so I bought the book.

This time of year in Florida, the weather is so hot and cold. Literally. It was 48 this weekend and it is 83 right now. Yesterday it was raining; today is beautiful. This weather takes a toll on peoples’ immune systems. Sickness is running rampant around here.

One of my hygienists got sick about three months ago. It started with a cough that lasted about a week. You could tell she was fighting it off. Then it turned into a full-blown sickness. Of course, she was still coming to work and everyone kept telling her, "Girl, you need to see a doctor." Then the other hygienists started sniffling and fighting it off. Then it started at home. One of my kids got sick and the others slowly followed. First it was the baby and we thought he was teething. But then my daughter was fighting it off like mad.

So both areas of my life are filled with snot and coughing. Then I started to have pain in the back of my throat. You know the kind: when you swallow, you feel like someone is shoving an ice pick in one spot.

And this has gone on for a couple of weeks. It is bad in the morning and I take an ibuprofen. Then I manage through the day and take another ibuprofen before I go to bed. Meanwhile, there is a third person at my office that is now hacking. She sounds terrible. "Girl go to the doctor."

Now my third child and my wife are sick. I don't have a chance. But I remain strong. I am a runner and I don't think I have been really, really sick in about 3 years. My body is a finely tuned machine (well, this is what I tell myself). But the sore throat persists. I am still running and feeling fine except for the ice pick in my throat.

For the last couple of weeks, I have been stressed out and unable to sleep. I have been waking up in the middle of the night sweating and not able to get back to bed. I start worrying about paying all the bills and buying out my dad.

So, with the combination of the ice pick in the throat and the 12 hours of sleep in four days, I have succumbed to sickness. My whole body aches. I am freezing cold all day and all night. I take steaming hot showers and I am still cold. I wrap myself in 3 blankets and I am still am shivering. But my life doesn't stop. I feel like I have to go to work.

I had to coach yesterday too. I went from work straight to the ball field and dealt with 15 kids. Then straight home, where I was asleep by 7:30 (which I haven't done since I was eight). I woke up after 11 hours of sleep and I felt a little bit better. But here it is, 2 p.m., and my body is begging for bed.

Looking back on it, where did I go wrong? When do you tell your sick, snotty, coughing staff to go home? You have patients that have changed their schedule around to get a cleaning. They keep the kids home from school and plan their day around it. They take off work, and then you call them in the middle of the day and tell them that your hygienist went home early because she was sick. They put on a nice face, but inside they are ticked and inconvenienced.

On one hand, you want your hygienist to put a mask on, throw in a cough drop and gut it out. I mean, cancelling a whole day of hygiene can't be good for business. You lose that production and then you might tick off you patients in the meantime (as I alluded to earlier).

Other times you want to force them to go home. But the hygienists are dealing with the same things you are dealing with: bills, family, stress. If they go home, they don't get paid (some of them haven't been here a year to get sick days). If they do have "wellness days” and go home, then they lose those days. And just like you and me, they don't want to use them except for our vacations during the summer or Christmas.

That all seems fine until I am sick. I am sitting here miserable and shaking. I am so cold and my body is rejecting being out of bed. And all because they didn't want to go home. Ugh. I feel like crap and all I know how to do is blame my hygienists. It kind of makes me feel better.

Have a great Wednesday,
john

Dentist vs. Physician

Let’s talk about the timeless age old debate. Which came first - the chicken or the egg? No, the real debate: is a dentist a doctor or is a physician the only real doctor? I think maybe the only other health care doctor other than a dentist that takes more of a beating is the chiropractor (as Rodney Dangerfield stated, “I get no respect!”). If you read my blog last week, I ended it telling you to go to YouTube, look up Dentist vs. Doctor, and watch the extra normal video.

My wife works at a hospital as an RN part time. She has commented that when people hear her mention Dr. Joyce, they ask what type of doctor he is. When she responds they say, “Oh, he is just a dentist!” This will make more sense if you watch that video. It appears from the comments that some physicians and dentists take this issue very seriously.

We have all sorts of doctorate degrees: PhD, PharmD, DMD, DDS, MD and so on. Each of them specify or indicate an advanced level of education and knowledge that come with the title. By no means do I think or feel I am a physician. I have a Doctor of Dental Medicine degree. I spent 4 years after undergraduate and then another two years of formal accredited education learning about the diseases and conditions that are associated with the oral cavity, head and neck. When I sit back and think about it, what I find amazing that not only do I examine and diagnose, but also perform surgery if needed (removing and repairing living human tissue), sometimes all in the same hour. Someone has to be well-trained and knowledgeable to do that and cause no long-term ill effects. For that accomplishment, one is worthy of the title Doctor!

