Holy cow, has the summer gone by quickly. The kids are back in school next week and we are back on a schedule. I know my wife will be happy. Having to keep three bored boys entertained is tough. They are now trying to pester each other to death, so the summer is exhausting at times.

If you remember, I talked about assistant reviews in my last blog. Everyone got a good-great review because they are doing well; they all got a raise. I thought it went. Rather, I was fooled into thinking it went well.

A week or so ago, one of our long-time assistants resigned. She said that things were changing at the office and that she did not like the stress. I have worked at other offices; I know stress and I know how hard other offices work their assistants and how they treat staff. Once again, I do not understand what they are thinking or expecting!

This particular assistant has never worked at another office. She was hired here right out of school and has learned basically everything here. We wonder if she understands some of the issues that other offices make their staff deal with. Yes, we are demanding and want things done a certain way. We do change protocols and rules to improve things, but some people do not like change.

We used to have a bonus system at the office, but we decided to get rid of it. It seems to me that patients could perceive that their care is influenced by cost and what will help the staff make bonus. I am sure you have heard the patients ask staff how much they make off a certain product or procedure. Now, my staff can honestly answer, “Nothing beyond my regular pay.” The PBS special seemed to harp on this compensation model, so we took away the bonuses. We did substitute it with a guaranteed Health Reimbursment Account that everyone gets to benefit from.

We hired a legal guru to help us rewrite our office manual. We needed to make it more official and compliant with OSHA and Florida worker laws. We were advised to set a continuing education or non-production pay rate for all meetings and CE, whether it was out of town or wherever. We made the compensation rate more than she advised, but from what we hear now, that upset her. Dr Jackson and myself try to be fair and do what is best for the business, taking into account that the employees are part of the equation. But I truly feel that, unless you do everything they want (and trying to make all 14 women happy can be difficult), people are always going to be irritated about something and the grass is always greener on the other side for some people. What can you do other than try your best and not look back if someone disagrees? My partner and I sadly realize that the odds are, in ten years, possibly none of our current staff will be here. We hope that is not the case. Just like in a marriage, things change and people change. Things will never always be the same.

We are looking for a new team member and hoping we can find one that appreciates the way we do things here, the honesty, respect and integrity we show patients and staff. If you know of anyone in the Ocala area with experience and a good attitude, send them our way.

Have a great week,

JJ

Friday

I hope you have had a good week. It has been pretty good here. While I reserve the right to change my mind, I kind of feel like things might be getting a tad (that might be a bit strong) better. I know the hygiene is still a bit of a struggle, but I am seeing some patients loosen up a bit and do what they need to do. They certainly are not coming in here and doing full-mouth rehabs, but it might be getting a little better. And this could be totally episodic and it could swing the other way next week, but at least we are not going down. Maybe we have leveled off here. How is it with you?

I saw a 20-year-old patient this week who has been battling perio disease for a long time. I think when this patient was 15, we sent them to the periodontist for ANUG. This patient had been on a two month recall, but was now up to a three month recall. Things were looking a bit better for them.

I asked how often they floss. I was talking to a 20-year-old, so my expectations are low to start. I mean, I didn't start flossing until I was about 28 AND I WAS A DENTIST. So when they said that they flossed about 2 times a week, I was encouraged.

Then I asked they brush, and there was a long pause I asked, "Are you trying to think, 'Should I tell him the truth or should I embellish?'"I thought they would tell me that they only brush once a day. They started by telling me, "It’s not every day..." I stopped listening at this point.

I was incensed. What am I doing here if we can't even get people to brush their teeth? What have we been doing for the last 6 years? You, kid, are wasting my time. I was so mad that I had to walk away. I had to go back into my office and count to 10. I went back up to the front as they were checking out and, not to alarm the parent (who was paying of course), told this patient that they have to at least brush once a day. We will start there and work up to 2 times a day. Now would it surprise you that this patient is a girl?

I don't get this generation. I mean, I guess I didn't brush my teeth in college because I was at an all-night party, drinking way too much and then passing out before I could find my toothbrush. What I meant to say was that I was studying throughout the night at the 24-hour library (this is what I told my parents). These patients are living with their parents and playing video games. Damn, I am out of touch.

And lastly on this short but sweet Friday blog, I finished a veneer case this week (first one in years). This was a retiring teacher who didn't have very nice teeth. All her life she has wanted nicer teeth. She has saved basically her whole life for this. You know patients like this; they are best.

She has been a patient here for a long time and the trust has been built. She came in one day and said she wanted veneers. Let’s do it! We had to do a root canal and clean her up periodontally, but basically we got her right in.

