Materials

I don't know if you guys care or not, but the Gators lost in the College World Series last night. I am a bit depressed. Losing in the National Championship game is tough. We are not used to this kind of stuff. I am in a bit of pain.

Today's topic is products I use every day. Just an overview of the stuff I use. Maybe it will spark some discussion.

If you have been a reader for a long time, you know I am a big REALITY guy. REALITY is a company that evaluates all products (well, not all; they only evaluate the products that are given to them to evaluate). They also have a forum that I frequent. This isn't a forum like Dentaltown; you ask a question and a panel of "experts" will all weigh in.

At any rate, the products I use I feel are the best, or at least in the top 3 (it could have been the best at one point and two years later it is in third place, but by this time I have already put it into the rotation and I don't want to change). I am also a big Clinicians Report™ guy.

First, I use Design for Vision 3.5 loupes and I use the Perioptix light that is attached to my belt. I could not go five minutes without either of these. I have a back-up pair of loupes that are brand new that have never been out of the box, but I know I have them.

If the ones I am using break, I would have to shut the place down. What I should have done was have a pair of 4.5 and used them sparingly. And the light. I know if the light goes down, they send you a loaner next day delivery.

I use Septocaine® on all uppers. I use Septocaine locally on all mandibular teeth, premolars forward. If I am working on one tooth I will just use Septocaine locally. If it is a molar and I am doing just one tooth, I will use the Paraject system with Septocaine. If I am doing more than one tooth on the lower, I will give a block and it will be with Lidocaine.

For prepping, I still use a 330 and round burs. I am a big fan of caries detector (the dye that you put on the tooth that stains caries). I use Caries Finder™.
After talking to a biomaterials professor with the 2011 Runners-up Men's baseball team University of Florida, I came up with this way of doing fillings. I etch the enamel and then use SE Bond. I know it sounds crazy, but I love it. I get almost no sensitivity. When someone is sensitive, which is rare, I adjust the occlusion and that takes care of it. I don't use it now, but I am mulling over using Fortify for after my fillings. Dr. Burgess says that using Fortify reduces wear by 15%.

I use Vitrebond on all pulp exposures and all really deep preps. This was kind of a process. I used Dycal in school. Then I used nothing. Then I used Vitrebond. Then I used Durelon. Now I am back to using Vitrebond and am very happy.

For 12 years or so, I was using Flow-It!® flowable resin at the base of my deep preps and class IIs, but I think I am changing to the SureFil SDR® for my flowable. I am not big into changing, but when a guy who does research for a living says that it bonds to tooth 100% of the time, this excites me. On top of my flowable I use 3M's Filtek™ Supreme.

I use a couple of different instruments to carve my anatomy. I don't know the names of them, but I can tell you the one I use the most I think you already have: an explorer. I use the perio probe end to make the pits and the sharp end to start my anatomy from the pits. And let me tell you, they are really looking good.

I finish all my fillings with a small football-shaped, very fine diamond bur with a fine tip on it. And lately I have been using a brownie point too. Then I use the Sof-Lex™ products paper finishing strip for the interproximal.

For class IIs, I use a sectional matrix and a Triodent V3 ring. I use a wooden wedge, a flexi wedge, or the flexible wedges that I have from Triodent. I also have toufflemiers that are curved up and down, side to side, if I need them. I don't have a problem with toufflemiers because of something called the Contact Pro 2, an instrument that can push the contact against the adjacent tooth while you are curing the composite.

As far as placing the material, yes, I incrementally fill. But if you ask 5 different "gurus" how to incrementally fill, you will get 5 different answers. So for now, I am doing it the most convenient way for me. Sometimes I will fill the box first, then the center. Sometimes I will fill parallel with the pulpal floor. Sometimes I will build the walls and move toward the center.

I use a Demi™ light from Kerr. I can't think of anything else that is involved in a filling. Although, that was more than I thought. Let me think of anymore info that I might have left out. I use the same material/resin for everything: anterior, posterior, class Vs and class IVs.

Of all the things that I have told you about today, I think I am the weakest with anterior esthetics. I know there are things out there, nano-hybrids and more esthetic materials, that they claim are more esthetic. But here is my thing: I used to have all that around, but I found they were a real pain in the butt. I would have 40 different shades in body and 40 different shades for incisal edges. I had stuff all over the counter and I would just use two of them. I just didn't do enough anterior composite esthetic cases to have all that around.

That is it for our material lesson for the day. I want to hear about your stuff. Do you use stuff that I left out? Did you find fault in my stuff? We will talk about root canals and crowns on Friday.

Talk to you then.
john

Phobia

7…8…9…10… Exhale… Whew, ok it’ s gone. I just saw a spider!

You see, I have this condition called “arachno-oro-phobia.” Granted, I made the term up years ago, but it is real. Basically, it’s a fear of spiders (or any bug, for that matter) crawling into any open orifice of your body. I sleep fully clothed for this reason, and the fear increases when I am sleeping because I have no control of keeping them out.

Growing up in Hialeah, I saw my share of creatures, and I noticed a few interesting characteristics about bugs. Most importantly, they can squeeze and fit into the smallest of areas. Because their brains are the size of a pinhead, they could care less. Now, most of you may think I am crazy, but I believe they know exactly what they are doing. They realize we are terrified of this, and they get pleasure from it. They have nothing else to do, so it’s a big game to them.

My latest run-in with these pesky varmints happened on US 441. I was headed south, going about 70mph. I was in the middle lane, my wife was with me, and I was on my Harley! During the ride, I notice a slight itch near my left ear; I reach up with my left hand to scratch, and realize I’m wearing a full face helmet. Ok, no big deal. I can live with this until we get to our destination.

