Friday, June 26, 2009

Just a couple of stories

Okay Noah is the funniest five year old ever. I have told you stories but this one might top them all.
He is doing Vacation Bible School for the first time this year.
It is the first time he has been with these teachers so I think he recognizes this as an opportunity to charm other woman or it is just could be natural for him.
One kid, Nathan, came into camp this week with a wad of gum hanging on the side of his head. Noah seeing this he went to the teacher.
He asked if Nathan was in his class today.
The teacher told him Nathan was in the other class today.
He said, "Good, because I think I see Nathan's brains coming out."
Now some of you may think, the kids is a goof but I tell you he had everyone rolling.

Another funny story.
I just joined the Florida Academy of Cosmetic Dentistry.
See they have an annual meeting this year in Orlando. They have put a pretty good program on this year, Dr. John Kois and Dr. John Cranham and Cathy Jameson.
I wanted to go to this meeting. I looked it up and it was free for members of the academy and it was $650 for non-members.
I thought to myself, "How much could it be to join? I mean if I join I am in the meeting for free."
I called the FACD and asked how much was it to join their illustrious academy and she told me $550.
I was like cool. I will join and save $100.
Well I paid for my membership and found out there is a $100 first time processing fee.
So I didn't save any money but now I am part of the club and I get to go to the meeting.
So the story begins here.
I get an email from the FACD...I will print it.

Dr. Gammichia,

This email is a follow-up to a voicemail left this morning. FACD recently determined that it was going to start a monthly e-newsletter as a value added benefit for its members. The newsletter will offer various tips for improvement as well as updates/changes in the profession and with your Academy.
Our first newsletter is right around the corner and one of the features will be a New Member Spotlight where we highlight a new member of FACD. Your name immediately came to mind as you are the newest member of the Academy.
If you are interested in being highlighted in our newsletter, please let me know. All it would entail is that you would need to answer the nine questions below and submit a headshot (there is an adorable one on your website with your family we could probably use).
I look forward to hearing from you and once again, thank you for your support of FACD!

This woman also left me another message on my voicemail.
I bumped up my chest and started with, "Oh they must know who I am."
I started thinking that the FACD offices were all a buzz that they now have a member in John Gammichia.
So I called them. She went over the whole thing again and I agreed to help them with this "New Member profile."
I then ended the conversation with "Why me?" I didn't really believe that I was the newest member....there had to be more.
She stated very clearly that they were doing a new member profile and that I was THEE NEWEST MEMBER.
So it was not because I am getting huge in the dental world. It is not because they know me up in the offices of the FACD. Man what a blow to the ego (the problem is I have an ego but it is all my own doing. It is not because I have deserved an ego)
I depressed my chest and told her I would do her stupid thing.
So look for the August edition of the FACD monthly emailed newsletter (it is huge) and you will see my ordinary, not so huge in the dental world mug.

Hey have a great weekend,

Two weeks until the AGD meeting. Anyone going? If you are you have to go to the baseball game on Friday night. I am going... and you know I am huge (almost 200lbs).

Wednesday, June 24, 2009

Invisalign II

Hi all,

I have been pretty busy lately. Summer is here. TV shows are no longer new (I guess that is why John and Kate plus 8 did better than all the networks on Monday night).
We are swimming everyday. It has been in the high 90's for a couple of weeks now. Our pool water temp is in the mid 80's. It is too warm. So when you jump in the pool to get refreshed you don't refresh.

So without the fresh TV shows we are in full movie mode.
I took my wife out on Monday night to see Pelam 123. It was pretty good. Not awesome but pretty good.
And the Netflix movies keep coming.
I just finished watching The Boy in the Striped Pajama's. Has anyone seen this one? It is a film about a family. The father is a higher up in the Third Reich. He is moved to the country side to "do work" for the war. Turns out he is in charge of a concentration camp. His kid is 8 and doesn't understand what is going on. He thinks the buildings he sees in the distance is a farm.
He wonders over there (even though his mother tells him not to) and meets another kid through the barbed wire.
Not knowing the evils going on around them they start a friendship. I won't tell you the rest.
I have The Curious Case of Benjamin Button sitting at home, I will let you know.

I started Same Kind of Different as Me and I am on page 20 so I can't comment on it.
I have about 5 books on my queue at home. My assistant says I HAVE to read Running with Scissors. And there are a couple of others so....I might get to all of them this summer.

Topic de jour.
I don't know if you have felt it but...the Invisalign thing is going to be huge.
I think we broke the story on this blog (I just love saying that even though it is probably not that true).
The AGD just sent out a stand to all its members and this is when I think this is when I appreciate being an AGD member the most. When companies think they are bigger than the dentists and the patients they are treating .
I can tell you my dad does not cuss.
My dad is the Invisalign guy at our office and last week we were sitting in our office doing work and I hear him say, "This is bullsh@#$%t ." I said, "what is the matter?"
He says I just got this letter from he wasn't happy. And things usually don't ruffle his feathers.

It is getting mighty steamy here in the south. The grass is growing an inch a day. This is the first time in my life I have hired a yard man and it was so nice to see the grass mowed and weeds pulled coming home from a long weekend out of town with 100% humidity and 98 F weather. That made it worth every penny.

Well thanks for the comments, like myself I have found there are several of us out there with similar feelings about Invisalign and their policies.

I was at the Florida National Dental Convention this past weekend, and sure enough so was Invisalign peddling their system. I wonder if they are telling the dentists taking Clear Essentials I that there is a yearly requirement? According to one of the dentists I know they are not. He singed up for the class at FNDC and when he found out that he was going to have case requirements he was well lets say…… upset! He called FNDC and informed that he would like to cancel his Invisalign registration and would like a refund. At first the meeting representative hesitated but then after the dentist explained to her why he was canceling she assured him he would receive a refund. I have not met one person that has seen this as a good move on Invisalign’s part.

