Have Fun, No Matter the Cost

Hey all,

At the Gammichia house, we are all going in different directions. Luke and Madison were both at different sleep-away camps last week. Noah was at Boy Scout day camp. Our house was pretty quiet, I have to admit. This week is a regular ol’ week, but next week we are taking a little vaca back to the mountains.

Yep. You know how much I loved the elevation and the clean air of the Smoky Mountains. We are going to Beech Mountain. My friend has a house up there and he and his family are going. We decided that maybe we shouldn't cramp their style and we should get our own place. If we rented a place 4 doors down from them, do you think that is still cramping their style? Well we will see, because that is exactly what we did.

We are thrilled. It has not been oppressively hot here this year yet. The highs and lows are about 74-94 right now. But the beauty of where we are staying is that it is 57-76 right now. Beautiful during the day and maybe even cool enough in the evening to have roasted marshmallows and wine by a bonfire. Biking, golfing, white water rafting, maybe a drive into Asheville... Oh my gosh. I am excited. I will post pictures.

I had an issue last week that I want to talk to you about. I do all the root canals in the office. I see my patients and my father’s patients for root canals. So sometimes I do not know the people that I am working on.

This fact is so important sometimes. When I first got out of school on the first day of the first continuum at Pankey, I heard, "Know your patient." And I think it is also important that the patient know you. That is going to be in the first continuum at the (not so famous) Gammichia institute.

My assistant and I are a different breed. We find that "the show" involves us talking all the time to each other. (If you don't know what I mean by "the show," it was an old blog entry. Every time we walk into the clinic area, we are putting on a show. If you are in a bad mood, if you are swimming in debt, if you are fighting with your staff, squelch it all. When you are in front of a patient, you are working. They want your best.) We both feel that the more you distract people from what is going on in their mouth, the less anguish they feel.

Maybe we argue about 50 Shades of Grey and the erosion of society, or whatever. We could talk about office politics. We could talk about my buyout of the practice. Anything I am thinking of or anything she is thinking of. Nothing is off limits. Patients know this about us from the first appointment. During the new patient experience here, we banter to get people used to the way we are. So they kind of get to know us.

Back to this incident last week. This patient has been referred by my father for me to do a couple of root canals. We had a few hours scheduled for the appointment. We exchanged the normal pleasantries. "Hi, how are you doing? Nice to meet you. We are going to be doing a couple of root canals, so let’s get started."

The first one went without incident and took about 45 minutes. The next one was very calcified and very tough, and it took forever. Now, there is only one thing more boring than doing a root canal and that is assisting a dentist doing a root canal. (I say that, but I don't really think they are boring. I actually like doing them.) My assistant got bored, so we were doing a lot of talking, joking, and stuff like that. Our usual.

This patient is missing a bunch of teeth and kept asking about the anterior bridge that she is getting. I told her that I don't know anything about it, but when she gets to the front we can get scheduled for this. When the 2 hour and 15 minute appointment was finally over, the root canals looked great. I was thrilled because they were so hard.

The patient went up to the front desk and asked about the anterior bridge. Nothing was in the chart. This is not usually a big deal, but my dad was on vacation and so was his assistant. No one knew what was next for this patient. She was not happy and stormed out, even though we told her that the doctor is on vacation and we would call her first thing Monday.

I called the patient the next day and left a message on her voicemail at home and at work, just to see if she was doing okay. Then the next day there was an email about how she is taking their records and going somewhere else. We replied to tell her we were sorry to hear that and is there anything we did or anything we could do to maybe rectify the situation.

She was angry about a bunch of things. First, she had already paid about $3,000 she still has spaces in her mouth. No one knows what the heck is going on with her bridge. She is in pain and Dr. John said she was not going to be in pain (not true: I don't tell anyone they are going to be without pain). And she had to sit for 2 and a half hours listening to Dr. John and his assistant talk about people and work and all that stuff. "No, you can't stop me from going somewhere else and no, there is nothing you can do to make this situation better."

Well, I have to admit that this stuff really bothers me. I want 100% satisfaction. But when I think about it, I know I can't please everyone. I know my style is not for everyone. My assistant and I have angered people in the past with our "chitter chatter."