The itch started to get a little more annoying, but still manageable. That’s when the realization set in. I could physically feel a spider in my helmet, moving all 8 legs rapidly toward my ear. My wife, at this point, is clueless, and so are the other drivers speeding by both sides of my motorcycle. I am trying not to panic, but things are not looking good. The spider is in my ear, head first. It decides to turn around and nestle itself down into my ear canal. I can feel its abdomen making its way down, and its legs pushing itself further in. Then, as if it couldn’t get any worse, it starts to bite! You have to understand that all of this is happening within a matter of seconds. I’m wondering, if I lay the bike down going 70mph, can I manage to kill the spider? Knowing my luck, the spider would walk away unharmed, because it was protected inside my helmet. Of course, my wife and I would be dead, but that didn’t bother me as much as the spider surviving.

And if I do survive, will my patients still come and see me with a deformed ear? I am convinced it is a brown recluse injecting its flesh-eating poison with its fangs. I can’t pull over because the traffic is too heavy. My wife is still clueless because I am doing everything humanly possible to keep my head together.

I was finally able to pull over into an abandoned parking lot. What happened next is still a little fuzzy (one of the side effects of arachno-oro-phobia is amnesia), but what I do know is that the spider did not survive. As a matter of fact, it was unidentifiable. This caused a problem later because I was not able to confirm the species, and who knows if any eggs were laid. The next 2 weeks were touch-and-go as I waited for my ear to fall off. My wife doesn’t talk it about it much, and she is the only one with a memory of what happened after we pulled over.

Arachno-oro-phobia is real my friends. If anyone else suffers from this, I feel for you. All we can do is just be prepared. Don’t let hats or helmets sit in your garage unattended, and please make sure you have snug fitting underwear at bedtime.

Have a great week.
Scott

What choice does she have?

Happy Friday!

I don't know if I told you, but my family and I are going out of the country tomorrow. Yeah, my wife's family is in Miami and we are taking a trip there this weekend. Miami is so crazy, I feel like we are not in the same country. There are people everywhere and they all drive crazy, people speak a different language and I don't know my way around. But they all smoke cigars and I am cool with that.

Kind of going along with what we have been talking about, I had a patient come in last week. Good patient. She has been a patient here for about 7 years. Married with a couple of kids. Husband comes here but the kids go to a specialist.

This particular person is a bit money-conscience. What I mean by that is she might say, "Will my insurance pay for that?" Or, in June, "I had a lot done this year and I know I am out of benefits, so I don't want to do that cleaning appointment until next year."

But, you know, she did ortho about 3 years ago. She needed perio surgery a couple years back and I sent her to my periodontist. She decided to go to a specialist, (that I was not that familiar with) on her insurance list. Kind of like that.

She came in and had broken the Facial cusp off of #5. The break went right through the pulp horn. The nerve was just sitting there. We all would do the same thing: this tooth needs a root canal. It needs some sort of build-up depending, on how big the break is, a post and core or just a CorePaste build-up, then a crown. The day she came in I happened to be wide open.

I told her all this could be done that day if she had the time ("Please, please, please have the time.") She made some calls to work and she was in for the long haul. Sa-weet. She asked, "Is this going to be expensive?"

"Yes."

All we talked about was money. Then we got started. Root canal turned out great.



For some reason, the back-fill didn't go all the way down, but the apex looks Tres bon. Things were going great. Move to step II. We did a post and core, and it turns out fine.



Move to step III. Prepped the tooth for an onlay. There was a pretty good chunk of the ling cusp left. I took it down 2mm and did basically a 3/4 crown. Impression came out like money in a bank. Locked on a temp and she was done.

My morning turned out great. Great patient, work was great, made some money (a lot more than if I was doing a couple fillings, which would make my friend happy). Just good all around. I am on cloud nine for the rest of the day.

I called her that afternoon to see how she was doing. I left a message on her voicemail and left all my digits. She sent me a text. "Everything seems fine....I was a little shocked it cost $2300....thanks." There goes cloud nine.

I guess part of my being happy is that my patients are COMPLETELY satisfied. Not kind of satisfied. It's a "value my work, value me" kind of thing. I mean, my root canal fee for a premolar is $825. My post and core is $375 and crowns are $1150. Nothing too crazy, I don't think.

Let's just say my fees are a little higher than yours. So let's lower them. Let's make my premolar root canal is $725, my post and core fee $275 and my crowns an even $1000. It is still going to be $2000. It is still expensive. It is still going to blow her insurance benefit out of the water.

I know. I know you are going to say, "Didn't you discuss prices before you started?"
And that would be a valid question. The short answer is no. I told her what she needed. I told her, "You did a number on your tooth. You are going to need a root canal and a crown."

This is an educated woman. She has plenty of dentistry in her mouth. She knows the cost. So if I had said, "This is going to cost you $2300." What was she going to do? Not do it and have a hole in the front of her mouth?

I am going to talk out loud for a sec. If I need tires on my car, I go to the tire place. I know that tires are expensive. I know if I walk in there and say I need four Bridgestones, it is going to be about $600.

If the guy behind the counter says "Well, they are $150 a piece," what are my choices? Do I get one at a time? Do I get two at a time? No, I suck it up and get tires. I NEED THEM. And doing one or two at a time is just going to make the wear on the tires different and it is not really good for them or the car anyway. Nothing I do is going to make $600 not $600. And if I don't have it? Well, that is what credit cards are for. I pay with a credit card and pay it off slowly. But I am not going to be angry with the tire guy because tires are expensive.

She could have said, "Well, I only want to get the root canal today and I want to do the post and core and crown next year when I have full benefit on my insurance." Then she would have a broken down tooth in her mouth for almost a year. A disaster waiting to happen.

I know most of you deal with this same thing. And probably most of you just blow this off. I kind of do too. I have to blow it off. She is just venting. I think she likes me and kind of values my work. What more can I ask for, right? I don't know. I must have a screw loose somewhere. I can't get over people not being 100% satisfied.

I am going to stop here because it is Friday and I am supposed to keep it short. I would like to know your thoughts. Do you have the same issues? Do you think I did it wrong?