How many times have you heard about someone going to their internist or general family practitioner with a suspicious looking mole and having it removed and biopsied. This is almost never done anymore. Sorry Michael J. Fox, but Doc Hollywood delivering babies and setting a fractured arm in the same day just doesn’t happen. (I used this reference because the town they filmed that movie in is just up the road from me.) It is an instant referral to the dermatologist and you know the rest.

Most of the physicians that I know understand and respect what we do. They know they need us and we need them! I think most of this inaccurate perception is from the general public. We are just dentists and you can pick one up at any Saturday morning garage sale. I guess this all started back in history with dentistry springing off from barbers. It has been the scarlet letter we have had to bare for many years. Being the redheaded step child of the medical/dental community has its advantages. When it comes to health care overhaul, dentistry has stayed out of the spot light. We have had to deal with insurances, but dentistry has still been able to operate as more of a small business model with not as much government regulation.

This issue has lead into the reality of compensation. I cannot quote or verify this info, but the last reports that I saw had the general dentist making considerably more money than a general family practitioner. I think a lot has to do again with government infringement on medicine and insurance dictating fees. Private practice medical doctors have a business to run and profit margins. Many MDs that I know have to see sometimes hundreds of patients a day to pay the bills.

Have you heard that dentists do not save lives but real doctors do? I have, on numerous occasions, drained a space infection that left untreated would have killed someone. This happens in third world countries, but not in our society due to the care. Dentists know that typically when a patient shows up to the E.R., it is usually a six hour wait and a Rx for an antibiotic and an analgesic, and they are told to go find a dentist. How many times does a podiatrist or psychiatrist directly save a life? Most physicians besides surgeons, oncologists or emergency room physicians probably directly save lives. All the rest are just like dentists.

I did not want the responsibility of having to be tied to a pager or on call for the hospital rushing out at 2 a.m. for an emergency. I know not all physicians have this lifestyle and dentists do have emergencies. I like the fact that I am out every day at 4 or 5 p.m. and go work out or hang out with my family. Dentistry can be very stressful, but quality of life is important.

I heard the jokes in dental school. Dentists are just dropout medical students that could not hack it! I never applied to medical school and only know one person in my class of 70 or so that was a flunked-out med student. I actually know some that dropped out of dental school and went to med school because they did not have the hand/eye dexterity. Imagine trying to carve a precise 5mm x 5mm x 5mm deep box in the side of an object in a dark wet hole and while looking in a mirror with an object that occasionally moves and makes unpleasant sounds. Sounds easy, right?

I think young people are starting to figure out some of these details. I attend a presentation yearly for the University of Florida, College of Dentistry that talks about admission statistics. The number and quality of applicants has been going through the roof the last ten years and it has become ultra competitive. They have a 4.0 GPA, they volunteer , etc… Many of these students could probably go to any medical school they wanted but chose dentistry as a career choice. This should tell you something.

We could go on more about this subject, but I feel this is mainly a misconception from the public about who we are and what we do (not from physicians). Some physicians may think and act like dentists are second-class citizens in the health care world, but for the most part, they appreciate us. I also know some dentists that think they are physicians and walk around like they are doing brain surgery every day. Dentists and physicians are different animals, but both worthy of the title of Doctor. Most physicians I believe value and respect us and want a dentist on the front line of battle with them. I feel the same.

Have a great week,
JJ

Ferrule Effect

Hey all,

First I wanted to address my last blog. I was angry and I might have sounded a bit harsh to corporate dentists. I might have brushed them all in the same stroke.

I thought there were some great comments, here is one:

First, let me say that I think your blog is great dentists both young and old. But I find your latest post a bit disturbing. I have worked for a group practice and private and if you are naive enough to think that over treating is just occurring in the multiple-doctor practices then you are sadly mistaken. I like you agree that far to often than we'd like we see patient coming in for second opinions with what can only be described as "aggressive" treatments. But I feel safe in saying that just because a private practice doesn't have a "CFO" managing daily production doesn't mean that they don't have daily financial goals. I feel it does it disservice to the dental profession to group "all" the dentists that practice a group setting as over treating and just-concerned-about-the-money people. It would be equivalent to saying after one bad experience to McDonalds that "all" McDonalds have bad service. To make a generalized statement about group practices is simply unfair. Again, let me state that I agree with you concern over dentists that over treat. But please be more conscious about generalizing all group practices and consequently all dentists that work in a group practice in the same boat.

I have to say I totally agree with this person. I think over treatment is a common problem, industry-wide, and I don't think all corporate dentists or multi-dentist facilities are bad.

I apologize for my curtness and I appreciate his/her comment. I will be more conscientious about my words. Again, I am sorry for being somewhat of a jerk.

