Are you sure I don't need veneers?

Friday. Oh yeah.

My wife and I are going to the UF vs. Alabama game tomorrow. It is supposed to be in the high 50s in Gainesville. We have a bunch of friends that got a party bus and are getting a driver. The game is at 8pm. They thought the 2am car ride back would have really stunk, so they thought the bus would be a good idea. I concur. My wife and I look like real world travelers lately. We really aren't, but we saw this chance and we took it.

Hey did you see “Modern Family” this week? Oh my gosh, it is so funny. When the dog looked into the camera, I totally lost it. "He drowned Cam!" Great stuff. Please tell me you guys like this show. Because if you don't, I think to further this relationship, we are going to need to go to counseling.

Okay, it is Friday, so I won't keep you.

Did some really good dentistry this week and got some pictures. I had a girl come in for a "cosmetic evaluation." A 22 year old with diastemas (spaces between her teeth for all you non-dentists out there). Her dentist had sent her to the orthodontist. He found her to be quite good orthodontically, so he sent her back to her dentist and recommended veneers. She had heard great things about me and she wanted me to do the veneers. She was hell-bent on the fact that she needed $7,200 to fix some diastemas.

I took a look at her and asked her where she got this notion that she needed veneers. She told me the story again and I told her, "First of all, you don't need veneers. So let’s talk about how we are going to make you happy with your smile for a ton less money."

(these are her before photos)

We talked (what a concept), and I told her that I thought I could do what she was looking for by putting some composite on her teeth and the she wouldn’t even know it was there. And you know what was funny? I almost had to talk her out of veneers. She was so brainwashed! I had to convince her that spending $7,200 was a tad too much at this time.

She came in Wednesday, this time with a parent, and they both told me exactly what they wanted. I listened and told them I knew what I was doing. I knew what she wanted and I knew it is going to be great.

It is hard to tell from the photos, but she has a very gummy smile. The first thing I did was make them a bit longer with a bit of electrosurge. This also was going to make her teeth less stumpy.

If you look at her befores again, her composite veneer is not great but it is not horrible. The issue with it is that it is the wrong size, it is so monochromatic and it is too flat. It is not breaking up the light, not looking very natural.

I started closing her diastema. I then removed her old composite veneer. This was very challenging because of all her colors. Now, I don't know if I am the only one that does this, but I take an opaquer (made by Kerr) and put it under the composite.
I make clouds of the stuff around the incisal edges and down the sides and cure it. When the composite is cured over the top of it, it looks like it is natural.

I ended up doing 5 sides (I charge what I would charge for a three surface anterior filling, which is about $190 and one composite veneer for $500). I didn't charge her for the electrosurge because I didn't want to pile it on. I worked about 1 hour and 40 minutes, and I think $1,400 was enough. Plus, I had fun doing it.

Okay, now the after photo stinks. It never looks good on the day of the appointment. I am tired, the patient is tired and everyone wants to go home. Things never look that good. The tissue looks torn up and they are oozing. But this picture actually gives me everything I am looking for.

This photo is not the end photo because I have rescheduled her in 10 days to touch things up. I told her to look at them and tell me what she thinks and tell me any changes she wants. But it also gives me a chance to look at my work and see what changes I want to make.

The embrasure space needs some work on #9. The gingival 1/3 of #9 has some weird color. I tried to blend a couple of colors and it didn't come out well. Get this - the gingival color is B-1. The other color is one of the WHITE shades.



It thought the embrasure stuff turned out fantastic. The canines sometimes have a weird look to them when you are adding to the mesials, but I thought these looked great. She is coming next Friday to touch things up. I will take some photos and I hope they turn out better.

All in all, a good case. I was happy, she was thrilled. She didn't get ripped off and she has treatment that will last her for at least a decade.

What do you think?

Have a great weekend.

john

P.S. Third Middle School football game yesterday. We were on the wrong end of a 31-19game. My 91 pound starting defensive back had 5 solo tackles last night. So proud.

Review

Happy Wednesday,

I wanted to open up discussion about the last blog. I got some comments that I wanted to respond to.

I talked again to my front desk person and asker her flat out, "Are you messing with me or exaggerating a bit about the five fillings in 11 years?" She said she was not exaggerating and that he never did fillings.

"So he basically just did crowns all day?"

"Yep, and root canals. He had three assistants and they cranked out crowns all day long" she finished with.”

I thought about it. That place is basically a clinic. They get a treatment plan that is 5 crowns at $800 a piece (which would be very cheap in my area). The patient thinks something isn’t right, so they call my office..

