All You Care About is Money

I know, I know. I told you I wasn't going to talk about money again for awhile. Has it been awhile?

Lately, I feel like I am getting some flak for "being expensive" or because "all I think about is money." But I feel like I am a fair, conservative dentist. I try to be the guy that saves people money.

Sure, my exam is thorough and when we are done taking a full mouth series and a Panoramic (which I don't charge for), the exam can be in the $225 range. But I think I am doing a pretty good exam. Perio charting (which most 50-year-olds have never had done), oral cancer screening, looking around, looking at their bite and teeth and joints. We have a sit-down conversation in a consultation room. Patients get my time. Isn't that what patients want? To feel like they are being cared for and not rushed? Or do they just want the $55 x-ray and exam done by the big teeth corporations? I think they want the former.

After I do a thorough exam and find some cavities, I tell them that they have some restorations that are broken (I show them the big broken filling with the intraoral camera; I am not making things up here). And I think that I can do a filling and restore that tooth to good again. No, I don't think you need a crown (which most dentists would do at 500% the cost of a filling).

My fillings are expensive. But are they really? I do a better job than the schmo down the street (if you are a dentist down the street from me, I like you; I am just being creative with my words). I use the BEST products. The filling I do is superior. So I am $20 more than another dentist. Maybe it is $50. Didn't I just tell you that most dentists would put an $800-$1,100 crown on this?

So when I hear from my staff (I never it hear it from the patient. They tell my assistant the person answering the phone) that all I care about is money. WHAT?! Are you fricking serious? I go to the best continuing education. It costs money to have a nice facility and good staff members. And all this costs about $20 more per filling.

Look, I get that money is a big issue. I get that dentistry is expensive. I know. But I feel like some people are killing the messenger. I am who I am. I am the dentist that does really nice work and hopefully the dentist that people go when they want to like their dentist and feel cared for. I am not a regular dentist, and it will cost a bit more. But for patients to come here and say that all I care about is money? Well, that hurts.

I am going to stretch here and tell you I am like the Hilton. The Hilton is a beautiful hotel. They have awesome beds, great sheets and pillows. They have great staff that say, "It is my pleasure." They have things in place to make you feel so good. And after a stay there, you feel special. Then you check out and say, "Man, that was a little bit more than I meant to spend."

Then the next time you try a bargain motel. You don't have a very good night’s sleep. You are just a number there. You get the bill and don't think anything of it. But you start to think, "Remember that Hilton? Yeah that was really was nice."

You can't blame the Hilton for being more than you wanted to spend. We as dentists feel like we are being thorough and find stuff. Then the patient always thinks we are trying to find stuff that doesn't exist (you aren't doing that, are you?).

It might be a bad time for them, I know. But if you look at me through a microscope, you are going to find warts. And maybe I used to just brush it off. Maybe now I am a bit more sensitive to criticism. I don't know.

I am trying to make this place worth the $225 exam and the extra $20 filling. It would be easy to just lower the price and work faster and make people feel a little less special, but I don't want to do that. I want people to say, "Remember Dr. Gammichia? Yeah, he really was nice." Or even better, "I love my dentist and I will stay there forever."

I am not bitter. Just sensitive, I guess. I will keep at it.

Have a great weekend.

Beer me,
john

Product Review

Hope things are going well for you and that you guys are busier than me. It has been such a grind lately. I think this lecture thing better take off soon because I might need that to pay the rent.

My father read my blog last Friday about old guys selling their over-priced stuff to the young guys who can't afford it (because the banks won't lend them the money). Even though it wasn't about him and me, it prompted him to come to me. We have agreed on the price and to the terms. Now I have to draw up a business model and go to the banks to see who will give me the best deal. It all sounds easy, but I know this is going to be a long process. I am getting tight just thinking about being the only owner of this sinking ship.

I’m making it sound worse than it is. I love this practice and the people that come here and the people in it. It is a great practice, but buying a practice that has decreased in production for the last 4 years is scary.

I want to talk about some filling products that I have tried recently. I have used the sectional matrix and BiTine ring for a long time. In the last 5 years, I changed my ring the Triodent V3 ring. This ring is so sweet. I kept using the sectional matrix.