I was doing a bridge on an 88-year-old woman on teeth 5-8. She is frail, but #6 was broken down below the level of the bone and it had to be done. Two days earlier I had done a huge filling on #8. I decided that there was too much filling on this tooth and it wasn't going to last, so I was just going to add it to the bridge. I prepped it with 5 and 7.

While we were making the temp, the filling broke off in the temp. I had to go out and tell the husband that I needed to do a root canal and post and core to fix this tooth. He agreed, so we reappointed and let them go.

Today, I did the root canal and post and core, and then I went to prep the tooth to add it to the bridge. The tooth was basically at gum level. As I was prepping this tooth, I started to think about the ferrule.

I remember talking about this ferrule effect in the first CE course I took right out of dental school with John Kois. John Kim describes it as this:

“This is something that's often confused. The ferrule is the ring of metal that goes along the gingival margin of a crown or a core buildup. It's not a ring of tooth structure. The tooth structure is removed in order to place a ferrule. The theory is that a ferrule will help distribute lateral forces and prevent fracture after you do a post and core.”

I think I remember the ideal is 2mm. Well, I have to be totally honest with you. I have never considered the ferrule. If the tooth has 2mm of good tooth structure, great. If it doesn't, I don't change my treatment one bit. I have never sent anyone for crown lengthening to get a ferrule.

I have never seen anything fail and said, "Damn, I should have sent her for perio surgery," or, "Why are all my post and cores failing?" They just don't fail.

Today, I was prepping and I saw the tooth margin. But I was prepping my core material and this didn’t bother me one bit. There was some tooth that I was prepping, but it surely wasn’t 2mm all the way around. It might have been 2mm in about 25% of the prep.

It is weird. I know the theory. I know what the books say. But I also know that this tooth is going to be okay. I know this patient is 88. I know that they are from Boston (their son is a great patient of mine) and are only here until April. And I know that this is going to add about 10 weeks before I can finalize this (the time doesn't bother me - I was just thinking).

I just did it. I packed my cord. I took my awesome impression and made another awesome temp. And in two weeks, I will cement this crown and not think about it anymore.

And I am writing this thinking, "I wonder if you guys are going to nail me to the wall on this one." You know I try hard to do things right. You know that I care and that I watch my stuff coming back. If anything fails within 5 years, I am doing it again for free. And if any crowns fails before 8 years, I usually do it again for free or for a significantly reduce the fee. But this is not the topic for today.

Do you consider the ferrule effect? Do you stop what you are doing and send someone over for crown lengthening? Do you think less of me? Be easy on me.

Have a great Wednesday.
john

Moving In

I do not know about your town (big, small or in between), but it is interesting to see a new dentist move into town. We have had some new ones move in and their welcome by other dentists is mixed. Some of the current dentists welcome them with open arms; others act like they are jumping their gold claim!

My town is full of good orthodontists. Lately, the grumbling has been that four more orthodontists are coming to town. I can see why the other people would be nervous. There was another specialist that moved in recently and some of the dentists that have been in town awhile seem to be stirring up some rumors about them.

It can be really hard for a new young gun out of school to move into a small to medium town. I withhold judgment until I feel proof they are good or bad. John’s blog about the corporate offices is so true to my area, as well. Mainly, they have new graduates working there. Working for certain corporate offices can already put a strike against you in some dentist’s minds.

How many dentists and specialists per capita is an ideal number? I know it would vary based on age and demographics of the population and specialty. I bet there is some organization with that info out there.

If you get a chance, go to YouTube and look up dentist vs. doctor extra normal video. I find it hilarious. Read the comments – people take this very seriously. I will write about this in an upcoming blog.

Have a great week,

J.J.

Discount Dentists

Happy belated Valentine’s Day. I took my wife out to dinner and a movie last night. We saw Contraband with Mark Walberg. It was okay, nothing great. This is the kind of movie I would put in the back of my mind for Netflix, but she likes action movies. She really wanted to see Mission Impossible IV, but it is not showing anymore.

Anyway, I hope you all are doing well. And I hope you are enjoying the blog. We are consistently getting over 1,000 readers a week. I remember a couple of years ago we were thrilled with getting 300 readers every week. It just keeps reinforcing to us that dentists need other dentists. Like a quote from the Bible about "iron sharpening iron." That is what we are trying to do here.

Today’s topic is something that I have been talking about for the last year or so, but it happened again and I want to talk about it. I am sure that, like me, you are losing patients to "the guy on my insurance." I am okay with this because I understand that it is hard out there for my patients. If they have to go discount dentist to get their teeth cleaned, I am okay with this. How bad could it be for them? That is my stumbling block: how bad is it?