I am finally seeing first hand why it is important to belong and support organized dentistry. The ADA has informed me that they are looking into the issue but the AGD has been the most active so far. With over 35,000 dentists members hopefully they can get the message across to Invisalign. If you have not seen or heard the Academy of General Dentistry has sent out a point paper and contacted the CEO of Invisalign for clarification on the policy. From what I have read Invisalign has not done anything yet but give out the same flimsy excuses to hide their true reasoning.

I encourage everyone to contact Invisalign to express your displeasure. It seems like all the field reps have their “talking points” and are like good little soldiers barking out the company line. The AGD email to express your concerns is . The ADG web site to contact the Invisalign CEO

Well if you are a fan of the Matrix Series movies you will understand this. Finally I have possibly found “The ONE”, Neo, which will help us topple the Matrix. I ran into another up and coming company called Clear Correct. They have a very nice web site that gives some basics of the system. I called and got some more detailed information and it sounds like a promising competitor to Invisalign. They are about two years old and are currently focusing on the west coast but will be moving east this winter.

One of the first things I thought about was “ok how long till Invisalign shuts them down with a law suite”. Well I called and spoke to a Clear Correct company rep, Arron (based in Houston) and he informed me they have already had a legal patent judgment in favor of Clear Correct over Invisalign proving there are no patent infringements. He stated that they knew that is how Invisaglin would try to shut them down and they took a preemptive legal strike” against Invisalign. Not to go into details but the systems seem similar top Invisalign with some additional advantages but the cost is about $600.00 dollars a case less than Ivisalign and no yearly requirements. Finally, an alternative to Invisalign and we can get “Big Brother” off of our back. This is not an official endorsement just FYI so go to the website and check it out for yourself. I would like to hear any feed back on what others think.

I definitely feel if we stick together and let these companies know that we will not tolerate their decisions that direct our care we can change attitudes and mindsets.

Have a great summer. Football season is just around the corner.

I promise I didn't tell him to say this last statement.
Have a great Wednesday,
If you have an opinion don't forget to comment.

Monday, June 22, 2009


Happy Father's day.
A rare Monday blog.
I hope you Father's had a nice day yesterday.
I had a really nice day. Family, food and fun.
My garage is done so I spent some of the day moving stuff in it. I now have a new attic so I was moving stuff in there. It was 101 degrees on Saturday so going to the attic this weekend was not a pleasant experience. You went outside in the 101 degree heat to cool off.
I was just excited to finish the garage. Its looking good.

Last weekend I was driving down the road and my five year old Noah says, "Dad, you know what you need?"
I said, "What do I need Noah?"
He said, "You need a Ferrari."
I got to tell you I totally agree with him.
But things are going to have to change in my life for this to happen. The blog is going to really have to take off and I will get international sponsors or the book I haven't written yet will be a best seller. Or someone is going to have to give me one. HINT HINT.

I finished my book, To Own a Dragon. It was good.
I am now reading The Same Kind of Different as Me. Everyone that has read this one has said the same thing. Dude that is a good book.

I went to the Florida state dental meeting this weekend. It is always in June and it is always in Orlando. Very convenient.
I saw a couple of lectures.
The first one was from a guy named Jeff Plank. The course was called The Fast,Furious and Fabulous Direct Posterior Composite Filling.
It was a four hour course. I saw 5 pictures of fillings. He spent 3 hours talking about composites. He spent an hour talking about himself. He spent a 5 minutes on how he does fillings. Then showed us his work at the end.
Here is my thing. Composites have been around in the mainstream for about 15-20 years. If someone doesn't know the science behind the composite filling TOO BAD. Don't spend an hour or TWO talking about adhesives and all the generations because all the old guys are trying composites for the first time.
Don't get me wrong he did very good work and he was fun to listen to but if you are going to have a four hour lecture on posterior composites don't you think you could show me some posterior composites.
I don't want you to tell me you do good work I want to see it. And I totally love this one,
"I did this filling this week with a product I just started using and I am starting to like it."
You mean, "you got this product for free and the company is paying you to use it and talk about it."
I hate that stuff. It is okay to get paid to do this but don't lecture on a product you don't know anything about and that you might stop using next week.

Is it me or is the pipeline slowing down?
I remember about 5 years ago I was being inundated with products. New products, new and improved products. More and more and more.
Now I don't feel overwhelmed by not knowing all the products because I don't feel like there isn't that much more coming.
Now it could be that I am just not out there as much or I don't WANT to know the new stuff.
I feel like I have settled in. I like it the way it is now and don't want to change.
I am telling you...I am turning into my dad.

I saw another lecture The Day in the Life of a Top Gun Team.
By Mark Hyman and his assistant Tina Calloway.
These kind of lectures are okay to go to but you really don't learn anything.
Mark is funny and a very good speaker but...if I wanted to laugh I would go to a comedy club.
I want to take stuff home. I want to go to office on Monday (or Tuesday) with new stuff. Not, I went to this funny course. And it was suppose to be a three hour course. It was one hour and 55 minutes.

I don't know, maybe it is me. Maybe I am too critical. Maybe I just pick the wrong lecture.
I now look back at the list that I had to choose from. Quickbook Essentials...NO. Estate Planning, securing your legacy....NO. A Typical Day of Laser Dentistry...NO. The Fundamentals of Air Polishing...NO. The Dental Spa...I am not into that right now. Ask and You Shall Receive, the Art of Getting the Yes...I am not into this either, ever. And Invisalign II...I would have taken this one but I haven't had the prerequisite.
So I am not a person that puts these things together but I picked the only two courses that made any sense to me and they both were average at best.
This is why I am looking forward to the AGD annual meeting. They know how to put a program together.
I told you I am seeing Howard Farran and Gordan Christensen. I am really looking forward to these lectures.
I am hosting the Howard Farran one.
I love doing this. I have done it about ten times and I think ONE of the guys gave me the time of day. I will let you know how it goes.