But I bought a sample of Triodent’s SuperCurve matrix. Have you tried these? Wow! The sectional matrix is about 25% of a circle and the SuperCurve is about 50% of a circle. It wraps around the tooth. You might not think it would make that much of a difference, but it does. The gingival 1/3 of this matrix bends in to form the CEJ. It is pretty cool.

I usually work with Patterson. They have this deal where, during the year, you build up reward points. Turns out, at the end of the year, I had 1,200 points (each point being a dollar). I had to use $900 before the end of the year or I would lose it. Instead of buying things I really needed, I bought the SonicFill system from Kerr. Have you seen this?

Now, I struggle with using something that might not be as good as the stuff I am presently using. So I did my research and everyone really likes it. Reality and CR are all giving it great props. I used it today for the first time. Let me tell you that it turned out really nice. A lot of my stuff is not really material-dependent, but if it is less expensive and it reduces my steps, then I might try it.

While I was buying the SuperCurve matrix, I bought some 360° Cervical Matrix. This is basically a form guide you put on a facial filling after the composite and before the curing. It is clear; you put it on the filling and cure right through it. Wow, is this thing nice. I have always worried about whether or not the filling is tight in my facial box and about it pulling away at the margins. This thing takes care of both, and then afterwards the margins are like a baby's butt.

One last thing. I’ve started sealing my margins after a posterior composite. Burgess says that the occlusal wear is reduced by 15% if you use a sealer. That sold me. I bought Bisco’s BisCover LV. Not only do I feel better using it because I know it is going to make my fillings last longer, but it makes them look so good.

I know it is good to hear about it, but the proof is in the pudding. Here is a case I did this morning.

30-MO

 

I told you.  Really nice filling.  And this took me about 15 minutes.  No joke.  Adding the photos to the appointment made it 35 minutes.

Have you used these products before? What do you think? Do you have any products that I should know about? Have you checked out the AGD’s Product Review Directory? Let me know.

Hope your week is going well.

john

Why Not?

Greetings,

I hope everyone is healthy and happy as we start out 2012. After a long discussion with my family and some close friends, I’ve decided to email the owner of the Miami Dolphins and express my desire to be considered for the head coaching job.

Hopefully by the time this blog goes out, they will still be interviewing (which will increase my chances). If I get hired, I will probably have to give up the AGD blog because I will be spending a lot of time going over game film and interviewing my potential staff. I will miss writing to you all and I will miss dentistry to some extent. Maybe I can work a month in the off season? We’ll see.

The way I see it, I have a good shot now that virtually every big name has turned the job down. As a matter of fact, I have a few things going for me:

1) Miami is my hometown, and who wouldn’t want a hometown boy?

2) I’ve been watching the Dolphins play for the last 45 years, so I have an intimate knowledge of the team and what they need.

3) I couldn’t care less if Jeff Ireland stays on as the general manager. Shoot, why not have someone else do all the work?

4) They wouldn’t have to hire a team dentist (I may want a slight bit more cash in the agreement to cover both jobs).

5) I can give a locker room speech after each game. Granted, I am only 5’6”, but if I had something to stand on, I could tell the men how proud I am of them and maybe give out a game ball.

6) I can talk to the media because I know all the coach lines. For instance, “They made more plays than we did”, or, “The refs made some bad calls out there.”

7) I wouldn’t demand a large salary. I would take half of what they were going to pay Jeff Fisher! That will save the owner over 20 million dollars over 5 years. Maybe we can use that to get a quarterback. Who knows?

I do have some good friends with football minds. I might be able to talk Dr. John Gammichia into being my offensive coordinator. I mean, he has only called some peewee league plays, but there can’t be that much of a difference. I went to dental school with a couple of football players that might be able to work with my defensive and offensive lines. There is so much to think about right now that it’s a little overwhelming. I am going to be up long hours trying to figure out how to keep Tom Brady off the field.

There is also the small snag in my partnership contract saying that I can’t leave for more than a few months. I am still working on that one. If it all works out, I can get the Dolphins back on top in just one contract period. After that, I could go right back into dentistry, or maybe travel for a couple months. I would love to be able to travel in Europe. Other teams might want me once they see my results at Miami, but relocating out of Florida is something I may not want to do. Time will tell.