Have a great weekend.
john

Why are you so expensive?

Happy Thursday to you. That's right, one more day until Friday.

How is your summer going? Here it is just HOT. At 9:00 last night it was 89 degrees out. It doesn't even cool down. The pool isn't even refreshing.

Last weekend, my 12-year-old and I made fliers for his new landscaping job. And yesterday we put 70 or so fliers on (not in) mailboxes advertising for Luke's Lawns. Everything is a learning experience for him. He made a flier for the first time. He went to Kinko's for the first time. He walked around the neighborhood and did something for the first time. I went with him this time, but next time he might do it on his own. And the best thing is that his 7-year-old brother gets to watch this kind of work ethic. Good stuff.

This weekend we watched the movie The Express as a family. This was the movie about Ernie Davis, the first black Heisman Trophy winner. I thought it was a very good movie. But it was a great movie for us to watch as a family to talk about race in the 60s. I mean it was no Rudy, but what is?

Anyway, we were talking about prices and thinking that if we are better at something then we should charge more for it. I am over-simplifying. When I say we are better, what I mean is we are spending more time being educated, more money on better products, and more time in the chair trying to make it perfect. We should be paid more right? If you missed Friday's blog, you missed a good one. Go back and read it and then come back.

I did think about this all weekend. I kind of got sidetracked on Monday when I couldn't stop thinking of Dr. Scott bent over in his doctors office and the secretary coming in with coffee. But, I digress.

There was a comment on Friday's blog that I want you all to read:

From a patient's point of view, I think you're right that most of us couldn't tell a well executed filling from a bad one so unfortunately price does become an issue. I know from experience that my own dentist is extremely expensive but my view is that he takes the time to explain the treatment, he doesn't push unnecessary work, he's a stickler for detail and if that means a filling takes 2 hours, then that's what it takes. It's about his whole approach to me and my teeth. THIS is what I pay for. He also goes to the bother to explain that a filling may take time to settle and there may be some flare up with a deep filling as the nerve settles - previously I would have been in a bit of pain, blamed the dentist for being crap, gone somewhere else and ended up with a crown. The extra time he takes to reassure me about this is why I pay him the extra. And I don't begrudge it but I do however make damn sure that I play my part in ensuring he has as little work as possible to do. Nice to see he's not alone in realising there is a patient attached to the teeth !

I think we all hope that all of our patients appreciate their dentist like this person. I think this patient is rare. We can raise our prices and spend the rest of our lives trying find patients like this person, or we can just do what we do.

Raising our prices. Let's think about this a second. What are we going to raise them to? We are raising our prices to make more than $80 an hour. Would $150 make my friend happy? Would $200 an hour make him happy? Let's say $200 makes him happy.

That would mean we have to raise our prices $60 per filling. For me, that is raising my fee 25%. Patients are going to go up to the front and hear, "For those two fillings Mr. Smith, that is going to be $550."

Are they going to be any more taken aback than if they were told those two fillings were $430? If $430 is expensive to them, $550 is going to be really expensive. But the people that willingly pay the $430? They would probably pay the $550 and just go on. But I think the former is the more likely scenario.

I think I am beating this dead horse. I talked to my father about this and he said, just like a wise man (that doesn't have 4 children that he has to feed anymore or tuition or have to by shoes every other week), that our reward has to be more than money. He said "Good work comes back to bless you." You maybe nodding your head or you may be thinking he is a crazy old man. I was nodding.

He is talking about having raving fans as patients, like our commenter. A person that thinks you do good work. A patient that will stick with you even though their insurance changes and you have become out of network. A patient that moves 20 miles away and still will drive to come see you. A patient that will tell others about you.

He mentioned one more thing that I didn't think of. He reminds people of the good work that they have in their mouth. On a recall he would say to the patient, "Wow, that bridge still looks good, when did we do that thing again?" And when the patient tells him that bridge was done in 1974, it just reminds them that they come to someone that does lasting work.

I think I do that and didn't know it. Someone comes in for a recall visit and I will say, "Damn that filling looks awesome, don't you think, Kellee?"

When Kellee says, "Oh yes, Dr. John, they are so dreamy," (I can't tell if she is being sarcastic or not), I am reminding her that she comes to someone that does good work.

I don't know. I am rambling, aren't I? So, we will continue to do good work. We will continue to be conservative, to the patient's benefit. We will continue to make $80 an hour (instead of $500), and like it.

Have a great Thursday,
john

P.S. One last thing. I eluded to this in the last blog. My prosthodontist charges twice what I charge for a crown (he charges $2500 a unit). How does he survive?

Well, with those kinds of prices, he only has to see half of the clientele I have to see. And for the most part, he is doing big cases. If he does 8 cases a year at $60,000 each, he's not doing half bad. But let us not forget: dentists are referring cases to him, but no dentist is referring patients to us. I brought it up, but I just don't think it is the same.

Seems Like Only Yesterday

Greetings,

I would like to thank everyone for the supportive emails I received on my Slip ‘n Slide story. Recovery has been a long process (haha).

It dawned on me last week that I started dental school 20 years ago! I can’t even believe that 20 years have flown by so fast. My two oldest girls have completely gone through 12 years of grade school and college. My youngest daughter is starting her junior year in high school and actually drives herself to her job! I’ve been in the Navy, and my wife actually retired from the Navy during this time frame (she still holds her Lieutenant Commander rank in our house though).

Looking back, one event in particular sticks out in my mind: “The Kidney Stone Fiasco of ‘03”. If you have never lived through the pain of a kidney stone, then some of this will not make sense. I was experiencing some bleeding on urination, a side effect of a piece of shrapnel coursing its way down the ureter (which, by the way, is just one big long nerve, as far as I am concerned). Nothing will scare you more than seeing blood in your urine.