Have a great day,

Friday, June 19, 2009

Dental Boards II


Nothing going on.
The AGD annual meeting is less than three weeks away. If you haven't signed up is time.
I am coming in to Balitmore on Thursday night. Classes all day Friday. I am giving a little thing at the AGD Booth for my council on the Know Your Teeth website. Friday night baseball game and then classes on Saturday. Come home Saturday night.
Now that is how I am rolling now a days. No real time for relaxing. You have to relax in the mits of the rushing.

I think CBS had a left over episode of Worst Week and my DVR picked it up.
I was like, "What is this?" while looking through my DVR stuff. I watched it and I have to tell you I laughed for 30 minutes straight. I love that show.

I still have such a sour taste in my mouth about this whole experience.
I know it is a right of passage but to have to go through dental school and still have to go through this is too much.
I had to go through putting on a good face for my professors for 4 years. I took all their demeaning comments. I had to put up with some professors who didn't give a crap about the deadline you were on and had to finished their phone call. I had to smile and say "thank you" when they were telling my work was no good and to start over.
I had to sleep at the library for weeks at a time studying so much.
I knew the custodians by name. I was in the library so much that I knew where the best place to poo and not be disturbed.
I passed all the tests. I completed all my lab projects. I kissed all their butts and now I have to do this.
It cost about $1500 to take the test (and that was 14 years ago) and don't forget paying the patients. (Also as a side note. When a dentist from another state comes to take the boards he usually takes a review course. It is like a crash course on what the test is looking for. It cost $3000).
Now the patients are who I want to talk about today.
Now as a graduating dental student you have a pool of patients. It is your job to complete certain procedures on the patients that were given to you. If your patient pool does not have the cavities you need to do, you have to get more patients or borrow from someone else.
But when you are graduating you usually have completed all the needs of your patients.
So for the boards you have to find patients that have a certain type of cavity. Your patients that you know and become particularly fond of (and vise versa) don't need any dental work.
Well where to heck are you going to find them?
So my friend and I decided about 4 months before the end of school to start soliciting patients.
We made fliers and put them all over campus of the university and the local community college.
It said something like Free Dental Exam.
Between my friend and I we probably did over 50 exam just trying to find the perfect cavity.
Now let me tell you there were some interesting people that want free dental exams.
One in particular that I will never forget.
Before you do an exam on their teeth you do an oral cancer screening. Well I started by looking at his palate and then his tongue and I started to notice little black flakes in his mouth. Then you go around to the lips and you take your thumb and index finger and rub to make sure nothing is growing where it shouldn't.
This is when I realized the guy was a snuff dipper BECAUSE HE STILL HAD HIS DIP IN HIS MOUTH.
He didn't bother taking his dip out of his mouth for me to do a dental exam.
Real fricking nice.
So as you can imagine this is the type of person that I have to bank on to show up for the most important test of my young life.
Okay so I get a young woman with the perfect "lesion" (this is what we call a cavity). Then I find a person with a really good cavity for my back-up. They both promise to be there at 7am the day of the test.
I told them I would put them up in the hotel across the street if that was more convenient. See if you do this then there is a much greater chance they will show up for the exam.
In the same manner I am also looking for a person to clean there teeth. I find this guy that hadn't had his teeth cleaned in over 15 years. He was perfect. In this test you only have to clean 5 teeth.
But needless to say that he had more than 5 teeth that needed to be cleaned. So I had another classmate clean 5 more the next day on his test. So the dude made $500 to get 10 teeth cleaned. Not a bad gig huh?
So my operative patient, the one with the perfect cavity, was a young woman of about 23 years old. Everything was set.
It is the day before the "filling" part of the test. I had just been through 3 days questions and lab stations and I was running on fumes.
I call this young woman to double check on her and confirm our date for the next day. I get her and she starts to tell me she was having second thoughts. Since our agreement, it seems she had been talking to some people and she now wants the tooth colored filling. Now for the test there is no option...we do the metal filling. I don't make the rules.
Now I try to remain calm. I try to keep my composure. Remember I told you that the test is not about ability it is about who can keep it together.
I wanted to reach through the phone and wring her little community college neck. Inside I was like, "Are you F!@#$%ing kidding me? You have this epiphany the night before my test?!"
So I told her that those are very expensive. I told her that she was making enough money to get this filling then go and have it removed and put the tooth colored filling in and still have money left over.
I then came up with this. I told her that if we do this tomorrow and I pass I would be more than happy to do the filling over with a tooth colored filling at my office at NO CHARGE.
She was good with this.
Now I knew she was a bit flighty so you have to imagine how happy I was to see her there in the morning.
We did the test together. I passed and I gave her all my numbers. My home number and my office number.
She never called. I lost 10 years of my life and she never calls.
I will never forget that woman.

One more quick story.
All your instruments have to be sterilized and wrapped and have your SS# on it.
I asked my friend to pick up my instruments for me. He FORGOT.
It was the night before my test when he told me. You are not allowed to use any one else's instruments. I had to have THIS tray.
I went to the school and everything was locked up.
If I didn't have instruments wrapped with my SS# on it I fail. So I was getting into that sterilization room if it meant me taking the hinges off the door.
Luckily it didn't come down to this. I found an employee that I knew, that could vouch for me. Then I got a janitor with a skeleton key. He opened the door.
It was funny, the room was about the size of your living room and it was filled with shelves.
And the whole room was empty. There wasn't a single thing in there except one tray.
I was never so happy to see a bunch of instruments in my life.
Now to you these stories might not be that crazy but everything in those five days are magnified. Every little problem is a life changing event.

Thats it.

Have a great weekend.

PS. I joined Twitter today. I don't know exactly what I am doing but I did it anyway.