I am not going to change. I think that people like me. I think our banter puts people at ease. At least it makes it more fun for me. Is that selfish? Heck yeah, it is. Can we be better at communication for treatment plans? Heck yeah, we can. And we will be, after this incident. Can we communicate cost to patients better? Heck yeah, we can. And we will.

But changing how we do things? Probably not. I mean, I can't tell you how many people tell us that we are great, that we made their visit so easy. So many people tell us how nervous they were and how we made it just a little more tolerable.

I listened to this patient. I apologized for not being everything that she needed. But I was not going to apologize for our efforts. As a professional, I have to realize that not pleasing everyone is going to be okay. I know I have written this in past, but you all have to hear this. It is okay for people not to like you. Do the best you can. Have fun (this is important). And treat people the way you want to be treated. That is the best you can do.

What do you think?

Have a great day.

john

Take Your Time

Greetings,

I hope everyone is enjoying the summer. Traffic seems a little lighter now that school has let out.

I recently attended the FNDC in Orlando and had a chance to check out Dr. Gammichia’s lecture (yes, I went to the free one). I was actually really impressed with his material and lecture style. He really got me thinking about my own work. I had decided that I am going to slow down a little bit and try to put my own mark on my restorations.

Looking back, I really feel as though I have been rushing things. Now I’m trying to take a deep breath and take my time. This new thought process of slowing down has reached into other areas of my life, as well. I find myself actually walking the shopping cart all the way to the shopping cart drop off area at the grocery store. After doing this a few times, I realized that it is faster than trying to balance the cart on a curb, or getting it just in the right spot where it doesn't roll away and smash into another vehicle. I thought I was saving time, but it takes longer to fiddle with it.

I am staying an extra few minutes in the movie theaters to watch the credits. You can really learn a lot by watching those credits! Sometimes there will be a little mini movie during the credits as well. I can’t believe I have been missing these my whole life because I want to rush out.

I am starting to take the back roads to work, so I leave a little earlier now. The scenery is much nicer and the drive is less stressful. I know what you all are saying. “Scott, you are doing all of this because of one lecture?” Yes, that’s what I’m saying. If anyone gets a chance to catch Dr. G. on the road, make sure you take the time to see him. ,

All of this “taking your time” stuff is great, but it does lead to another problem. I need to make up that time somewhere else. I started thinking; how can I make up the time I lost without being more stressed? The first thing I thought of was taking shortcuts in conversations. We use shortcuts when we are texting on our phones, right? “LOL” or “LMBO,” etc. Wouldn't it be nice to have shortcuts at work? This will allow me the valuable time to start putting nicer anatomy in my restorations.So, with that in mind, here are a few suggestions in case anyone wants to implement this at your own office:

IGS........I’m going to scream
WWIT.......What was I thinking?
DAPDA......Dog ate patient’s denture again
LCNHLTP....Lab case not here, lie to patient
IHDD.......I hate doing dentures
INAV.......I need a vacation
CTOSN......Call the oral surgeon, NOW!
IPTDS......I perforated the darn sinus
YAIOTP.....Your attorney is on the phone
INAGOW.....I need a glass of wine
SMAY.......Staff mad at you
PLTA.......Patient lost temporary again
INAVB......I need a vacation bad
YBIOTP.....Your bank is on the phone
ISHBAC.....I should have been a cook
COL........Crying out loud
DYAFAS.....Doctor, your afternoon fell apart, sorry
ADRIHTSY...Another dental rep is here to see you
PWTMB......Patient wants their money back
IRRNAV.....I really, really need a vacation
SMAYA......Staff mad at you again
BAFITD.....Broke a file in tooth, darn!

These are just a few that I tend to use more often. The moral of the story is: take a deep breath, relax, and take your time. Your patients deserve it.

HAGW.

Scott

Erosion… And I am Not Talking About Teeth

Hey all,

Hope you are having a great week.

Well, I did it. I gave my lecture at a state meeting. I think it went great. The morning session was $60 and there were 25 people there. The room was the size of my kitchen, a very intimate setting. But this size room kind of gives the feeling of a study club. When you ask the audience a question, people feel much more comfortable answering. They kind of get to know you a bit and are apt to come up to you more and offer their criticism. One guy came up to me and told me that if I wanted to go far with this, I should probably get better pictures. Then he proceeded to tell me how to take a better picture and get less "wash out." Talk about squishing an already fragile psyche.