I wouldn’t forget about all of you out there either. Being the head coach, I could probably score a few tickets to some games. Just shoot me an email and let me know how many you need. I can have a Dental Block! (Total pun intended.)

Of course, if Mr. Ross hires someone before he gets my email, then I guess I will have another blog here in a couple weeks. It also means that I will have to see Mrs. Smith next month for that 16th denture adjustment. My plans for traveling in Europe will be shot down, too. The sad part is, we will have to all suffer through another bad season for the Dolphins.

Talk to you all in a couple of weeks (maybe).

Scott

What Would You Do?

F-R-I-D-A-Y! Oh yeah!!! Hope all of you are having a good week. Pretty good here.

I saw Hangover II last week and I didn't think it was that good. I am in the middle of Super 8. I have to say that I haven't had much time for movie or books, and nothing I have read or seen has been that good. Let me know if you have seen anything good lately. My queue is kind of flat.

I liked Wednesday's blog and that "what would you do?" kind of thing, so I am going to do another one.

Before I forget: I have been asked to be the guest speaker at a study club in Miami (or as my kids would say, “Your-ami”). You know the study clubs where the meeting is in a restaurant and there is a speaker at the front while everyone is eating? I am going to be that guy. I am kind of nervous, but I got myself into this so I might as well jump in with both feet. It is on a Thursday night. I will finish work at 1pm, get in the car, and be there a little early. I’ll eat, speak for 2 hours, sleep, get up and come home.

I think it is a great way for me to practice and get my name out there. Triodent is putting it on, so there is a little pressure for me to perform. They will have their rep there and she will tell corporate if I stinks or not. It is in three weeks and I am freaking out.

Anyway, I have this patient. He is a 70 year old man and a really good patient. I took this x-ray the other day.


Knowing what we talked about the other day, take a look at the distal of #30. Man, this is a tough one. There is a little spot, straight distal. But I know that to do this little thing, I have to blow through the marginal ridge and do a DO. If I wait, there is a chance it would be humungous the next time I take an x-ray. You can see on this x-ray that he isn't very cavity-prone. On this x-ray, all he has is a facial filling on #5. Would you do it? Would you wait? Tell him to up his home care?

Okay, next one. This patient is 7 years old with decay on distal of #F.


On paper, there is no question: do the filling. But looking at the x-ray, the permanent molars are getting close. Her 9-year-old sister is in the other chair getting her teeth cleaned and she has already lost her upper first baby molars. Is that cavity going to be an issue in two years if not done? If it becomes an issue, what is the big deal? Just take it out. We know the permanent tooth is going to be really close. But to do the filling is so easy. Just 0 minutes and she’ll never have to worry about it. But I don't want them to have to pay for something that might not ever be a deal.

Anyone have an opinion? Oh, let me rephrase that (I know you have lots of opinion; I have read all the comments). What do you guys think?

I hope you have a great weekend.

john

Cervical Burnout

Oh my gosh. Are the weeks flying by, or is it just me? It seems like we spoke on Friday and bam! Here it is Wednesday. I hate that my life seems to be going so fast.

I got to play golf this weekend with some buddies. I love golf, but I never get to play. How does this sound? "Honey, I am so glad it is Saturday. I had such a hard week. So, it is 8am now and I have a tee time at 9. I am going to leave now and hit some balls before my round. The round should take about 4 and a half hours, and then afterwards we are going to sit around and have some beers. Expect me around 4pm. And yes, I know you have been with the four kids all week, but I need an avenue to relax."

I don't know about you, but this stuff doesn't fly at the Gammichia house. If I said the above, all my stuff would be on the front lawn when I got home. But I digress. I went on a church retreat and part of it was golf. The weather here is so nice and the golf course was beautiful. I love stuff like that. It is really not about the score but being outside and having a beer and a cigar. Awesome. That is why I want that Shelby Cobra. Then me AND my wife can jump in the car (lock up the kids in the pantry) and enjoy each other and the beautiful weather that central Florida gives us.

Today I want to talk to you about Cervical Burnout. I realize that most of my posts have been about money, and I want to try to get away from that. I realize that most people are dealing with money issues one way or another, and I wanted to talk about things that are current and on the minds of dentists. But too much of one thing can be bad. This is a non-money issue.