What do you think they are going to say? They don't say they need a second opinion. They ask how much I charge for a crown. My people say, "$115,0" and they hear a click on the phone. The patient goes running back to their dentist thinking they are getting a great deal where they are at. They don't think to ask if they really need the crown or not.

So after the blog and before my vacation, I called the board of dentistry and I talked to a very nice lady. I explained to her my story and told her I had enough of letting these things go. She was taken aback by my story. She ended up telling me that there are rules and guidelines that she must follow.

The only way to file a complaint and to open up a file is for a patient to file a complaint. She said she can't just barge into an office and demand to look through a dentist’s charts. On an side, we need to stop worrying about this happening to us. I know they brainwashed me in dental school about "the man" coming in and going through our charts, but it is not going to happen.

I guess a dentist can't tell on another dentist. So if you are an associate of a guy who you think is a shyster and you quit, then you think about all the patients he scammed and you want to do something, you can't. You have to get a patient that is unhappy and get them to call.

But then again if me and another dentist had a disagreement and we parted ways, I guess I am protected from him having an axe to grind against me. The rules go both ways.

But that still doesn't stop Dr. Crown. Do I let it go? Am I trying to be too righteous? Am I Super Dentist, trying to save all of mankind from the evils of the world? Yes, I think I am, to all of them (well, no to the first one and yes to the rest).

It is not over. I am going to start by going to the peer review in my area. The clinic that this guy works for is owned by a guy that I know. I know him because he is in one of my Bible studies. I have met him a couple times. He started this thing about 22 years ago and there are about 25 locations around town.

Now, I guess I can go and talk to him. But maybe he doesn't even own the thing anymore. Maybe he doesn't know this kind of thing is going on (yeah, right), but I think as a "brother" I have to confront him. I will let you know.

On to the returning of the Ryobi. I have a friend who is a small business owner. He competes with places like Home Depot. You can imagine if you have a small business that competes with Home Depot, you might be a bit angry with Home Depot.

It is like a mom-and-pop grocery store next to Winn-Dixie. How does the mom-and-pop store compete? We have talked about this before. Taking things back is just another way of Home Depot squashing the little guy. The mom-and-pop grocery store can't take a gallon of milk back because you let it sit in the kitchen and forgot to drink it before it expired, but Winn-Dixie can.

He told me, "John, you screwed up, you should pay for it. Don’t give Home Depot a chance to take the loss; they’re just going to pinch Ryobi for it.” And I started to think maybe he was right.

I was having a discussion with someone that used to work for Sears and he said Ryobi has a customer screwing up fee added to the cost of the machine to Home Depot. I know that if no one screwed up then everyone would get the product a little cheaper, they put it into the cost of the product. It is like the cost of doing business.

Just like Dr. Joyce was talking about. You give the guy a discount because he was
honest. It is in lieu of marketing. Getting a raving fan by giving him a discount. I do it all the time.

I know what my friend is saying. I know that Wal-Mart, Costco, Home Depot, Winn-Dixie, are pinching the little guy. Trust me, I hate it for my friend.

What about LL Bean? They have a LIFETIME GUARANTEE on all their products. LIFETIME! The shoes could be 20 years old and they will take them back. You could accidentally run over a chair with your car and they will take it back. But you look in their catalog and guess what? LL Bean is just a little bit more expensive than the next guy. What if I ripped my shirt on a nail as I walked into the garage? "Sir, just send it back."

I am not going to be angry with Home Depot for taking care of me. I am not going to take the money into the store and demand that they take my money. I don't know how to rectify this with him. But I know I am going to get an email before the day is out. I will let you know how it goes.

Hey, have a great Wednesday.

See you Friday,

john

Crown vs. Anterior composites and honesty!

Hope everyone had a great weekend. Here in sunny Florida it is starting to cool down. Not too many 90 degree plus days and it feels nice. Football is in full swing and I am enjoying it. In the south, college football is a big deal. I remember living in San Diego and how Saturday was nothing special. I am glad to be back in the south.

I was reading John's blog about the weed eater and trying to return it and it made me think about a recent patient. This patient was a nice guy. He came in with a chief complaint that his front tooth was broken and that he would really like to get it fixed since he was in sales and it really made him feel self-conscious. #8 had a large fracture, no caries, and needed a large class four composite or a crown. I asked him if he had ever had it fixed prior and he said yes but the filling "came out." I told him that this tooth was on the fence between a very large filling or a full coverage crown and with his past history of having a filling and it coming out, I would first suggest a crown. He stated he really wanted to try the filling.

I do not know what you do, but if I really think it needs a crown, I will tell them I will do the filling but I cannot give them any reassurance as to how long it will last. It probably depends on how careful they are with it. I really hate saying “guarantee" because I doubt any other type of medical surgeon gives a guarantee on their work, but maybe I am wrong!