The afternoon session was free. A bunch of people signed up for this. I think three weeks before the event there were more than 125 signed up. I had to tell myself, "I can do this. That guy told you that your picture quality sucked, but it is going to be okay.”

They put me in the largest room they had. The screen was 10x12 FEET. A room this does not lead to an intimate setting. I did my thing and there were very few questions. When I asked if there were any questions, only crickets. I had to keep on. But when I gave everyone a 10-minute break, lots of people came up and wanted to talk to me. At the end of the lecture, again, lots of questions and then lots of compliments.

My wife and two of my staff members went to this one. Lots of people thanked me and told me the lecture was “great” and “awesome.” But best of all, my wife was really impressed. She said that even as a non-dentist person, she thought it was really good. Of course, she had some constructive criticism, but nothing I couldn't handle. My staff said they see and hear this stuff every day, but it was okay. I peeked at a couple of evaluations; they were all very positive. I had a really good feeling when it was over, and still I am on a bit of a high. I think I can do this.

Today I want to talk about this book, “50 Shades of Grey.” I finished it. I have been advised not to talk about the content of the book; I am not allowed to get specific. I think I am allowed to tell you that when the talk shows call this "mommy porn," they are just about right on.

If you have heard about it and don't want to read it, I would say that you are not missing that much. And it is as bad as people are saying. As far as authors go, I would say that this author is average. The story is terrible, the character development is terrible. I felt like I was reading an X-rated version of “Twilight.” The character says, "I know, but he is so hot," about 1,000 times in this book. That is what a 13-year-old girl would say. The book is all about sex. We all know that sex sells, and this book sells a lot of it.

I think this book probably would have fizzled out if it wasn't for the whole library thing. I don't know if you heard that all Florida libraries banned this book from their shelves. This was a huge deal. It made big news and that got it on everyone's radar. People started talking about it and then, bam! It went viral.

But let’s talk about this book for a second. I know this is a dental blog, but it is on my mind, so humor me. Okay, I get it. It is a fad. But so is walking around with your pants under your butt and your underwear showing.

I can't tell you how many women in their 60s have told me that they loved this book and that I should read it. What does it say about us as a society when it becomes okay for us to talk about porn in public? Look, as I am writing this, I know I sound like a prude. But I am not thinking of me. I can handle it, but I worry about my kids.

I think the silent majority is remaining quiet as our society continues to erode. I am okay with talking about sex. I am all for it. In fact, I am pretty open about sex and stuff. When I was a kid, I used to hide Penthouse Forum in my treehouse and read it when my parents weren't around. Now, it is a national bestseller. And when the library decides that it is trash and they don't want to put it on their shelves, they get slammed.

I don't have a problem with our family talking about sex, but that conversation is never casual. I want more for my kids. I don't like that they can't walk in a grocery store isle because I have to shield their eyes from the magazines. I don't like that I have to police what they watch on the freaking Disney Channel because the shows about high school kids are talking about sex. I hate that my kids can't watch anything on TV on the regular channels after 8 p.m. I hate that magazines glorify people not worth glorifying. I hate that I can't read the paper in the morning with my kids around because they can read now. [It sucks when your eight-year-old asks you what rape is. "Didn't I tell you to read only the comics?!"]

I know sex is from God. He made it good. Just leave it to us, man, to ruin a good thing. I mean, you read about Sodom and Gomorrah. I feel like we are not there yet, but we are inching closer and closer. I know I am just getting old. I am just seeing things much clearer now. I now know what my folks were talking about. It is hard to understand adults until you are one. But it is just not sex that I feel is eroding our society. And maybe it has always been eroding and I am just seeing it now.

We sink to the lowest common denominator. And I don't think the church should be the only one yelling. What about the middle? They don't have to be church-going, but they shouldn't have to go to school and be afraid. They shouldn't have to be afraid to send their kids to the freaking mall or to the 7-Eleven.

I don't know. I like the book, okay. But what is that saying about me and how I might be eroding? What do you think? Am I being a prude? Am I just getting old and crotchety? I am seeing the world differently now that I am a parent, and I can tell you, I don't like it much.