I assume most of you that read blogs are more on the high-tech side, which leads me to believe that most of you probably have digital x-rays. Five years ago, when I got digital x-rays, I had to make a decision about which product to go with. We are big Patterson people here and we were already using EagleSoft, so it was kind of natural that we would go with EagleSoft and Schick.

Anyway, that is not what I want to talk about. What I want to talk about is that I find there is a lot of cervical burnout showing up on digital x-rays. One of the issues with digital x-rays is not with seeing a dark spot but deciding what that dark spot is. Most of the time, what I am seeing is virgin teeth next to crowns. If there is a crown, the adjacent tooth has a lot of radiopacities on it. Sometimes I go in there and try to feel something and the contact could be too tight. Now I have this supposed lesion on a tooth that I can't feel. What do I do? It looks like decay, it smells like decay, it is in a prime spot for decay. Is it decay? Most of the time, it is.

Check out #15 MO.


I want to say that I am really good at reading x-rays. I thought this was decay. I appointed him and I got into it, and I didn't see decay. It is tough because sometimes I go into the interproximal and it is two steps. I cut a box and nothing. Then I go deeper than I think and there it is. Or I think the decay is on the straight mesial and it turns out to be on the ML ling angle. So I cut into this thing and I didn't see anything. I went deeper and there wasn't much there. I went a little wider and I started to see what was going on here. IT WASN'T THERE. So I did the best damn filling I could and hoped that I actually took out some decay while drilling this tooth.

Anyone dealing with a lot of cervical burnout on their digital x-rays? Ever go into anything that wasn't there? (For the record, I did this once or twice with film as well.)

And before I forget, the next thing on my list is to get Kodak sensors. I know there are going to be some bridges and it is going to cost a bunch, but I think it is the best image and my patients should have the best.

Thoughts?

john

Deadly Combination

Happy Friday to you. I have been talking to a lot of younger guys lately and it seems like all of them have the same story. Guy/gal has been a dentist for a very long time, has built up his/her practice for a long time, has worked hard, but doesn't really save a lot of. Life, school, cars, college, weddings all get in the way of saving money. But don't worry; his/her retirement is going to be selling the practice and either leasing or selling his/her building to the new dentist.

Have you heard this story before? See, practices used to be worth a lot. There used to be lots of buyers with money. Properties used to be worth a lot. Words you should key on are “used to.”

It’s very different now. All the dentists that are ready to retire have seen a drop in production and have seen their practices decrease in value big time over the last 3-4 years. And the rent money they were counting on? It is now about half.

So the guy/gal getting ready to retire is in a bit of a pickle. The associate dentist or new dentist coming out of school might be a couple of things:

1. He/she could be very wise to the way things are going and realize that the practice he/she was going to buy is now worth less. The awesome, money-making practice that he/she was going to buy is now barely paying the bills.

Or...

2. He/she might be just getting out of school and have tons of debt and have no credit to go to the bank to borrow money.

Do you see what is going on here? These are deadly combinations.

Now the story I keep hearing is "This guy is crazy!" Dentists my age are getting ready to buy the retiring dentists’ practices and it seems like the sellers still think their practices are worth what they were four years ago. And the same with the rent. I can tell you from experience that my rent is too high. And it has been too high for a long time. But going to MY landlord is pretty tough.

I have a friend who is in an all-out brawl with the guy who owns his building. The guy is on the moon with the prices. His lease is up in September, but my friend knows that moving his practice would cost him an arm and a leg. Getting a new place, architectural drawings, the build-out, equipment. Then there is the simple fact that moving the practice is a pain in the butt. And patients don't like it. Plus, he likes it there. He wants to stay. Staying is good for the practice, but paying ridiculous prices is cost prohibited. Then lawyers are going to have to get involved, and nothing good can come of that.

Now in many cases, including mine, the deal was done on a handshake. This is very,very bad. People forget things, especially those who have been sucking on amalgam dust for the past 15-40 years. At the time when the agreement was made it seemed fair. But now it isn't or someone forgot a detail. Or one of the situations is different and one person can't live up to their end of the bargain and the deal had no clause for that.

I have to tell you that I am moving in the direction of practice transition specialists. I used to think they were so expensive. “Why do we need them? We are both reasonable people." NOT.