We brought her in and we spent the afternoon together. We prepped them down. You can see I did some crazy stuff (like on #6). This was an abutment to a 3-unit bridge, so instead of changing out the whole bridge, I did a veneer on #6. I talked to my ceramist before hand and we thought we would try it. As you can see on the temps, it looked pretty good.

Anyway, I thought the temps looked great. I gave her a smile, in these temps, that I thought she could only have dreamed of. This was $7000 well spent!!! I gave her a mirror for the big temporary reveal and .............crickets.

Okay, maybe she was just tired from all the work we did. Maybe she was uncomfortable from being numb. She was expressionless. Man, was I disappointed. Maybe I was just tired. Maybe it wasn't as good as I thought. I looked at the photos the next day and DAMN those temps were nice!

I called her to see how she was doing. Maybe I would get something from her after she got a good night’s sleep and then looked at her new teeth in the mirror. We talked and she told me she wasn't having any discomfort. But she didn't say anything about the appearance.

On Tuesday, I cemented in the final restorations. We spent a couple of hours together and got them looking very nice. We had an issue with an embrasure space, so the lab came and took them back and added to two of the veneers. Oh, it’s nice having a close lab.

Again, I gave her a mirror for the big reveal, and time she said something. "Oh." That was it.

Not, "Oh my gosh! I don't know how I can tell you how much you changed my life!" Not, "Oh my gosh, I just wasted my money." Not, "Oh, I have never felt so young." Just, "Oh." And it wasn't an expressive, It was just, "Oh." (By the way, sorry, but I didn't get final photos yet. The canine veneer looks so good!)

Again, I called her the next day and she seemed fine. I think she was happy. I guess she just isn't a person that gets excited easily, which is kind of foreign to me. I mean, people know how I feel. I am off-the-charts expressionfull. That’s a cool word, isn't it? I just made it up.

She still is talking about doing the lowers. I guess I will just lower my expectations next time. What I am saying is that part of the reward to what I do is making people happy. Yeah, yeah, the satisfaction I get when I know that I have done my best and it is good. No. I want to change people’s lives. I want the hug. I want the affirmation. I have to have it. I guess I just won’t get it from this patient.

Have a great weekend.

john

Twitter

I am so loving the Olympics. I am losing sleep because of it. It is not the events or the contest for me; it is the stories. The one that I just can't get over is the runner that doesn't have any legs below the knees. This story is so crazy. He is RUNNING an OLYMPIC EVENT without LEGS!!!! And to watch this guy run, wow.

How can the Olympics not inspire you? How can the stories not resonate with you? It is not the medals or the competition that will stick with me, but the stories of people overcoming obstacles. I will take these stories back to my life and say, "You know, this isn’t so bad. I know I can overcome this petty little thing." That is what is going to stick with me.

Missy Franklin, the 17-year-old female swimmer, won 3 golds and a bronze medal. She says she can't wait to get back to her senior year of high school. Can you image what her high school swim meets will be like? She is turning down gazillions of dollars so she can swim with her friends in high school.

And lastly, I am going on record and saying this publicly: I am not a fan of woman's gymnastics. I think about this 15-year-old kid that has been taken out of school and home-schooled so she could practice gymnastics for 15 hours a day for 8 straight years. Then put on a strict weight program so she will stay less than 80 pounds (or something ridiculous like that). She gets there and she has to put on all this makeup that makes her look like a doll.

I know, I am totally over thinking this, but I have seen it happen. I have had patients whose daughters were good at something, and they started this stuff. One was good at ice skating. They took her out of school so the mom and daughter (without the dad and the siblings) could move to Colorado to train. She was 10 years old. And to think: there are only 5 girls every 4 years that make it. You think the odds are bad for the NBA or the NFL? Try being an Olympic gymnast. The odds are about .0001%.

Okay enough of that. I want to talk to you about Twitter. You know what this is, right? Everyone is talking about it. You can't go five minutes listening to the media and not hear about it. I watch a TV show and on the bottom left corner of the screen, there is something like #suits. Watching the Olympics, there are ads that finish with #olympics. I assume this has something to do with Twitter.

But I have to confess, I don't get it. So you are telling me that I can say something on my twitter account (@johngammichia, just in case you want to follow me) and all my followers will be able to know it almost instantaneously? And if I follow you on Twitter, I can hear what you have to say instantaneously? You know what I say to that? So what? What am I going to say that everyone wants to know about? There is nothing you have to say that I need to know RIGHT NOW.