Have a great Thursday. john

That One Employee

Hey all,

Hope you are having a good week. As you know, I am speaking at the state meeting this weekend. I had been pretty calm up until last night. I have tried not to over-think the whole thing, and I haven't really changed the lecture from last time. But now I am almost in a complete panic. I know my stuff is good and I know people will like it, but I am starting to totally freak out. If any of you read this and are at the lecture, come say hello.

Trying not to think about my lecture, I watched a few movies this week. We Bought a Zoo and War Horse were both okay and worth the rental. I am almost done with “50 Shades of Grey.” I will give you my review next Wednesday.

Today I want to tell you about a friend I have. He has a staff a lot like mine, a pretty good, small team. Speaking of a team, they like to do stuff together. They do stuff with the doctor and even plan things just with themselves (like "girls night out"). Most of his staff are getting older and now that the kids are out of the house, they don't have to run home to their families. The ones that do have families get babysitters so they can enjoy a night without crying, boogery kids.

As you can imagine, my friend is thrilled. We all go through the day and realize that, to some of our staff, it is just a job This guy has a staff that really like each other. Damn him.

But the other day he was telling me that one of the staff members doesn't ever do anything with the others. She can’t go to a movie because she has to take her dog to the vet. She can’t make it to girls’ night out because her husband has “this thing.” She didn’t make it for dinner and drinks because she forgot.

Oh, and it can't be the money. When they go out, the doctor pays (he thinks it is worth the money). She always goes to the CE (again, doctor pays). But when it is just fun, an after work thing, she never goes.

My friend said he and the rest of the staff like her. She comes to work and she does her job. But he is concerned about this. He thinks the others might be getting a little hurt because she won’t hang out with them. Also, as the leader of this team, he feels like it is important to maybe have a beer with the people you are in battle with everyday.

I don't really know how I feel about this. It is good for morale, but there is no reason that she has to fraternize. There becomes a sense of team. People will have your back when things get messy. If you are just in your room, saying hello when you come in, then doing your work and going home, there is not a whole lot of unity being built.

I know what some of you are thinking and I think about the same thing: leave her alone. Don't mess with happy. We all, as bosses, want our team to like each other. We want them to like us. But, as I get older, my expectations of my staff are not as lofty. I am just happy when they don't talk behind my back and they like their jobs. I want everything the magazines and lectures tell me could happen, but I also know reality.

What do you think? Would you leave well enough alone? Should the doctor try to sit her down and tell her how important building a team is? Does he tell her she has to go? I am interested in your opinion or your stories.

Have a great rest of the week. See you at the FNDC.

john

I Hear Voices

Greetings,

Have you ever heard of the term “batching it?” Well, I am in my fourth day of being temporarily single. My family is actually out of the country, and I am left here to work. At first, the idea of being alone for a few days appeared attractive. I can have a little “private time” to myself and maybe get some reading done. If I want to cook a hotdog at midnight, I can probably do it and no one but me will know.

Batching it is not all it’s cracked up to be. There is absolutely no noise in the house at all. The only things I hear (and I know this sounds crazy) are my own thoughts! “AN APPLE MIGHT TASTE GOOD ABOUT NOW.” It’s almost like someone is screaming into my ear. I turn on the TV to try to drown myself out. This has gotten really creepy. By day two, I knew where every loose board was on our hardwood floor because I could hear them snap as I walked across them. I find myself avoiding areas to walk on! I am also more aware of my dogs. They stare at me. All three of them sit and stare as if they can hear my thoughts as well. If the phone rings, I practically jump out of my chair. I haven’t been answering it because I am convinced that the voice from the movie Scream is going to be on the other end.

By day three, I thought the voices had subsided. “IT IS 8 O’CLOCK; YOU HAVE TO EAT.” I got up as though someone had given me an order to do something. Normally, I would have cooked something by this time of night, but when you are alone, time is somehow altered. I have already oiled the hinges on the doors because I never realized how loud they were. My ceiling fan goes “tick tick tick tick,” and I’m not even sure how to fix that. Sometimes I catch myself humming a tune to the rhythm of the ticking.

“Stayin’ Alive” from the Bee Gees seems to be the song that pops up. (Explain that one.) “YOU NEED TO GO TO SLEEP; IT IS 2 IN THE MORNING.” The bed time ritual is somewhat different. I walk backwards to my room to make sure no one is following me. I just know the dogs are aware that there is someone in the house but they can’t tell me. After I get in my room, I lock the door. When I close the door in the restroom, I lock it as well.