Wednesday, June 17, 2009

Dental Boards stories

Magic lose.
I have to tell you I am not that upset. I am definitely heart broken and I hate to lose especially to the Lakers and to Phil Jackson and Kobe, but I am trying to look at the whole season.
We had an awesome season. We grew up this season. We will be stronger for it.
(I think this is what all the losers say)
But the best thing about the NBA being football is right around the corner.
Oh my gosh. If you were sick about hearing about Tim Tebow and the Gators last year. This year is going to be sooooo much worse.

We watched Rocky IV this weekend with the kids.
This is the one with Dolph Lundron as Ivan Drago. My kids just eat it up. They love everyone of these movies.
Then our next door neighbor came over with Rocky Balboa and we watched that one.

My wife and I watch a movie called Shining Through with Melanie Griffin and Michael Douglas.
It was a romantic WWII movie. It was all right. Nothing special.
We watched Taken last night. WOW!! This movie was good. It was a lot like Bourne Supremacy, where the action starts and it doesn't stop until the credits roll.
Definitely two thumbs up.

I started a book called To Own a Dragon by Donald Miller (the guy who wrote Blue Like Jazz).
It is just about the author's walk through life without a father. He talks about the hole he has in his life because he grew up without a father. Then he talks about what it means to be a father and to talks about how he filled this hole in his life with his Holy Father.
But the reason I am reading this is because my "talk" with my 10 year old is looming.
I am trying to get myself pumped up for this (maybe "pumped up" is not the best wording).
I am thinking alot about how I am going to do it.
I have a good relationship with him and we talk but we have never "talked".

Okay the topic of the day.
I want to start a fun series on the stories I remember from the Dental Licensure Exam.
First I will tell the non dental people about this test.
This exam is after you finished dental school. You have to prove your proficiency. The state of Florida kind of dances to the beat of its own drum on this one. Some states will take your degree from a University as proof enough. Some states will take certificates from other states as proof.
But you have to understand how different states like Florida and California are.
Everyone and their mother wants to retire in Florida. So what happens is that a dentist who is 60 and can retire thinks about moving to Florida (by the way, it was 96 degrees here yesterday with about a 200% it ain't that great right now) and working a couple of days a week.
So there has to be some weed out process. And the state of Florida makes a ton of money by making dentist jump through all these hoops to practice here.
So it is what it is.
Everyone who wants to practice dentistry in Florida has to pass this exam. Now, I am a liscensed dentist in Florida which means I can use this liscense and practice in most other states. But like I said it is not recipricated.
The test.
This test will bring most people to their knees.
It is not as much as who is the best dentist but can you handle the stress. Can you jump through the hoops and not have a nervous breakdown in the mean time?
It is a five day exam. Two full days of just multiple choice questions. This part was in a huge auditorium. There are two 4 hours segment where they would have a slide for every question. Like....Can you tell me what type of cell is on this slide?
Then there are two half days where we had a laboratory test. Half of the exam was in a lab and there were stations with questions. So every 4 minutes and you would move from desk to desk answering different sort of laboratory questions. FOUR HOURS.
The second half of this day was a lab profiecency test. You would have to do Root Canal on an extracted tooth. Then, you would have to do a crown on a dentiform.
Then there was two half days of working on working on live patients.
You would have to have patient that needed the exact cavity you were asked to perform a filling on.
Then the second half was to clean someone's teeth. Now it just couldn't be anyone. It had to be someone with some form on periodontal disease.

So there are so many ways things can get screwed up during these five days.
Remember the hoops I talked about, well I will try to explain.
First let me tell you that the hoops were necessary and they did it to keep us on our toes and to try to protect from cheating.
For instance, in the root canal part of the test. You were expected to take an extracted tooth (it had to be a premolar) and mount it in an acrylic block. You were to have a pre root canal set of x-rays. Now if you were thinking you would pick the easiest tooth to work on and looking at the x-ray you can a fairly high probability of less problems. But the kicker was that you had to have two potential teeth to work on. That means two blocks of teeth and two pre root canal xrays.
And they were to be labeled "A" and "B" so as someone taking the exam you did not know which tooth you would be working on.
For every part of the exam you had to have a different set of instruments wrapped in sterilization paper with your social security number on it.
Now for the live patient part of it....
You had to line up your patients and make sure they were going to show up (because if your patient didn't show up or their cavity didn't meet the criteria of the particular exam you couldn't do this part of the exam and you would fail.
This is why they have companies that all they do is provide patients. Now when I was taking this test 14 years ago people would pay in the thousands of dollars for a patient (the company would guarantee that the patient would meet the criteria).
So if you don't have a couple G's to get a patient you have to get your own. So what if the patient that you think for sure will meet the criteria fails? You have to have a back up patient.
So how do you get them to show up? Well you have to pay them just to show up. You say to them I will pay you $200 to come and show up here and get evaluated. If you "pass" and I do a filling on you, I will pay you $100 more. So you have to pay the patient and the back-up patient to at least show up. And you have to pay your "filling" patients and your "cleaning" patients.
I am explaining all the things first because when I start to tell you the stories you have some background information.
Then after the test you have to wait 3 and a half grueling weeks to get your test results.
Last thing. If you fail the test it is major deal. They only give the test 2 times a year. So if you fail, not only are you emotionally a mess, but you have to wait 6 months to take it again and all the stress starts all over.
But what that means in dollars is....if you make $75,000 in a year, you are losing $37,000 because you failed this test.