The big thing is actors and sport figures. Do I really want to know what they are thinking right now? I don't care what Angelina Jolie is doing right now. I don't care what Dwight Howard is thinking right now. I think the sports talk show hosts do, but you know what? When they report on it, I will hear it.

I know, I know. I am old and crotchety. I know I probably could tweet that I just finished a veneer case and send out a picture. But that would mean I need potential patients to follow me. That is work, just like Facebook. I have a page and I put a case on there about 3 times a year. Does updating it make it more likely that people will follow? Maybe.

I realize that, at 43, I might not be someone to ask about this. I had a single guy in my chair. He works and lives in downtown Orlando. I would think if anyone has his finger on the pulse of technology, it is going to be a guy like him. I asked him about Twitter and how much he uses. He said he has never tweeted or read a tweet. Hmmm. Is it something for 20-year-olds? Teenagers? I talked to a couple of 22-year-olds at my church; they all said they have very limited experience with Twitter.

Can someone please tell me that I am not crazy? Am I missing something? Is anyone using Twitter and loving it? Is anyone using it for dentistry and, if you are, it is working? Let me know.

Have a great rest of the week,

john

P.S. The AGD tweets! Follow us on Twitter @AGDadvocacy to learn about the latest local and national advocacy issues affecting you.

Leaving a Legacy

Happy Friday.

I am so tired. I cannot pull myself away from the Olympics at all. I find out during the day all the results then sit and watch them all night. Go USA. I would be interested to know if you blog readers like the Olympics, too. I think Americans love the Olympics. I know this because NBC spent $4.4 billion (that is with a B) for the TV rights.

Anyway, today I want to talk about your legacy. I often think about what are we here for. I want to tell you a story and then we can talk about it.

My assistant broke her ankle and she was in the hospital for four days. After surgery, they told her she couldn't put any weight on it for three weeks I think I told you but I needed to get a temp. I called all my assistant friends and put the word out. One of my friends called me with someone she knows, and she was able to help.

Things worked out pretty well. She was able to handle my dry sense of humor and I think she appreciated the type of dentistry I do. But about two weeks into her stay here, a 23-year-old man came in. He was a good looking kid that said his front tooth was loose.

At first, I thought this would be nothing. I asked him how long it had been loose. Two days. RED FLAG. I looked in his mouth and, sure enough, he had broken this thing horizontally at the gum line. I explained that he was looking a root canal, a post and core, and a crown. I saw his concern when I talked about cost.

I looked around and didn't see a parent or anything like that. I know that 23 is an adult, but usually this is still an age when parents come with them. I asked him how he felt about all of this. He said the he had an idea it was bad, but it was going to be hard to pay for. I asked him if he had family that was going to help him out with all this, and he told me he had never met his father and his mother is battling stage 4 cancer. He has a job at the local shooting range, but…

I told him that I was here to help and that I would do the best I could to keep the cost down. I told him that I would help him and if I needed to lower my fees to let him get it done, I would. I told him we could do a pulpectomy and do a temp post and core and see how long that would last just so it wouldn't be $2,200 at one visit.

He said that it might take him a month to save up the money to just do the minimum. So I said that if the tooth fell out before then, just to call me and we would work it out. After the kid left, this assistant said that she has been in assisting for 12 years and has never heard of dentist doing what I had done. She said she had never seen anyone give something away.

I was shocked. I give stuff away almost on a daily basis. Do you remember the Dunkin’ Donuts blog? Last week, a girl, 25 years old with no family, that worked at Taco Bell (for $8.10 an hour) came in with terrible teeth. She was so embarrassed about her smile that she was crying. There is no way she could afford to fix her teeth. I told her I would help her.

I want to help people. Don't tell me that am not making enough money because of it; I make good money. I have a talent that God has given me and I am going use it to help people. Sometimes for money and sometimes to help someone improve themselves. Simple as that. This assistant and I got along before ,but she definitely sees this practice in a different light now.

I have told you that undergraduate students hear about me and find out that I am someone that will allow shadows. They call me up and I let them come in and hang out. Well, for the last 8 weeks or so a young man was shadowing us from 7 a.m. to 3 p.m. every Friday. He started shadowing at a couple of offices, but after a few of weeks, he said he only comes here now. He told us he liked it here and that he kind felt like he was in the way there.

What we try to do is, when a young, bright, enthusiastic person comes in wanting to be a dentist, well shoot, this is our chance to set the hook. We treat him/her like family. We laugh, we play, we educate. We put some gloves on this kid and make him hold the suction. We let him assist on an extraction. This means the world to these young, impressionable minds. I want this kid to love our profession like I love our profession.