The patient stated he understood and would accept the risk of the filling possibly debonding or fracturing in the future. I know you might be mumbling, "Yeah but the patient never remembers that in six months or a year when it fractures again and it is all the dentists’ fault." Well, I did the restoration and he loved it and I sent him on his way.

On this blog, and just in general, we talk and hear about dentists dishonestly or unethically, which even once, is too much. It saddens me to see and hear these things, but I am a big boy and know it happens. However, what about patients being honest? I see it all the time, whether they are trying to get pain pills, free or reduced care or they want us to change a code or something to help them scam their insurance company. It goes both ways!

Well back to the story. Sure enough, about six months later he came back. The filling had fractured off. I put my guard up and got ready. I walked in and we started talking and immediately he started to say that HE screwed up and that I warned him and admitted he was chewing on a pen and bit down on it and the filling broke. I was so relieved. So many times the patient is complaining that it was just done and that they did nothing and it just fell out and it is everyone’s fault but their own.

I have been using a total etch technique and OptiBond Solo Plus for about ten years and have had very few issues with "spontaneous debonding.” The stuff works well, but I know there is always a chance it could happen. It might not be the gold standard, but it seems to always be ranked very highly in research reports.

So depending on the situation (a long time loyal patient or someone that only shows up every couple of years when something is broken), sometimes I cave in and do the restoration for free again but tell them this is it and next time it will need a crown, no questions asked. They always agree. Other times I will stick to my guns and remind them we discussed this concern and they will have to do a crown or pay again for the restoration.

Back to the other patient. I told him that I appreciated his honesty and it was refreshing to hear someone in today's society take responsibility and not try to blame others. I told him that he really needed a crown, but he wanted to try the filling again. I agreed and told him that for his honesty, I would give him a decent discount. He was very happy. This time, I modified the prep, placed some retention groves and etched and bonded to more enamel. Again, he was very happy. He told me he agreed he needs a crown and he will begin to save up for it and plan on the future to have it done. I wish these situations always went this well.

On a technical note, I typically do not place retention groves in my composites. I usually rely on bonding. I have seen some composites with pins, but they always seem to discolor and they were probably done a long time ago by a dentist who was desperate with the restoration falling out.

What are your thoughts?

Have a great week.

JJ

Lazy Friday

As I said before my wife, and I are in the mountains (without the kids). It is so beautiful. We left and it was 92 Orlando. It was 72 when we got off the plane.



We got to the house, unpacked, and almost immediately poured some Gentleman's Jack, lit up a cigar, and sat on the rocking chair, looking out over God's unbelievable creation. You can see Virginia and Tennessee from the porch.



After some relaxing we fired up the grill and had some steaks to top the evening off.
Wow, what did I do to deserve this?

Today, after sitting around, talking on the porch in our pajamas, the boys are going to play golf and the girls will do some shopping. I think our hosts are going to drive us around to look at the homes that are for sale. My dad is going to retire in 20 months, so I am trying make him love it here, too.

Tomorrow we are going to drive up to Virginia (about an hour) and we are going on this 17 mile downhill bike ride. I think they drive you up to the top, put you on a bike and then you just coast down. They even provide lunch halfway through! My kind of bike ride.

Listen, I am not bragging. I am trying to urge you to get away. We are totally doing this long weekend on the cheap. We got a cheap flight up here and we are staying for free. We traded with a babysitter and we are eating in for all the meals. Vacations are not biblical or anything, but they are sure good for the soul. Especially when you are with friends and your soulmate, looking out at God's creation. I am urging you.

But I have to go. My wife and friends are giving me that look. So I am going to leave you with a couple of YouTube videos that I have seen recently.

http://www.youtube.com/watch?v=mTTwcCVajAc
This video is so crazy. It was referenced in an article in the Wall Street Journal. There is much discussion about wheter it is real or not.

http://www.youtube.com/watch?v=SsWrY77o77o
Just a funny comedian bit. So many of the people I have talked to have seen it. I think you will like it.

Have a great weekend. And remember to start planning that weekend get away.

See you Wednesday,
john

How much is your integrity worth?

If you have been a long-time reader, you know that I wrote a blog awhile back called "Whistle Blower" (I think). I told you that the next time I hear of unethical behavior I am going to blow the whistle. Last week, I heard of two things that I have been incensed about.

I had an assistant last week that I have known awhile. She fills in when my assistant is on vacation. She said the dentist that she works for just made a declaration that all MODs will now be crowns. I am so mad that I think my head is going to blow off my body.