Okay one quick story.
My friend Jay lived in Miami. His father was a dentist. Now his dad was tickled pink that Jay was graduating dental school and wanted just to be there at the end.
His father stayed with Jay a couple weeks after graduation just to hang out and try to get Jay through the boards. Well the last day of the boards started that morning so dad said to Jay, "I am going to go home, good luck today and I will see you home in a couple of days."
Jay's dad loaded up the car and started the 6 hour drive home.
One started the drive with all of Jay's root canal instruments and mounted teeth in the back of his sporty Lexus.
Now Jay was getting ready to leave for the exam and realized this about a half an hour after his dad left. So he borrowed his friends sports car and started down the highway at about 100mph. He figured he would catch him in about an hour.
Now you have to understand this is not the days that everyone has a cell phone so he was not able to get a hold of his father.
Also realize that if Jay doesn't have his stuff he would get a zero on the root canal part and almost automatically fail the whole thing. Because a zero is hard to make up.
Jay never caught his dad.
He got back into town about a half hour before the test was about to begin.
It was a mad scramble. He borrowed someones instruments (I think there was some fudging with this because they had to be his instruments with his SS# on it...but I don't remember). Now the tooth was the real issue.
Remember I said that you had to mount two teeth and at the time of the test they tell you which one you will be working on. Well that means people will literally be throwing out the non used tooth.
Well, after the announcement of the tooth, he went into the trash can and picked out a tooth.
Now he is saying to himself this is a $35,000 decision. Do I take something out of the trash and possibly get in trouble or do I take the zero? Now they could have caught him and banned him from taking the test again. But it is not like he is turing in someone else's work. Or cheating. So he risked it.
I can tell you I would have done the same thing Jay did.
You are so stressed (not that I am saying if you are stressed it is okay to lie) and so many things are riding on this. Jay probably was suppose to join his dad's practice in three weeks. You have to plan on passing. I can tell you your head is spinning round and round and you are definitely not thinking straight.
I am not remembering the story perfectly but I remember there was a problem with the xrays.
Like he found a tooth but couldn't find the pre root canal x-rays that went with it.
So he took a penalty by not having that x-ray.
He said his root canal totally sucked but at least he didn't get a zero. I think I remember him getting a 1.5 out of five. And I know he passed his exam.
Remember I said it is not to see if you are an awesome dentist, it is how you handle all these things. Can you keep your head? Can you keep it together long enough to pass the test?

I am sorry for the length,
I would love to hear your board horror stories,
I tell you mine on Friday,

Friday, June 12, 2009

Magic, books and dental adhesives

Hi all,
I started writing this on Tuesday and I picked it up this morning.
You will be able to tell my moods when reading.


I went to the Magic game last night. It was so great.
Now you know that I have a great couple of years as a Gator fan.
Just a reminder...National Championship in Football in 2006 and 2008 (and possibly 2009) Basketball National Championship in 2005 and 2006 and many more.
I am a huge basketball fan. I like the NBA but it is about my third favorite sport.
But I live in Orlando and my father had season tickets for about 15 years (even my wife and I had season tickets for a year), so we are Magic fans.

I went to a NBA finals game in 1995 when Shaq was with us. But the NBA is so much larger than 15 years ago. There were snipers on the roof of the arena outside. There were huge banners and limo and lights and much much more. It was a spectacular event inside the arena and outside the arena and the Magic won.

This I am writing on Friday.
Being a Magic fan totally blows right now. Just writing this is making my stomach queezy.
Nothing like grasping defeat out of the hands of victory.
I like the Magic but it is over. Down 3-1, no chance.
Missed free throws, turnovers, bad defense....I need a sports therapist.

I have to tell you a story. I just got this awesome new family at our office.

Parents and 6 children (with two sets of twins). The mother came in and brought the two youngest twins...I think they were four years old.
When a kid comes in for the first time we take a picture of them with the hygienist. We send the picture to and it comes back printed with a border around it. Then I write the kid a welcome card and tell them how great it was to meet them and stuff. Then we put the picture with the card.
Well these kids really loved it.
So then the other four came in last week but Timmy and his sister came with the old four.
So when everyone was leaving, I was busy so I wasn't able to say goodbye. Then I came up front and I saw that they were out in the parking lot so I ran to the front door and yelled "Goodbye everyone."
Then Timmy asked his mom a question and she started to laugh. I asked what he said.
Turns out he asked his mom if I could get my keys and follow them home and eat dinner with them that night.
This was so perfect. You know I am 40 years old now so I don't think Timmy and I could really hang out but I love that kids love it here.
I always say that I am trying to change people's attitude about dentists one patient at a time.

I finished my book Hope's Boy on Monday.
I told you it was an autobiography about a kid who was left to the LA foster kid program at seven years old. He was placed for 11 years with a family until he went off to college and then on to Harvard Law. Now he is an advocate for foster children in the area he grew up in.
You know I had a real problem with this book because he never once blamed his mother for not being able to handle him. His grandmother who contacts him after 10 years finally told him that she never fought for him because she thought he would be better off with a family that has a pool.
So the grandmother thought that a pool was a fine substitute for family.
But he blamed the system.
Look, the system is flawed, there is not doubt.

Then you have all sorts of kids. Kids with detatchment disorders, kids that are violent, kids that have learning disabilties, and then the normal everyday kid. But what other choice do they have but to run the facility like a juvenile detention facility.
Not a very loving environment.
But it so far beyond that. The family unit is not sacred anymore.
There is no discipline, no boundaries. And you know what kids who don't have boundaries or discipline grow up as? Parents that give less discipline or even less boundaries. Then it is...
People have babies they don't want or can't handle and then they give them up. People on crack having babies.
I don't know the answer to the system problems but I know one thing...the family unit is huge.

So I have to tell you this. I have read a couple of books about these people and they have been good. I am becoming more and more convinced that I want to write a book about my nephew Seth. In case you don't know, my wife and I raised Seth for seven years. From his almost 6th birthday to his almost 13th birthday.
Seth's story is so unbelievable.
A quick for instance....His mother had a boyfriend who was arrested for taking 4 year old Seth with him on a robbery.
I will let you know.
The problem is is that it doesn't have that happy of an ending.

We have got a couple of comments on the Invisalign blog but not comment and I will give you my feelings also.