My doctor wanted to take a peak inside my bladder to make sure it was “just a kidney stone that was causing the bleeding.” He explained to me how he was going to insert a flexible camera to gain access to my bladder. What?! I asked him if there was an easier way, like maybe slicing open my back and removing all of my organs to get to it.

I ended up in a room lying on a steel table. The nurse lays this huge hose on my stomach in preparation for the procedure. I said, “Um… miss? There must be some mistake because that camera is way too big.” She informed me that I would be just fine and not to worry. Now, I don’t know if anyone has ever been to a Jiffy Lube, but there was a hose hanging from the ceiling in the room, with what looked like a gasoline nozzle on the end of it. Evidently, this was the apparatus that was going to pump some sort of numbing gel into the area to make everything more comfortable.

Shouldn’t I be put to sleep for this? It was bad enough having to be sprayed down with ice cold Betadine®, but the rest of this was going to be too much to handle. I am looking at all this stuff around me, and I can’t even comprehend how this is going to work. Without going to into all the details, I did survive the procedure. If I have to do that again, I will request ahead of time to be sedated. I did eventually pass the kidney stone, which is a whole different story.

Another great moment in the last 20 years was when I thought I was developing ulcers. I went to see a friend of mine who is a physician and told him I was having stomach pains. We were chatting in his private office, and he said he needed to check me. Right here?! He shut the door, and took out the paraphernalia that he needed.

To this day, I do not understand why he would have had all of this in his private office. I wasn’t too sure how to do this in his office, so he told me to just put my hands on his desk. So, there I am, ready for my exam, and I hear a knock on his door. “Come in!” Am I in some kind of horror movie right now? Well, in walked his secretary with his coffee. He thanked her and told her to set in on the desk. She glanced at me and said hello. (Is this really happening to me?)

“Oh, hi Linda.” My eyes were closed, because I was kind of hoping that if I didn’t see her, then she wouldn’t see me(my wife call this the ostrich theory). I was wrong. I later found out that I didn’t have ulcers, but I learned not to complain of stomach aches.

I guess the fact is I am getting older. These last 20 years have gone by so fast, but I have a lot to be thankful for. I have a great family, great friends, a great career, and at the moment, I’m healthy. (Whew!)

Have a great week.

Scott

Raising Prices

I went the the Florida National Dental Conference last weekend. I didn't see much that excited me as far as lectures go, but as you know, I am thinking about lecturing on posterior composites, so I went and saw what I thought was going to be competition.

Dr. Burgess, out of UAB, was presenting a lecture on posterior composites made easy. I have heard great things about Burgess and I was kind of amped about seeing him. I must not have read the program right: it was a hands-on course.

Anyway, Dr. Burgess is a big wig in the biomaterial department. He has graduate students doing research on all materials that he oversees, and he does some private practice stuff also. To be able to see the materials in the lab and then see them in the mouth would be an ideal job for me. That would be cool. But that is besides the point.

What is the point? Okay, I am getting to that. I sat in a room with 24 other people and he started by telling us a new flowable product that is having 100% success. Have you heard of Surefil SDR?

Then he talked to us about how to do a class II composite filling. For the next hour, we did a class II composite filling on a model. I was blown away. I have been doing it the way he teaches for over 13 years. Do you know what that means? Nothing has changed really in a long time when it comes to composite fillings AND there are people out there that have never seen it done this way. I was bored out of my mind and others in there were riveted by everything he was saying. Are you kidding me? Some people have not heard of the Triodent V3 ring, or the Garrison ring. WOW!!!

My buddy and I were at the bar after our lectures and we got to talking. I was refreshed to hear that he practices just like me. Lots of fillings to save teeth from the crown cycle. Very conscientious. He was taken aback like I was about the people in my class NOT knowing how to do a simple class II composite. He wondered how our prices can be the same as these other dentists.

Before we go into that, let me tell you about the first part of our conversation. He told me you can't make a lot of money doing fillings, but I thought you could. He broke it down for me. He said, "How much do you charge for two class II composites and how long does that take you?"

"$480 and about 50 minutes."

He broke his overhead down. Paying all the bills, paying all his staff and how many working hours he spends in the chair, his break-even point is $400 an hour. He said with my speed and my prices, I make about $80 for that hour.

He schedules 90 minutes for a crown. That is $1200. Take away the lab bill and it is still $500 or so an hour. He says that is why so many people are skipping the filling and going right to a crown. He and I both believe it is wrong to over treat for the money, but he was just telling me the way it is.

He wrote me an email saying he was convinced that he needs to raise his prices on his fillings. What convinced him was that he knows he does it better than most. And if you are doing it better shouldn't you have higher prices?

(This is a photo he sent me of some fillings he did. Very good. 30-MODF and 29-DO.)

Now, we are not comparing apples to apples when it comes to product. You can't compare the price of a guy who does this all the time and does it very well to a guy that is throwing in a tofflemiere and plopping in some resin, pressing his thumb on it and calling it a filling.

So back to the original question. How do you price yourself? This was the next part of our conversation. I call all the local dentists in town and ask them how much they charge for a two surface class II composite. I don't want to be the guy that is super expensive. If you use this method, you are going to be making $80 an hour for the rest of your life.

But his argument is that he is better at it than they are and he will save your teeth longer because of his methods, so he should charge more for being conservative and being good at it. I totally agree, but...

1) Patients don't know he is better.
2) Patients don't know he is conservative.
3) There really isn't a way to educate a patient on the ins and outs of fillings and why you are charging $100 more for a filling than the guy down the street.
4) I don't see how we can do this.

Is this the mountain we are going to die on? Because I think we WOULD die on this mountain. You know what I am talking about: the "I am good at this so I feel like my service is worth more" attitude. I get it. But knowing more, and doing a better job, I think, is for me. Knowing I am doing the best I can for my patients, using the best products available is for me.

I know I can make a good living doing dentistry the best way I know how. And if I want to charge a couple bucks more to make myself feel better, that is going to be fine. But if we charged $100 more for a filling than the guy down the street, we would eventually lose the patients that are concerned about money right now. And that is a lot of people. That is just my opinion right now. (Maybe you can convince me otherwise.)