Then I started talking about this to another member of my staff. This employee is new to my office and I started asking her about her last boss. I asked her about if he did a lot of fillings. She was the office manager, so I thought she would know. She said that in 11 years she worked there, she thinks she remembers him doing a total of 5.

WHAT?! FIVE fillings in 11 years.

She said he did all crowns. Then she said, "Oh yeah, and he did a lot of crown lengthening." I have been pacing my office for the last couple of days. I don't know why it keeps surprising me, but it does. I think every dentist got into dentistry to make the world’s teeth better. Maybe they did and life got in the way.

If you are not in the dental field and you don't know what all this means, basically these dentists are over treating patients and what they are doing is borderline malpractice and totally unethical. I am going to blow the whistle on these dentists but I don't know how. I will keep you posted.

I have a story that I wanted to tell you and I am sorry that these two sorry dentists ruined the intro.

I have told you that I do my own lawn. One of the pieces of equipment that I have is a Ryobi engine for all my other stuff. The engine is the driver for the edger, weed-eater, and hedge trimmer. On the shaft of the engine is a quick release and you can just snap on which tool you want to use.I love this thing. It is not the most expensive or the most well-made, but it does the job. I usually buy a new one every two years; they are about $150.

This one has been through the ringer. Halfway through its life I had it lying in the garage and I ran over it with my truck. It had a little bend in it. I still used it but I knew it was on its last leg. This weekend I was using it and it just stopped working.

I said a little prayer for it and played TAPS on my bugle, then got in the car and drove to Home Depot. I bought another one and I was out the door in 10 minutes. I got home and busted it out of the box, put gas in it, and continued to edge.
I was in the middle of edging and the engine stopped working. I tried and tried to get the thing working, but it wasn't happening. I put the thing back in the box and jumped in the car. I was in Home Depot in 10 minutes. I exchanged it for a new one (telling them that this one didn't work) and was home in no time.

I busted it out of the box and this time I noticed a yellow tag on the opening where I put the gas. The first time I just ripped it off. This time I read it. It said in big letters THIS PRODUCT IS SHIPPED WITHOUT OIL. PLEASE ADD OIL TO THE MACHINE BEFORE USING. WE HAVE PROVIDED THE OIL ... and so on.

I found the oil in the box and was like OH S!@T! I didn't put oil in the engine (and if you don't put oil in an engine it will probably run for about 20 minutes before it freezes up and will be ruined). I didn't read the instructions and I ruined the machine I just took back.

I thought about it for a while. I knew what I had to do. But I started to try to justify another option. "Just let it go. No one is worse for the wear. It is Home Depot; they make so much money they are not going to care. Home Depot will just send it back to Ryobi. They will not lose on this deal. They don't know me."

None of it held water with me. I don't know what it is with me. I am honest to a fault. I do not have the capacity to lie. I don't know if it is how my mom raised me or Scripture (Luke 16:10 - Whoever can be trusted with very little can also be trusted with much, and whoever is dishonest with very little will also be dishonest with much). I knew I had to call.

And I knew the worst that could happen was that I would have to pay $150 for the first one. Maybe we would split it or something. And I knew there was a small possibility they would say, "Forgetaboutit." But it was not up to me to speculate.

Anyway, I called and told them the story. The woman I spoke with was very knowledgeable and knew exactly what I was talking about. I told her that I thought I probably did the damage and asked her what I could do to rectify this situation. She said, "You got a new one right?"

"Yes."

"And you are happy?"

"Yes."

"Well, then that is good enough for us. We appreciate your honesty but we are good."

I was thrilled. Not only thrilled that I didn't have to pay, but that I was willing to do the right thing even though it was going to cost me. I hate spending money but I hate being dishonest more.

Look, we ask our patients to treat us fairly and now that I am a customer/patient, I feel they expect the same thing from me.

Just a story to make you think. I don't really know how much it relates to our profession but... What would you do? You can be honest; it is anonymous.

Have a great Wednesday,

john

P.S. I am going to the Mountains tomorrow for a couple of days. I will try to write a blog for Friday but I might be enjoying the 63 degree weather too much.

Tid Bits

Greetings,

I hope everyone had a great summer. It was hot one here in Florida, so I am looking forward to the cool air. I am glad football is back. My Dolphins didn't do well against the Patriots Monday night. I hope my heart can take it the rest of the season.

Fall is also a great time for house concerts. If you have never been to a house concert, or hosted a house concert, you need to check them out. First, you have to enjoy live acoustic music. There are so many talented singer/songwriters that tour the country (or the world, for that matter) just to play in people's homes. There is usually a suggested donation to the performers of $10.00, and everyone brings a dish to share (like a potluck). If you love music, there is nothing quite like it. If you are interested, please let me know; I can give you more info.