I want to give you a quick read today.
I got last months JADA magazine and DENTAL ADHESIVE was on the cover. I normal don't read this magazine but this caught my eye. So I read it.
Turns out it was a 12 year clinical trial on a particular bonding agent.
In so many ways this article was disturbing in so many ways.
Okay let me give you the Readers digest version of the article.
They were testing one bonding material.
The authors restored 100 non carious lesions without mechanical retention.
The 12 year retention rates were 89%.
Great stuff.
Only one problem, they were testing Optibond Dual Cure. Well what is the problem with that? You may ask. Well, Kerr no longer makes this product.
You see, that these companies are trying so hard to create "better" products that they stop making the best product.
They are so busy being dynamic that we can't even do a simple longevity test on a certain product.
I have always kind of been ticked off that I can't keep up with the products out there. By the time I learn about three new products, four more have been made "new and improved".
Okay I read the whole article and I want to give you some of the one liners that I highlighted.
(and you will know see why I hate reading).
"Researchers have reported the longevity of adhesives in general to be three to eight years."
"The retention rate at the five years was lower among the two step etch and rinse adhesives (69%) and the lowest among the one step self etching adhesives (60%).
Two other studies that studied Optibond Dual Cure got very different results.
"Dijken and Pallesen found that the retention rate of Optibond Dual Cure at 13 years was 60%. Boghosian and colleagues found the 13 year retention rate to be 97%"
And last but not least the disclosure...
Dr. Swift holds a research contract with 3M ESPE and has received honoraria for consultation and continuing education from the Densply Kerr. Dr. Heymann blah, blah, blah and his son works for Kerr.

Very confusing data.
My head was spinning. I am frustrated with the system and I still don't know who to trust.
What material to use.
Thank you JADA for this fine piece of "science".

Have a great weekend,

Wednesday, June 10, 2009

Invisalign....Ghost writer

Hey all,
I hope you are having a good week.
I have a ghost writer who has a soap box that he wants to stand on.
It is a bit long so I will not write anything about me.
Except GO MAGIC (I went to the game last night. I will tell you about it on Friday).

Here is a scenario; an major implant company representative walks into your office and smiles. He/She proceed to inform you that they have great news and have instituted a few new policies to make you and the implants you place better! Sounds great right, well here comes the kicker. They proceed to tell you that you will have to attend place and/or restore ten implants a year or they will no longer let you buy their products!

Why stop there, how about the endo rotary file representative that tells you that to continue to be able to purchase their files you must submit endo cases that you have completed with their system on a yearly basis to continue to purchase their system.

How well would that go over in your office? This is preposterous scenario and would never happen correct! Think Again!

Essentially, that is what Align Technologies, parent company of Invisalign has done. They sent out and placed a letter (see their web site) requiring 10 cases to be completed per year and 10 Invisalign approved CE classes a year in order to maintain your Invisalign account in an active status.

This has all been done under the disguise that it is to better the doctor and assure that the patient is protected and has a well trained provider. You must first take the Clear Essentials certification course prior to being certified and this “supposedly” made you trained enough to treat cases. This has been the only certification process to begin Invisalign for some time now. I guess they have now determined I am not “trained” or “qualified enough” to treat patients. I “feel horrible” (wink wink) now for all this time putting my patients at risk not knowing what I was doing. I have been told in the past by others (4-5 years ago) that all it took was letting the Invisalign representative buy you lunch and you were certified. Oh how things have changed.

I am a member of the AGD and do not get me wrong I am all for continuing to improve yourself and your skills via continuing education but to have a company mandate what I have to do seems a little extreme.

The last time I recall having clinical requirements was in residency and dental school. I checked in my home state and once you have met the requirements for a dental license you do not have to do clinical requirements except for continuing education. One of my local oral surgeon buddies commented that once he has meet the initial requirements (clinical) cases for IV sedation he did not have to continue to submit cases after other than anesthesia CE. I would think the complications and risks involved with IV sedation far out weigh the risks with Invisalign.

The goals Align are seeking could and should be achieved via CE and hands on CE. Continuing education is acceptable enough for every other phase of dentistry and to maintain a state dental lisc. then why not for Invisalign.

My suspicion is that during a down economy this is an attempt to force practitioners (general and specialist) to “sell” more cases to patients. Based on my experience with Align I would be shocked if they had not run statistics on how much increased profit they would achieve by forcing ten cases per provider and factor in how many providers would be pushed out of the company. Align has had requirements for case submissions in order to be listed on their web site to encourage doctors’ to complete cases. This latest round of requirements is just another poor attempt to push and promote Invisalign.

Others have said that this is in collaboration with orthodontist specialist interest groups to limit the general dentist’s role in orthodontics. This could be possible, but from my experience local orthodontist have encouraged my use of Invisalign. They have been more than happy to help if I had any questions with the cases I was treating.

I understand that Align is a company and reserves the right to limit their product to whom they chose and impose rules on whom they provide it to. However, with Align currently the only provider of this system it is unfortunate they have taken this stance. We as dentists also have the right to let Align know that we disagree with the requirements.

What about the small offices and dentist in remote isolated areas that want to provide this service to their patients but might not have the patient flow to meet Invisalign requirements. I guess Align is telling them tough luck you will just have to refer everything out even if that is not convenient for the patient.

I believe that the biggest and most important thing a provider can do is know their limits and select cases based on comfort level and training. I do non complex and simple cases. That is all I want to do. If I want to increase my knowledge and do more challenging cases then great but right now I have treated several patients and have had few issues and all were minor and have enjoyed treating the patients with Invisalign. Invisalign is just a small part of my practice and was never intended to be a large role in my practice.

I strongly feel that this was not done primarily for the patients benefit and the doctors’ improvement and more for the increase in profits and benefit of the share holders.

This is a poor decision that if successful could encourage more companies in dentistry to follow suite seriously jeopardizing dentist autonomy to provide care.