So I started thinking. What impression are you leaving? What is going to be your legacy? Do you have kids in your practice that want to be dentists? How about kids that have gone into dental assistant school? Or hygienists?

Don't tell me NO. Don't tell me that you are not influencing anyone. Don't tell me you are not leaving an impression on anyone.

I had a 82-year-old man in my chair the other day. He is a good ol' boy and he always wears a cowboy hat. Before he left, I asked if I could try on his hat. I put it on and everyone got a kick out of Dr. John with a cowboy hat on. My staff got out their phones and were taking pictures of me. It was fun.

That patient came back this week and told me he left the office and went to the hat store and bought me a brand new cowboy hat. I just thought that was so awesome. It is great doing this job sometimes. It is so nice that someone would think of me enough to go out and buy me something. This is a picture of me and my new hat.

That, my friends, is what this is about. Having a talent and using that talent to help others, using it to make others better. And to get them to think about helping others.

Have a great weekend.

john

Hey all,

Sorry about Friday. I had half the thing written and then just left the office. And when I leave the office, I really leave the office. I don't bring my computer home and really don't think about work much when I am gone.

My son comes home from Mexico today. He seems to have had a great time, but at home, we have not been ourselves. We are all just looking forward to having him home. We have gotten emails from a couple of friends that went, and some sent us some photos. Here he is. (He is a good looking kid, isn't he?)

Anyway, I saw a lecture a couple of months ago and I have been reviewing the notes. I think I talked about it before. The guy was Alan Atlas, a dentist out of UPenn. Very good lecture on adhesives. He began the lecture talking about composites versus amalgam. We all agreed that amalgam was the better material for longevity, but if we were getting a restoration, most of us will choose composite (as will our patients). So, we need to make composite better.

We talked about the negative of composites. He showed a study on composite that claims 30% have to be replaced within the first 6 years, and he talked more about failure. The number one reason for failure within the first five years is technique, fracture or sensitivity. Between 6 and 17 years, the number one reason for failure is secondary caries.

He went on to say that responsibility of the failure rests first the patient, second on the dentist, and third on the material. He said that the caries risk patient is that way for two reasons: diet and genetics. According to the lecture, for patients at low risk of caries, COMPOSITE did better than amalgam in a 12-year study. Hmmm.

This study is from the Journal of Dental Research from 2010. I still don't know about this. I have always said that you can find research to say whatever you want. There is an article for everything. For every article that says amalgam is a great product, you have two that say that is causes Lupus. Use a rubber dam; don't use a rubber dam. Bleach in a canal for an RCT; bleach is poison. Ceramic versus gold. You can find an article that will back anything you want.

In this case, we find an article that says that composite is holding up better than the gold standard. I know composite is getting better. The more we place, the better we get at it. The more research we do, the better the products become. I don't know about you, but I have not seen a 45-year-old composite filling that looks like the day it was put in.

I think composite is awesome. I have spent my life trying to make teeth with restorations look like natural teeth. I have 19-year-old composite fillings in my mouth. I have pictures of 16-year-old composite fillings that I did. But do I believe that, in a 12-year study, composite has a higher success rate than amalgam? I just have a hard time believing this.

Am I the only one that has a hard time with this? Do you just read this and then move on, and not really think anything of it? It is not going to change the way you practice… is it?

BUT, we are almost there. It is like last week’s blog: 22 years of success. Every day, I am more and more convinced (especially after all the reading I am doing) that we are on the right track. We are saving teeth and we are doing it better and for longer. Okay, that is going to be my last composite blog for awhile. Sorry about all that.

I have to go now. I have to get back to watching my 16-hour-a-day obsession with the Olympics. I can't stop watching. GO USA!!!

Have a great rest of the week.

john

Alginate

Greetings,

I hope everyone is surviving this hot summer. Here in Florida, we are seeing temperatures up to 104 degrees Fahrenheit!!

I will give you a quick update on my house. If you remember, we had the “mother of all floor leaks” back in February. e just got the new floors down , along with a new kitchen countertop. The only thing left is putting the baseboards back down. My wife is sanding and restaining all of them before we (she) put them back on. I know what you are thinking. “Why are you making her do it?” Listen, I have to buy her new shop tools at least twice a year. I am lucky if I can say I own my own screwdriver, but that is a blog for another day.

I was thinking about technology this week and how far dentistry has come over the last 100 years. I teach at the local dental assisting college, and I always give the students a history lesson in dental materials. Today, we work under microscopes with high tech instruments, lasers, CAD/CAM computers, digital radiographs, rotary endo files and 3D cone beam images, just to name a few. Then, there is alginate. The stuff works great, don’t get me wrong, but I feel like I’m working in the dark ages when I use it.