I love this topic. I want to marinate on it awhile. I am going to go home today and have a beer and sit in the pool and think about it. And I want you to do the same. Think about the ideal situation, and we will talk about it on Wednesday.

Have a great weekend.
john

P.S. Last thought: my prosthodontist charges more than twice what I charge for a crown.

What's he got that I don't?

Hey all,

My father is on vacation, and so is one of my assistants; it has been crazy here. Not huge production stuff, but more like hygiene checks and "Will you take a look at this little spot on my gums?" patients. If you have two dentists doing all this, it is easy, but when it is one guy, it can get crazy. So I might be brief.

I am reading a book called "Unbroken." It is a WWII story of survival. I am not usually into these types of books, but a couple of people told me about it. I asked one of them if they had it and, next thing you know, I am reading it. Another big book so it is taking a long time. It is pretty good so far.

Okay, I will get right to it. Something happened to me last week that I thought we should talk about. I have a perio maintenance patient. As far as getting her teeth cleaned, the periodontist and I share responsibilities. Every three months she is getting her teeth cleaned here and every three months there. She came back and saw me one time and told me about her appointment at his office. She said that Dr. K. did an oral cancer screening with a fancy light, and she was thoroughly impressed with that.

Then she started questioning me and asking me why I don't do the cancer screening with the light thingy. I acted like I didn't hear her. She asked again; I avoided the question. I "ducked and moved" for about five minutes until she let it go. What was I supposed to say?

My specialist bought the introductory kit that had a bunch of lights and stains in it. I don't know if he totally believes in it, but he has all the stuff and he has to use it. You ask the patient if they are interested in enhancing the oral cancer screening for $65 (or something like that) more.

I had the rep at my office and was milliseconds from signing on the dotted line, but I didn't. I decided to call a couple of people first. They said it was expensive (not a big deal if it's good for the patient), and that the stuff expires and no one wants it. Hmmm.

Then there have been some studies out there that have questioned the effectiveness of the light. A call to a patient of mine (a pathologist) confirmed that the research is not very strong on their specificity or their sensitivity. Now, listen and listen close, I don't have an opinion on whether it works or not. I am just saying that, if it is expensive, no one wants it, and I don't know if it works or not, I'm not buying it.

But how do I discuss this subject with a inquisitive patient? I guess I can just tell them that he is a specialist and he kind of needs to have some bells and whistles. Or that he is the guy people go to see for oral cancers and this is just one more thing he needs to have. But I can say that about every product I don't have. Digital impressions, CAD-CAM, Lumineers...

The subject has not really ever come up. He and I agree on most things do things almost exactly the same. We did at one point talk about the system, but I decided not to get it.

So, I kind of look like a shmuck because I don't have something (at least, I feel that is what the patient thinks). I know enough about them to know I don't want it (at least not now), but I don't know enough about them to tell people why. Does that sound stupid?

I think I have enough stuff around my office that keeps people thinking we are up on the technology side of things. I have a TV in the reception area. We have computers in every room with monitors on the ceiling, digital x-rays and the like. I don't hear much of the "I read about X in the paper, why don't you have that?"

I know some of you haven't bitten the digital x-ray bullet yet. Are you getting comments? Are you getting questions about why you don't have something? Do you feel like you lose patients because you are still paper scheduling?

I don't blame you. When we converted our office over to all computers, it cost about $90,000. That is a big nut to crack. When people were asking me about it, I would flat-out tell them that it is too expensive. I would be interested in hearing your comments.

Let me know. I have to go - I have 3 hygiene checks waiting.

Have a great rest of the week.
john

A Rock and A Hard Place

I received a call the other day from another dentist. He had a small dilemma, and he asked me my thoughts. Here we go!

Let's call him Dr. Straight Teeth (ST). He wanted to know how I felt about a situation. He had referred a patient to another dentist to have #5 and #13 removed for spacing issues and midline symmetry correction. His written referral and extraction prescription were clear and correct. You can see where this is going, right? The patient came back to Dr. ST's office, and #5 and #12 had been extracted. Oops. This is not the end of the world, it was just going to extend the treatment time and change the treatment plan some, but it is a mistake that Dr. ST could reasonably work with.

He wanted to know what I would do. I have always felt these situations, however uncomfortable, must be handled upfront, immediately, and honestly. I leaned that approach from my parents, school and the military. I told him that I felt he was obligated to inform the doctor, the patient and the parents of what had occurred and how it would change the treatment. Of course, document this in the chart, along with all discussions that occurr with all parties. In my opinion, he would be an accessory to the mistake by trying to cover it up even though the patient would probably be clueless. This, to me, seems like an easy decision to make even though it is difficult to follow through on.

I am sure he is a little concerned about upsetting the other dentist and losing a referral source. I know that if I was the dentist that made the mistake, I would be apologizing up and down to the patient and the referring dentist for my oversight. Whenever I get extraction prescriptions, I double-check and usually even call if it is for ortho and the tooth is otherwise in perfect condition. Unfortunately, you hear about the horror stories of surgeons amputating the wrong leg or arm. This is bad, but certainly not on the same level as that. I try to remember a saying that talks about leadership; it can also translate to morals and ethics. It goes something like this:

"Leadership is not what you do when everyone is watching, but what you do when no one is watching."

What are your thoughts? Is this the best way to handle the situation?

Have a good week.

JJ

Tracking new patients

Friday! Woooo hooooo!

Lately, since I am not doing as much dentistry, I have had more time to think about practice management. I started a spreadsheet to track what is going on with my new patients. The patient will come in for a new patient exam and then get a cleaning the next week. Are they coming back in six months, or are they falling through the cracks? Do you do this? Do you track stuff?