Very well done ghost writer.
I have an opinion and I am sure you do lets hear it.
If I get enough comments maybe I will post them all on Friday.
Have a great hump day.

Friday, June 5, 2009

Why didn't you go to the orthodontist that I recommened?

Oh my gosh, what a great time for the Magic to play the worst game of their lives.
The whole town is grumpy today. Not only did we stay up until midnight to watch this game but out team got beat like a red headed step child.

I wanted to talk to you guys a minute. I just wanted to tell you how much I appreciate your comments. And lately I have received a bunch. I appreciate you reading and I covet your thoughts. And listen, if you have a critique on the blog I want to hear it. I am sensitive but I am trying to give you what I think you want. If I don't know what you want then I can't give it to you.
Am I making sense?
Like one comment said, " have an interesting blog." Interesting?! Is that like I have a great personality.

Todays entry is going to be short.
I wanted to talk about the specialists a minute. Not talk about them but about referring to them.
Specifically I wanted to talk about me sending my patients to certain specialists.
Over the years I have widdled my specialists down to one or two doctors per specialty.
My periodontist and I work great together. I like the guy and I trust him with my patients. I trust his judgement and his work.
My is more geography. If they live in the North part of town I send them to this guy and if they live in the south side then I send them to this guy.
Oral Surgeons...well I like a bunch of them. But I try to use just one or two.
I do like consistency and I think it is easier

I specifically want to talk about referring to a specific specialist.
Let's say for this purpose we talk about orthodontists.
I see a 10 year old kid in my office and tell them that I recommend a certain orthodontist. I give them a referral sheet. The ball is now in their court.
Let me back up. I refer to certain people because they are good. Not because they send me gifts, not because they send cupcakes to my staff. Not because they are close to me. Not because they are nice or drive nice cars or have a nice office.
I refer to them because they are good. PERIOD.
But if the good ones wanted to send me gifts that would be so awesome and I would definitely take it. I like steak, just in case someone is reading this that knows my specialists.

Now are my specialists expensive. I honestly don't know. I think they are in the ball park as the rest of the specialists in the area. There is an orthodontist in town that is very good but he is 25% more than anyone else. I don't refer to him.
Could ortho from my guy be $500 more, maybe. But over 2 years of month to month payment would be like $20 more a month.
(I know this isn't chump change and I don't like to trivialize money but it could be the difference between good ortho and crappy ortho. )

So we have established that I send to only the guys that I think are great specialists. And I have put the ball in their court and I expect them to do the right thing and go to MY orthodontist.
So why then do some of them come back to me a year later in full braces and their orthodontist is someone I have never heard of.
So now I have to watch for the next two years as these kids get there teeth straightened.
Now I say that sarcastically. I could straighten teeth. I do not, however, know how to do orthodontics.
To the lay person out there, straightening teeth is not what orthodontists do. Well they do but they also put teeth in the most ideal position to improve function.
Now to a dentist like me, function is so much more important than straight teeth.
So after one year and a half or so the kid is so excited because he is getting his braces off in two months. And I am saying to myself the teeth are not even close to where they are suppose to be.
Then the mom says, "Well doc, what do you think of the braces? I mean how do you think it is looking."
And I am thinking to myself, "Well, I think they look straight but I think the ortho sucks. I think if I told the truth you would be pissed at me. And if I told you the truth and got all over the orthodontist he would be in braces for another year and a half while he corrected his own mistakes"
And I say, "I think they look real straight." Meanwhile cussing under my breath.
Now I know I am going to get a bunch of comments because I don't speak up and be an advocate for my patient.
I want you to know that I do.
I have called and called the orthodontists that I don't know. I wait on hold for 15 minutes while the doctor comes to the phone. Then he doesn't know the patient I am talking about. Then I just ask him to take a note of my concern. I say to him very gently, "THE TEETH DON'T INTERCUSPATE."
Then he always says, "I will see what I can do."
They just don't care or they are just not that good at what they do because the kids always come back at their next recall and they are out of braces and there teeth don't intercuspate.

I have gone down the road of fighting the good fight. I have told the mom the truth and quite frankly they don't want to know. All they see is that their kids teeth are straight and they are happy.
I try to show them what I am talking about in the kids mouth and their eyes start to glass over.
And they don't want they kid to be in braces for another year.

So now I am their general dentist for the rest of their childhood and sometimes longer than that. And I have to look at their straight teeth that are now in cross bite. Or I have to look at their straight teeth that are in end to end occlusion and see them abuse their teeth.
I have to see the results of bad orthodontics for a long time.

You know the ones that are your new patients and you say to them, "You never had braces right?"
And they respond, "Oh, yeah I had them."
Now, just think if you were that person's childhood dentist. Because you are for some of those people out there.

Am I rambling?
Are you guys having to deal with the same thing?
Do you have a gentle way of tell parents the bad news?
Be gentle with me.
Have a great weekend.
Go Magic,

All because the mother wanted to save 500$ to go to an orthodontist that their neighbor goes to.
Yeah that is probably a better source of referral, your neighbor. Yeah what does the dentsist know.

Wednesday, June 3, 2009

You know, that patient.

How do you like the new photo?
I thought I might change the picture once a month.
Oh, before I forget, I am looking for someone to help me with Monday's blog.
As you can see I am having trouble getting a Monday blog together. So I was thinking someone could, once a week do an article review.
If you read a lot of articles and want a forum to talk about it then it could be you.
Write me at

Magic are in the Finals. WOW!!! I was lucky enough to go the 6th game in Orlando.