I had a dad come up to me at church on Sunday and say, "My son needs to come see you. His dentist told him he needs a root canal." The dad comes to me and the mom and kids go to the local corporate dentists. The kid is 20 years old. When I asked him, he said the tooth didn’t hurt.

I told the dad that his son probably has a cavity that needs to be filled, but that if it doesn't hurt, there is a very small chance he is going to need a root canal. I told him that the corporate dentists have a knack for over-treating (if you are a corporate dentist and want to talk, email me at jgammichia@aol.com). They have a CEO and CFO that want them to meet a quota for the day, and sometimes their judgment gets clouded by "the man."

I told him to make an appointment and I will look at it. The dentists that say they are going to save money would have cost them a root canal, post and core and crown, when the kid probably just needs a filling. That is $240 at my office and it would be about $2,000 out of pocket. Coming to me could save them $1,760. Hmmm.

A 55-year-old woman with a lot of decay came to me for a second opinion. She knew about the decay and wanted a treatment plan. She had a tooth that was in bad shape but it could be saved. She had an $8,500 treatment plan full of extractions and bridges and a bunch of crowns. I looked around and things were bad, but not that bad. I could do a bunch of fillings and a couple of crowns, nothing crazy. Her discount dentist was going to pull out the tough ones and do bridges and then do crowns on everything else. (I don't know about you, but I don't do too many bridges for an extracted tooth any more. I do implants. I think they use bridges for the quick buck.) This patient would be saving about $3,000 by coming to me, and I am supposed to be the EXPENSIVE one!?!

How do high-quality, fair, relational dentists, like us, get this message across to the public? This is what I have decided to do. We have these community magazines. You get them in the mail, thumb through them (I do, too), then throw them away. I never thought anyone noticed these magazines until I was at a "Taste of the Town" event and they put my picture in the magazine. I had so many people email me and stop me and tell me that they saw me in that magazine. I am going to buy space in this magazine and write an article telling the above story.

I am going to buy space in the local newspaper (not the Orlando Sentinel) and write these stories. I have got to tell people. I don't care that they see me. I just don't want them to see the discount dentist, the wolf in sheep’s clothing. I feel like I have some responsibility to people and to my profession.

What do you think? You think I am nuts, don't you? Is this happening to you? Don't you just want to shake people and say, "Why are you going there?!"

This is my soapbox and you can't make me get off.

Have a great rest of the week.
john

Root Canals

Greetings,

Well folks, as you can see, or probably have already figured out, I didn’t get the Miami Dolphin gig. They picked “the tall guy,” which I’m cool with. They just have to realize that they had a true dol-fan that they passed on. Honestly, I thought I would get a call for maybe an assistant position. I guess it was the “west coast” offense they wanted to install (which I know nothing about).

So, I was driving back home to Ocala from the Panhandle of Florida this weekend. I-10 seems to go on forever (I think it was just a coincidence that the air smelled funny as I went through Tallahassee, hehe), and it gives a person a lot of time to think.

One of our reps was in our office last week helping us organize our endo armamentarium. Now, through the years, I have had several different endo kits. After dental school, I was told that the way we were taught is outdated and this is the way I need to do it. I bought all of this new equipment: files, motors, gutta percha, etc. A year went by before I was told that there was a better way to do endo.

Evidently, someone had done some research somewhere and the results showed that what I was doing didn’t work. Well, I didn’t want that! I did some exchanging and buy-back deals and then I was set with the “right system.” Ah, finally I was doing something right.

Time went by, and guess what. You can see where I am going. Today I am on my 8th “right system.” I agree that it’s a little confusing. Constant taper, different tip size, same tip size, different taper, single cone, lateral condensation, continuous wave, vertical condensation, back fill, biogeneric cement, and on and on.

I have realized that (I know I am slow), for the last 17 years, I have been maintaining teeth that have been endodontically treated by people other than me. For instance, many patients in their 80s have a mouth full of silver points. Sure, some of them had to be retreated. The root canals I performed using all the other 7 systems before the one I’m using now seem to be surviving. I didn’t think they were good and yes, some of those had to be retreated.

My endodontists have had to retreat some of their own endo over time as well. I see radiographs sometimes that make me wonder how that worked, but it was done 20 years ago and its fine. I’ve seen hundreds of endodontically treated teeth that look like they were filled with a 15 accessory point, and they seem to be fine.

I’m beginning to believe that identifying the canals is 90 percent of it, and almost everything else is pretty forgiving. Now, granted, doing tooth number 15 that distally inclined on a patient that gags takes amazing skill and talent; I am thankful for my specialists. Am I off on this?

Have a great week.
Scott