Okay, here is what I found. Wait, before I tell you everything, let me tell you about our new patient exam (experience). They get a full mouth series and a pan, then the new patient and an interview. We just talk about what they expect from me, what they should expect from my office, stuff like that. Then we talk about teeth and what their chief complaint is. I educate them on what perio disease is and explain to them that we are going to do this exam in the room (more than 75% of my new patients have never had perio charting done and don't have a clue about gum disease). Then we go to the operatory. I check for decay, occlusion, TMJ, perio, oral cancer, everything.

I think it is a thorough exam. It takes, from x-rays to exam, about 80 minutes. But I hope they feel like I care. I hope they feel like I am thorough and have time for them.

My exam is $60, so I am not over the top on my price. Though, the x-rays are a little steep at $172. Now, before you get ticked at me for the x-rays, you all know that a full mouth series shows you a lot about a patient (and if you don't take a full mouth, you wish you did). I take a full mouth series every 5 years. You all know that bite wings are not enough if you are trying to be thorough. And while you are trying be thorough, you have to admit that a pan is necessary. I don't know why, other than price, I wouldn't do the most thorough x-rays. (Did I say "thorough" enough in that paragraph?)

I looked at Jan-June of 2010, and found that 103 new patients came to see me. Now that is kids and adults, charity and everything. I wanted to know who is coming back. I told my staff to look up the New Patient exam code and print out every patient because I want them to investigate every one of them. It is a "Where are they now?" kind of thing.

Now, I would say a percentage of those patients would feel that we are not the office for them. They want the total opposite of what I try to do. They might feel like the new patient exam was too much. "I just wanted my teeth cleaned." They went through the exam just to get their teeth cleaned and never come back saying, "This guy is over the top. This kind of dentistry is a bit intimidating and"it is not like my old dentist." I can see that.

Now for actual numbers. I am embarrassed to tell you these, but I started this and I might as well finish. Out of 103 patients, 52 have been back for two cleanings. I feel this is kind of the threshold for new patients that like us and are probably staying. Eighteen are a bad debt issue - ON THE NEW PATIENT EXAM!!! Some of them are college kids that have not been back abd some of them live in another state. But some of them have just not come back.

I am not going to get all upset. I am not going to jump off a cliff. Do I just blow it off, knowing I can't please everyone? No. I am going to learn from this. But how?

I am thinking of drafting a letter to send to all the "I have no idea why they did not come back" people. I understand that these are hard economic times for some people. Who's to say they didn't love me, but they lost their job and insurance and they just couldn't afford to come back?

In the letter, I just am going to ask them straight up, "How did you like our office? If you didn't like our office, can you please tell me WHY NOT?" All under the umbrella of "we are trying to improve our service every day."

This is hard because there is a part of me that just doesn't want to know. Has a friend ever come in and told you there weren't greeted when the walked in? Has a patient that you are pretty close to ever said that someone was kind of rude on the phone, or they the front staff wasn't helpful? This drives me absolutely CRAZY.

I have this idea that everyone in my office is on the same page. People first. And if this isn't happening, then something is very wrong in my world. It could mean that it is happening all the time and you only hear about it from your friends. Then you have to go and have conversations with your 15-year employees about service.

Do I want to know that my people are not on the same page as me? Do I want to know that when I am not looking, there are staff that are not treating people with Ritz-Carlton service? Argh!!!

Okay, I am going to stop here. I will let you know when the letter goes out. About a week after that letter goes out, I might not be in a very good mood.

Do you track your new patients? Are my numbers like yours? Or do you not want to know? Let me know.

Have a good weekend.
john

Tweople

Okay, before I get started, I want to send you to my website.

http://www.asofttouchdental.com/

I just put ME on the website. Go ahead and go to the website now. Wait about 5 seconds and I will come up. I will wait here while you check it out.

I don't think this is a new thing, but it was new to me. I got a hot tip from Scott (one of the other bloggers). He did it to his website (he had an actor do it). He sent me to his website and I was hooked. I said, "I have to do this." One of the best things is that this particular business, Tweople (Tiny Web people), is here in Orlando. So I went to www.Tweople.com and followed the steps.

I had to draw up my own script, and tell them if it is going to be me or if I wanted someone from their pool of actors to do the deal. I wanted to do it. So I made an appointment to go down there. I two of my kids because I thought it would be a great learning experience.

The reception area is about 60 square feet. There were two offices off to the right and then a back room. When I was called to the back room, it opened up. It was a huge room with a 25 foot high green cloth hanging from the ceiling, a camera in the middle of the room, lights everywhere. Then there was a dude sitting at a computer that fed the camera.

He and I had quick discussion of the script. He suggested some changes to the wording, and I adjusted. When all the kinks were taken out of the script, they put me on the green cloth (which was also on the floor) and told me to look in the camera. The camera also had a teleprompter that the script rolled off of.

It was time to tape. I was supposed to say "Take one," then do my thing. I got about three lines in and made my first mistake. They told me that if I messed, I should keep going so I could practice. I did that, then went straight to, "I am sorry." They said, "No big deal. This is what we do all day. No need to apologize."

So we did it again. And again. And again. First, it was me messing up my lines. Then it was how I held my hands (apparently not allowed to cross your fingers). Then I did a perfect take and he told me a truck went by and he could hear it in the background. Then I messed up my lines again. Then they guys were not saying, "No big deal." It was a lot of sighing and hands on the face.

So on take 15, I almost nailed it and it was good enough for me. By the time I was done, I was sweating and my mouth was parched. I thought about it awhile. Why did I have so much trouble?

How often do we talk with a smile on our faces? I don't speak with a smile on my face. And if I do, I sound ridiculous to myself. How often do you speak to someone and never look away? Look at one point on the wall and smile. Now look at that spot and smile and talk for one minute. You can't look away, and somehow you are supposed to maintain a smile while speaking. Oh, and also, don't cross your fingers. All this to say I have a new-found appreciation for actors.