Also, now that summer is over, I need to get back to my cooking series. (pausing for effect while that sinks in). I think I am up to 15 views on YouTube! It’s just a matter of time before I am picked up by a food network. You can all say you knew me when…

I titled my blog "Tid Bits." The disjointed nature of the subject is on purpose. I am going to place my first implant on Friday! To say I am nervous is an understatement. I have been to a ton of courses that let you place an implant in a wooded block, but for some reason (call me crazy), I don't feel like it is the same experience as placing one on a live patient. I screened close to 100 patients to find the "right one." There were certain criteria that had to be met:

1. You had to be able to open 60 mm, and stay open for approximately 3 hours and not complain. This criterion eliminated about 80 people right off the bat.

2. You had to have an alveolar ridge width of 13 mm, and an alveolar ridge height of 20 mm. (I was trying to make this as easy as possible for myself.) Another 3/4 of my pool of patients were gone. If you had a rare anomaly of having no nerves or blood vessels in your mandible or maxilla, that would have been good, but I couldn't find anyone.

3. You had to be able to drive.

4. You couldn't be related to me (that's obvious).

5. You couldn't even know someone related to me. (just in case things go sour)

6. You had to have another home, more than 200 miles away from Ocala, which you were planning to move to by the end of the year.

Believe it or not, I found someone! I will let you know how it goes in my next blog. It should be a good story either way.

Have a great week.

Scott

Swiss cheese

Greetings,

Yesterday was Luke's first football game. I told you that he was the starting defensive back. Well, things went surprisingly well. Two sacks, nine solo tackles, three tipped passes. No, I am just kidding! He did have his first game and he did have one tackle (they said his name on the loud speaker!), and he was all smiles.

The other team was small, but they were much faster and obviously had been doing this much longer than us. We were on the wrong end of a 38-0 score.

Speaking of football, I am going to Gainesville tomorrow for the University of Florida vs University of Tennessee game. A 3:30 p.m. start time. Yesterday it was 93 degrees at 3:30 p.m. I guess I will just have to stay hydrated....if you know what I mean.

Also, I recently watched a movie called "Casino Jack." Fairly fascinating how people can get so crooked and then get blind to their own depravity. But overall, not a very good movie.

Okay, onto the topic.

I was talking to a friend of mine this morning and he asked me how it was going. I mean, we all kind of know how it is in the back of our minds, but when someone asks you and you have to verbalize it, it is different. I told him my schedule was busy. Good people. Good work. Things were really good. But the weird thing is, my hygiene schedule is not good.

Since I have been working hygiene has been slow, but now it seems different. Usually if there is a problem it is the day of. What I mean is that the day is full when we have the huddle in the morning, but then people "get sick" or make a schedule change on that same day. And it was months ahead too. Meaning, we schedule people before they leave, and that means everyone who is coming has an appointment. So then six months from now, there really aren't any openings. So you might be booked and it would be hard to get anyone in unless someone cancels.

But lately, it is different problem. We come to work and there are eight openings in the hygiene schedule (for three hygienists). This is a problem. I know what you are thinking, "Well, you just need to let someone go". Well, and I know we all are in the same boat—I like the people I work with. Each one has their own niche in our office. But our situation is a bit different.I have a hygienist that is 7.5 months pregnant. So, it is going to be four more weeks or so until she is going to go on leave. Then things will be okay.

Until then, I have begun to communicate my concerns to everyone. I have told her that if she is miserable and not feeling up to it, just let the front know and they will move all her patients to the other openings (I mean they all see it and they all know that there is a lot of pressure on everyone). The hygienist has been very understanding.

We are all working our butts off to fill the hygiene schedule. Everytime there is an opening I see the hygienist working on the schedule. It is like a sales room here. We have a bell that we ring and they yell out "Got one," and we all cheer when they have booked a teeth cleaning.

But boy, have things changed! I don't know if this hygienist being gone for four months is going to bring many changes. I don't really see it getting better. I am seeing that this is going to be a struggle for a bit. But I am sure hoping.

I keep track of how many openings there are in the hygiene schedule monthly. I track how many openings there are at the start of the day and how many cancellations/reschedules there have been. It ain't pretty. I don't know what else to do. As the penguins say in the movie "Madagascar,"—smile and wave boys!

How is it with you? I would love to hear it....misery loves company. See that is the thing, I am not miserable. I am busy, and while I am running around I see a bunch of hygienists on the phone. It doesn't get me miserable because I know I can make up for it. But instead of my profit going to me it is just going to them. And that stinks.

Have a great weekend.

john