I just finished this book called The Glass Castle and I don't know if I told you or not but I am reading a book called Hope's Boy. They are both very good. Remember the Glass Castle is about a woman that came from a really poor home to become a correspondent for MSNBC.
Hope's Boy is about a kid who bounces around from foster home to foster home. Then end's up going to Harvard Law and now is an advocate for foster care kids.
I think what is so great about these books is people that against so many odds succeed.
But the reality is that they are about .000001% of the norm. Which is why these kids that are abused emotionally spin around and around and never get out.
And if you ever have heard me talk about my nephew (I wrote a series of blogs on him) now THIS would be a memoir of a emotionally abused kid and how he never comes out of it (and he is still in it).
I guess it wouldn't be as exciting if the kid wallows in his own misery. It is like the main character in a movie getting killed.
He lived with us for 7 years and then his mother came and took him from us saying, "it is time Seth lives with his mother." Only one problem, she didn't have a place to live. So they lived in a car for two months.

Anyway, to more happy thoughts...
I saw Rocky III with the kids. I pity the fool. Awesome movie. Now I know why the Rocky movies were so popular.
I also saw a movie call Nothing But The Truth. It was very good. It was about the one female reporter that wrote a Pulitzer Prize quality piece and then the law came down on her for not revealing her sources. She ended up going to jail. It was about the highs of writing the article to the lows of losing her family because she was in jail.

Okay topic de joir.
I wanted to talk about this patient I had. This patient was referred by a great patient.
A lot of times you can tell what kind of patient they are going to be by who referred them.
The referring patient thinks I can walk on water and sings my praises all the time.
So this referred patient comes in and their mouth is a train wreck.
I mean not only do they have broken teeth but their teeth are just plain ugly.
So we do an exam and this person has periodontal issues, missing teeth, decay issues and occlusion (bite) issues.
This patient need a multiple facet treatment plan and needed to see more than one specialist.
I did a full work up (doing a lot of educating of the patient) and spent a lot of time talking to my specialist and working up something that I was so excited about because it would have been life changing.
So when it came down to talk about getting started this patient says, "Nothing hurts so I don't want anything."
I was a bit shocked but that is okay.
As long as the patient understood all the things that are going on in his/her mouth and know what will happen if nothing is done. Well that means I did my job and it is their decision. And we all know that if someone does something they don't understand or don't want then they start to resent the provider.
So this patient disappeared for a couple of years and came back in pain.
The patient had a perio abscess. I explained to this patient that there is no easy fix. You have teeth that are unrestorable. You have teeth that need to come out because they can't be fixed. Now you don't want to spend any money on teeth that can't be fixed do you?
I think this is when this patient went to the periodontist and had an exam and never followed up with him.
Another year goes by and this patient shows back up and this time says that it is time.
Now this is not a patient that is excited about doing their mouth. This is someone that kind of blames me for things.
Now I am starting to get a bad vibe from this patient but I still continue.
This patient is plain grumpy.
I am okay with this but it is certainly easier to work on appreciative patients. This person is not a warm fuzzy kind of patient and I am okay with this. But you know what I like working on warm and fuzzy people. It makes it easier to come to work.
And I like warm and fuzzy people to refer their warm and fuzzy friends.
But not this patient.
Not everyone is going to fit the mold of perfect patient and I have to be okay with this.
So we are going to get started and we have had a couple of just talking appointments. Just to educate. This is what we are doing and this is what we will do the next appointment....things like this. Then this patient would go up to the front and say something different than what I just said. So then we move this patient back to the consultation room and reiterate what we just talked about.
Then this patient tells me that they only want to do the lower teeth. "They are the teeth bothering me, so this is what I want to do."
Now all along I am hoping this patient will change dentists.
I am still the friendly, warm, happy go lucky dentist and this patient is maintaining grumpy.
I am thinking that we are not jiving and they are just going to go somewhere else.
But they keep coming back.
So we end up doing the lowers in temporaries. I had to remove some teeth and this patient claimed they were going to go to the periodontist and do some implants. So I told them I would see them after they were done at the periodontist.
A year goes by and no one has heard from this patient, they have disappeared again.
Finally, the temps break after a year and a half and this patient calls. They want to know why these crowns didn't last.
I said because they are temporaries. Temporary crowns means they are temporary.
This patient is confused because they thought they paid for final crowns.
Back to the consultation room. "This is what we did. Remember we talked about this and then did the work and then you said you were going to go to the periodontist."
"I guess." They say.
"Okay so I guess what I am saying is that I want to finalize things but I am not going to the periodontist."
So I know what you are thinking. Why haven't I told this patient to find another dentist.
The answer is, I DON"T KNOW.
Every time this patient would come in my energy would be sucked out of me.
So before we got started I sent this patient a certified letter.
The letter spelled out everything we have done in the past. Everything we are going to do.
I spelled out the limitations by not going to the periodontist and the limitations if the upper is not done. I then spelled out what he has paid and what he is going to be responsible in the future.
The patient shows for their three and a half hour appointment.
But the patient wants to talk to me about the letter first. The letter upset this patient because they claimed all I cared about was money.
The letter was about a lot of things and money was one of them but I just didn't want them to be shocked when the work was done and then my people say you owe $8000 and then say, "I had no idea."
So even though they were pissed at me they were ready to get to work.
I kept saying to myself, "This patient doesn't appreciate me. This patient doesn't like me. This patient doesn't value their teeth. What am I doing?"
Do you have this patient?
Is it just me?

I did the work and saw this patient for the prep and impression appointment. A metal try-in appointment and a cementation appointment. Everything went great. The work turned out great. And nothing from the patient. No accolades. Never warm, just very matter of fact.
This patient always seemed to hate it here and my staff and I kind of hated working on them.
I tried to just do my job and do great work but it is no fun unless you are working WITH someone not ON someone.
Am I making sense?

And the kicker, we were all finished and we showed this patient their new lower teeth and they said, "I don't really care about my teeth, but I know you guys are good so I don't really want to see them."
Was that kind of a compliment...I guess this is progress.

But where do you draw the line. I like doing dentistry. I like people. I like working with lots of different types of people.
I don't know.
Do you have any feelings about this?

Have a great Wednesday.


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