If people would just spend $5,000-$10,000 for a transition specialist, all of this would have been drawn out and we could just sit back and relax. Saving of $5,000 five years ago might now cost my friend $50,000-$100,000 in leasing and building out another building.

Are you guys hearing this story? Anybody the seller? Are you being pinched by the present downturn in the dental biz? Anyone about to buy an office?

Have a great weekend. I have to go, I have my transition consultant on the other line.

john

How Much is Enough?

Back in the swing of things, I hope. Well, I am going to get right to it.

As you know, I am going to start lecturing. Every day I think of another way to relay my message about being conservative. I know that money drives people.”I might not make enough if I do this kind of dentistry.” What am I going to say to these people? If you are doing a lot of crowns, you are going to stop? I have to be able to tell them that they can make enough money.

But how much money is enough money? I went to the ADA's research center; they have all this data put together that they will email to you or that you can just look up, and it’s free: www.ada.org/freereports. I looked up what people make. I figured if someone is doing a bunch of crowns and is making $310,000 and I tell him that the average income of a dentist in his/her area is $180,000, they might see things a little clearer.

If I know the average salary in my region of the country is $179,920 and a dentist is making $250,000, “how much is enough" gets put into perspective. I know, I know. Your pathologist friend is making a lot more than you but guess what. You are not a pathologist, get over it. (That is a shout out for Connie.) Now that this is established, I will go to the numbers.

There is no question that doing fillings is harder on the body than doing a crown. There is no question that you need to do fillings on many more teeth to make the same kind of money that you make doing crowns. Personally, I don't hesitate to do a filling because I believe that it is the best thing for the patient (it is my job as a presenter to possibly get them to agree with me).

Let’s break this down. I schedule 90 minutes for a crown Temporary time is included in this. Then the cementation appointment is usually 30 minutes. So I have two hours in this procedure, and I charge $1200 for a crown. That is easy math: $600 an hour. But don't forget the $200-$275 it takes to make the thing, and then the impression materials. So we’re down to what, about $475 an hour?

Now, all you non-dental people, don't get all crazy. These numbers look great, but don't forget all the insurance we carry, the rent, the employee wages, the employee benefits, electricity, supplies, etc. I am not saying it is bad, but we don't make $475 an hour. I am letting you see behind the curtain. If I get lots of nasty comments, then I won't ever write stuff like this.

Let’s compare this to fillings. On Friday, I did a photo shoot with one patient. It was a perfect example of what we could do with fillings. I took photos of all the stuff we did, of the teeth, and I also took pictures of the clock.

It was a 2 p.m. appointment: 3-MO, 4-MOD, 5-DO. After some normal pleasantries, we got going at about 2:06. Injections and then drilling. I have to admit: these were easy. The fillings were breaking down, but there wasn't too much decay or real breakdown. I took out the amalgams and decay and took pictures at 2:18. Fill 'er up, take pictures. 2:32. Clean-up, finishing, polishing, check occlusion, repolish and then seal. Take pictures. 2:41. They turned out great.

I will say it took 45 minutes. I usually don't schedule this tight so I think his appointment was probably an hour (maybe a little more). But for this exercise, let’s say an hour. In my office, this is $240, $280 and $240 for a total of $760. There was no lab bill, just some supply cost (not as much as impression material). So basically, $760 an hour. Okay, maybe all fillings are not that easy. I did a DO and an MOL this morning that took me 90 minutes. That is $520, which is about $350 an hour. So fillings might range from $346 to $760 an hour.

What if the patient only needs one filling? I usually book 30-40 minutes for one filling. It doesn't take me that long, but I allow time for greeting, anesthetic, filling, polishing, saying good-bye. The minimum filling appointment is 30 minutes. Sometimes it might be a facial filling for $180. Say you do that all day. That is 16 half an hour appointments doing 16 facial fillings. This is a $2,900 day. But don't forget you have broken the rooms down 16 times and you may have had a decent production day, but you are dog tired and your assistant is really ticked at you. I guess there are worse things we could do.

All this to say that fillings are, and can be, profitable. Trust me, I am telling you this from experience.

What do you think? Do you agree?

Hope you are having a great week.

j