Oh, before I forget, go back to my website and go to the "About Us" section. The tweople guy decided to film my son Noah. I thought this was a great touch.

All and all, I am thrilled by the way it turned out. I can't help but show people. This was a great way for me to take my template, impersonal website and make it a bit more personal. So many people are going to websites for information, and I think this is just another way that I can stand out from the pack.

Just today, I was sitting at my computer and my dad wass looking through the phone book. (For you young people, a phone book is a book that the phone companies used to give to everyone; it had every person's phone number and every business phone number in it.) As he was cussing because he couldn't find the number, I asked him what he was looking for. I Googled it and found it in about 5 seconds. And he said, "Well, I guess nobody uses the phone book anymore."

"Uh, no Dad, they don't."

I think I Google something about 25 times a day; it's so easy. And I am not done with this Tweople thing. I can film something for each part of the website. Take a look at this website. It is so cool. http://mezomedia.com/ I want a website like that. Bad.

Are you doing anything special on the web? Do you not believe in the web yet? Do you have an awesome site? Tell me.

Have a great Wednesday.
john

Wanted: Non-dental friends!

Do you ever feel like you never can get away from the office or get a mental break? Since my wife and I both work at the office, it seems like work is always spilling over to the evenings and weekends.

Over the last 16 years or so, most all the people I hang out with or spend a majority of time with are related to the dental world in some way. It is easier to hang out with dental folk becuase we have so much in common, sometimes too much. It seems that my social and professional life have intermingled and become one. Somehow, everything seems to come back to teeth or how to run an office so we can fix teeth.

This weekend, we were invited to spend some time at a local lake with one of our kids' friend's family. It was a pretty day, and they seemed like nice people, so we agreed. He runs/owns a local non-dental buisness and she is a teacher. Almost a totally related event to dentistry, except that the family comes to the office. I am not the most outgoing or social person. It takes me a while to get warmed up to people. My wife is the opposite; she is very comfortable talking to almost anyone.

I was not sure how it was going to be since my normal conversation piece (teeth) was not going to be a topic of conversation. I was hoping there weren't any "anti-dentites" there (thanks, Kramer). Eveyrone at the lake was very nice. It was weird not thinking about dentistry or the office. The converstations did not evolve into the office or some other aspect of my profession except once when one of the kids bumped thier tooth on the intertube. Only once or twice did dentistry come up and it was very brief, which was refreshing! I enjoy what I do, but feel that all of my time gets too wrapped up into it and yesterday was a nice break.

I enjoy the time with my dental friends, but I would really like to spend more time with some non-dental people. I need to develope a friend application.

Question #1. Do you know what a pulp horn is?
Question #2. What does RPD stand for?
Question #3. What does "customary and usual fee" mean?

Get all three wrong and you are accepted!

Have a great week.

JJ

Yelp

Friday!

I can't say I am tired; I hardly did any work this week. I am not going to let it get me down though. I am going to keep on chugging away.

Anyway, I decided to Yelp myself this week. You know anything less than a five star rating is just unacceptable. Well, I have 5 comments that are five stars, which makes me very happy. But I have one comment that is a three star, and this has turned my world upside down. Okay, okay. I know it is not the end of the world. I know that I can't please everyone. Before I go on let me let you read the comment.

"very expensive.. front office staff does not work for the patient. no assistance with insurance. charge you all up front and tell you to go work the admin. bad mouth insurance companies, and dont take time to find out what is paid / allowed. charged me 350 for first visit.

dentist is great. very caring. want to get you engage and going. young man and his father."

Let's break this comment down a bit. First and foremost, the person should spend some time learning to type before he starts reviewing people and places. I mean, put a full sentence together, for crying out loud. (I know what you are thinking, "That is real mature. Bad mouth the reviewer. Typical.")

Okay, now that I've gotten past my anger/disappointment/hurt, let's review. $350 could only be one thing at our office - a pulpectomy. So I can only assume he (or she) showed up in pain with a hole in his tooth. I usually steer people in the direction of saving their teeth. I am assuming that because he reviews on Yelp, he is young enough that he should save his tooth.

I assume that we got him out of pain, removed the decay, did a pulpectomy, put in some cacium hydroxide, and put in a temporary filling. As a side note, if he gets the root canal completed here in a reasonable amount of time, the $350 is put toward the root canal fee. How much fairer can you get? And it looks like I didn't even charge him for an exam and x-ray. But he says, "very expensive."

As far as the insurance comments, we do not take insurance for emergency visits on people we don't know. We have been burned so many times by people saying they have insurance when they don't, and then it becomes a huge collection problem, so we just stopped.

And the bad-mouthing the insurance company? Well, guilty as charged. I have found that some insurance companies try to find every way not to pay a claim or not to help their customers, and that gets me kind of annoyed with the whole system. I tend to not talk all that nice about them.

You know most of his issue is with money. I get that: dentistry is expensive. It is. But don't kill the messenger. I am fair and I think I am very good. Good dentistry costs money. He had a toothache and went to the dentist. What was he expecting? If he has insurance we will help him file and there is a chance he is going to get some of the money back.

If I don't take care of regular maintenance on my car, and then I have trouble, I take it to the mechanic and he fixes my problem. I am not going to get angry at the fee. When cars need fixin', it is going to get expensive. I am not going to blame the mechanic.

So, it is what it is. But you know what? I don't like it when people are upset with me. I don't like it when someone out there feels slighted by me. On YELP, there are ways to contact the reviewer. I wrote him and wanted to make things right. I told him that not getting a five star rating was unacceptable. I told him the reasons why we don't take insurance on the first visit, and that I talk the talk and walk the walk. I told him I wanted to make feel great about me and my office, and asked him contact me and that I would work with him on the second half of the root canal. I told him to get in touch with me and we would talk about how I can rectify this situation.

I have not received any correspondence from him. What else can a business owner do?