This revelation became very clear to me a few days ago when I decided to make an alginate impression on a patient. I usually have one of my assistants do it because, frankly , they are much better at it than I am. Everything started out well. I remembered somewhere in the back of my head that you had to place the water in the bowl first, so I made sure I had the measuring cup of water filled right to the 3rd line. I even knelt down to eye-level with it to make sure. I very methodically measured my 3 scoops of powder, making sure I had a perfect level with each scoop. I picked up the bowl and introduced the spatula into my perfect mixture. With the very first whip of my hand, at least half of the powder came out of the bowl onto the counter. I heard a snicker from my assistant.

I very calmly cleaned everything up (while talking to my patient about my new floors as a distraction). My 2nd mixture (yes, there will be more), was measured perfectly again. This time I was careful not to spill the powder. After about 10 whips with the spatula, the alginate was completely set up. Now, not only was my assistant laughing, but the patient had joined her. At least this time it was easy to clean up because it was just one hard chunk. The 3rd time was a charm! I loaded my tray quickly and placed it into the patient’s mouth, being ever so gentle. Then, out of nowhere, the patient hacked vigorously.

I wasn’t about to let go (all I could think about was a bull rider having to hold on for 8 seconds). At this point, “something” came flying out of her mouth, headed right for me. I instantly did one of those “Matrix” backbends, the kind where you bend 90 degrees backwards and 2 seconds takes about 5 minutes. The “substance” flew right over my face and hit the wall behind me. Is this real? I didn’t even know my body could move like that!!

The impression turned out okay, but my assistants have banned me from touching the alginate again. What a mess! I can’t think of any other procedure I do where I have to hand a patient a roll of paper towels while I excuse myself to go change my clothes. It’s time we invent an alternative!!

Have a great week.

Scott

A Six-Month Study

I know; it is Thursday and I am blogging. Wednesday came and went, and I totally forgot to do a blog. I am so out of it. See, along with my assistant still being out, my son left to go on his first mission trip yesterday.

I was totally fine. I wasn’t nervous or concerned about anything until I dropped him off. I made sure he had his passport, and the hard realization that he was going out of the country to a drug cartel-infested country hit me like a ton of lead.

I have not been myself today. I know, I know. Trust God. And I do. But this is hard to do when it is your son. I am okay. I just have to keep telling myself he is going to be fine. It is going to be such a good thing for him. He is such a great, tender-hearted kid, but he is as spoiled as the day is long. This trip will give him a little perspective (and a little case of the "runs," too).

Today’s topic is composites. I hope you are not tired of this topic. This is the stuff that I am reading about, so this is the stuff that I am learning, and I have to tell you about it. I have been to a couple of lectures recently and they both said different things about the longevity of composites. The first said that five years is still the average on a composite filling, but the second guy said that they are confident that they will last 12 years.

I was sent a journal article from the Journal of Dental Materials about the longevity of composite fillings – it is a 22-year study!!! They looked at 362 restorations and they only had 110 failures. I did the math for you: that is 70% success rate. And the kicker is that only 41% of the failures (49 out of 362) had to be replaced (60 of the failures just were repaired). How about that? That means 49 out of 362 restorations had to be replaced at the 22 year mark.

I think this is a study of restorations from one dentist. This guy was pretty good. There are pictures of his work, and you can tell the guy was good. He put anatomy in all his restorations and looked to be very conscientious (and that was 22 years ago). Does that mean all restorations will last 22 years? No. Does this mean they all still look awesome in 22 years? No. But they don't need to be replaced.

It is the same thing we were talking about with the root canal failure rate in last week’s blog. Endodontists claim about a 2-4% failure and that article was saying about a 19% failure rate. But this article was saying is that if you do it well, if you try hard and use the right materials and you are conscientious, composite restorations are dynamite.

We knew that. We know because we see it in our own practices. We are looking at our restorations and doing our own studies. How do my fillings look? How are my margins holding up? At every recall appointment, you get to have your own research study. And not just for fillings. I look at the margins of my crowns and get angry when the tissue recedes or there is an overhang. I look at the color of the teeth and how stable the color is in all my all porcelain crowns. I look at everything I do and see how it is going.

You guys are doing this, right? I mean, along with looking for things that are going wrong in my patients’ mouths, I look at the things that are going right. I am my own worst critic, so it really does make me a better dentist. The problem is that by the time I think I have this profession licked, I will be right at retirement age.

Hope you are having a good Thursday. I will talk to you tomorrow.

john