As an aside, there is a place on Yelp where a business owner can respond to a review and everyone can see it. But when you press the "Owner comment" button, there is a pop-up that bascially says, "Think before you send this." I wrote out this long response and then just started to think about it and decided to leave well enough alone. I deleted my response before I sent it.

That is my Yelp story for the week. Anybody been slammed on Yelp yet? Do you even check yourself? You better, because people are talking about you. Sometimes good, and sometimes bad. Who knows? It could make you a better dentist. Check out "Glowing Recommendation?" in the June 2011 issue of AGD Impact for tips on checking your online reviews (page 22 in the digital edition).

Have a great weekend.
john

Go Mavericks.

Burnout

Happy Wednesday to all of you.

I just finished The Girl With The Dragon Tattoo. I have to say, I impressed myself with the speed I read this book. It was 600 pages, so I expected to finish it by November. But, I liked it, so I read it faster. It was slow going at first. It took about 140 pages to start getting good, but that has been the knock on this book and I knew this going in. I thought it was very good and I am looking forward to reading the other two.

I watched a movie called "Deadly Impact" this weekend. I fell asleep watching it. Does that tell you something? I could have written this screenplay. It was okay, but very predictable and there are about 4 million movies just like it.

Okay. I was flipping through some of my magazines and I came across the July 2010 edition of Dentaltown magazine. Howard Farran, DDS, MAGD, MBA, wrote a commentary on "Extinguishing Burnout." I skimmed it and got totally ticked off. (As you may have read, Howard and I have had a run-in. But I have talked to him, and I really really like him. He is my kind of guy. Just a guy who loves teeth and has a passion for dentistry. We need more people like him.) But I reread it, and I think I agree with him on most parts.

Okay, here is the premise of the article. Burnout is a problem, but it is mostly self-induced. "Burnout lives in the closet of so many practitioners and everyone is afraid to talk about it. Burnout will ruin your life. It can lead to harmful vices like alcohol and drug addictions, extramarital affairs, and a litany of self-destructive behavior. Burnout has also killed. It's sad. It's depressing. And it must be stopped. One huge contributing factor in burnout is your environment." Click here to read the entire article.

He talks about how your environment includes space, gear, and what gets you excited. Space is our office space, and we spend about 25% of our time in our office. He says you might hate to come to work because you are leasing a small, dreary office that you hate. As soon as you walk in, you want to go back home. Your office sets the scene, and for some of us, the scene is bleak. He then goes on to talk about how real estate is down 35% and this is a great time to buy.

I agree with him, BUT...

It seems like he is assuming we all have money put away to buy that very visible corner lot, when some of us have used our savings to make payroll. Isn't everything down 35% because banks are not easily parting with their money? They are not lending because "you have potential" anymore.

I like for a three-operatory dentist to go into a bank and ask for a $2 million loan because we want to "be more visible." I get that we need to love our space and love the office we come to. But maybe some new carpet or a new LCD TV would make our lives just a little happier.

He doesn't talk about how owning your own place is very expensive. We own this office building and it needs a new roof. The landscape is ALWAYS a problem, with grass dying and sprinklers breaking. We still need tons of trees trimmed. And the list goes on.

Then he talks about gear. "Some dentists will buy themselves a boat or a cabin or a Harley Davidson because, hey, why not? They are fun! But what fun stuff do you have at the office that makes it worth commuting to everyday?" He has a point.

He talks about how someone will come up to him and ask him about lasers or CAD/CAM with a sparkle in their eye. He compares it his kids playing in their sandbox. If there were no toys in the sandbox, they would get up and leave. But if there were trucks and toys, and they would stay there forever. His point is that if a product gets you jazzed up about doing dentistry, JUST GO GET IT!



I totally agree, BUT...

Do your homework. Be a good steward of your money. Do you know how many CEREC machines are sitting around people's offices not being used? The dentist got all excited about it. But didn't realize it was going to be hard to get used to, or that there would be a learning curve, or that he didn't do enough all-porcelain crowns or onlays to warrant the purchase. (By the way, if you are one of those dentists with a CEREC machine sitting around collecting dust, call me.)

Just remember, toys don't have to be expensive. You know how I love to do fillings. I bought a new instrument that helped me do better anatomy; it got me really jazzed. I know, I know - BORING.

Lastly, he talks about what gets you excited. He says doing fillings doesn't excite him anymore. What excites him is pushing himself, and he tells his audience to do the same. He talks about getting competitive with dentistry.

And he says to do it now. Stop wasting time and do it before it is too late. He says guys that don't like what they are doing want to retire early. He ends by saying, "You can blame burnout on just about anything, but nine times out of 10, you're burned out because you caused it."

I think we should do what we love. I love doing meat and potato dentistry. Pushing myself? I don't know. I wish I knew how to do implants. I wish I could take out third molars but, I don't know...

It is not that I am not not happy doing what I am doing. I am good at it. Why would I do something that I am not going to be good at just because I want to make myself more exciting? I know I will get good at it, but still.

I guess I can learn to put in an implant and be pretty good at it after I do 50 or so. But my surgeon has done 15,000. Can I do as good a job as him? Which would be better for my patient? That is what I am thinking about.

I know you guys are thinking I am boring and need to do it. I get it. But for me, change takes a little more than jumping in with both feet. I am usually one toe at a time.

I enjoyed his article and don't ever plan to burn out. I encourage you guys to try to prevent it too.

Are you trying to prevent your own burnout? What have you done that might not be as drastic as spending $100,000 on a CEREC machine or $2 million on a new building? I just pinned up an article in my office about the 25 most fun things to do in Orlando: airboat rides, hot air ballooning, shooting guns, things like that. I want to do some of them with my staff. You know, liven up the place a little.

I look forward to hearing from you.
john

P.S. If you are an Ohio State fan, wow, things are really bad for you now. Just remember, it is probably going to get worse before it gets better. My Michigan friend just bought a shirt that said, "Liar, liar, sweater vest on fire." Hilarious.