I have a confession to make. I tried doing the moon walk once. It’s something I always wanted to do, and the dogs were the only ones watching. By their expressions, I think they were pretty impressed. I think by the end of the week I might have a little dance routine down. “Tick tick tick tick, stayin’ alive, stayin’ alive. Tick tick tick tick, staying aliiiive.”

Now at day four, I am beginning to accept the voices. I’m looking forward to what I am going to tell myself tonight. I am still avoiding our main hallway at night because I’m pretty sure those creepy kids from The Shining are at the other end of it on their tricycles. Wish me luck, folks. Hopefully I won’t totally lose my mind before everyone returns.

“HAVE GREAT WEEK.”

Scott

Marketing

Happy Friday. Hope things are well. I have been just going crazy lately. I am so busy that I haven't seen my desk in about 3 weeks. I told my wife (okay, I screamed at my wife) about how I have a job and just saying goodbye to the last patient at 4 p.m. doesn't mean I can be home at 4:20 p.m.

Don't get me wrong; she is very supportive. But she will still ask if I can pick up son #1 at 5 or if I can home so she doesn’t have to take the kids with her to run errands. I agree, but when I leave, I leave a ton of charts and business stuff. I can usually catch up the next day when there is a lull in the schedule, but thanks be to God, my schedule has been pretty full.

I blew up. I cracked under the pressure. I told her that I NEEDED TO STAY AT THE OFFICE. I was here until almost 7 p.m. on Tuesday and Wednesday (I get here at 6:45 a.m.). I was about two weeks behind on my chart-writing. had stuff in my inbox that was a couple of weeks old. It was getting bad. Today, there is a little spot on my desk that Iooks like wood. I am getting there. But being busy is a good problem to have.

I want to talk about marketing today. What are you all doing? I have to tell you: I do nothing. I know, I know. I should be marketing. But to market, you need either time (to do it yourself) or resources.

Okay, let me back up. We have never been an external marketing practice. We have an office next to two very large communities. I put a full page ad on the inside front cover of both of these communities’ directories, and that is it. We have a website that we don't update. We have a Facebook page that I don't update. We have a Twitter account that I don't tweet on.

We have dabbled in external marketing, but most of the time we are just not consistent enough or we find that it doesn't bring in very good patients, so we lose interest. One thing this office does is internal marketing, but this is also very inconsistent. The entire internal marketing department is only one employee: ME.

Our office doesn't announce rewards for referring friends or anything like that. If a patient does refer someone, I sent them a hand-written card thanking them and telling them I am honored. I throw in a $20 gas card (I have been told you can't send a gift for referrals, so we call the gas card a random gift). One thing the external marketing department (also me) tries to do is use its ears. We all know that the best time to ask for referrals is when someone is complimenting you. I try to ask people for referrals all time, but it is so much more than that for me. For me, it is all about making people feel special. I want people to like this place enough to send their friends here. This is where it has to begin.

With external marketing, you never know what you are going to get. With our internal marketing system, I know that I most often get patients that are like the patients I have. And that is good. It is a good return on investment (which is nothing but time). I have told you before that EVERY new patient gets a hand written letter from me. The letter welcomes them to the practice and tells them I am glad they’re here. I tell them that our office tries to be a lot of things, but we want to be great at service. We try to be warm, friendly, great at teeth, professional and a little fun. I tell them I hope they liked it here and I hope they stay for a long time. There have been variations of above, but they all are written by me. This letter tells the patient that this office is different. We can't drop the ball after that.

It doesn't stop there. I call a lot of my patients after their appointments, usually the next day, to see how they are doing. I will sometimes call patients when they are having dental surgery at another office (say, perio surgery or an implant). I get the letter from the doctor and pick up the phone and ask them how it went. I am just letting them know that I care about them (this also is a great way to make sure your surgeon is taking care of your people).

Our external marketing department also gets involved in the community. You know my biggest marketing event of the year is Dentistry with our Hearts. People love when you get involved. Our community sponsors a lot of stuff: Christmas parades, art festivals, food truck events, health fairs, Taste of the Town. We’re there. My family is there. You will see us. You know what is way better than getting a post card in the mail? Meeting the dentist (me) face-to-face.

What do you think? Do you market externally? Is it working? Do you have an internal marketing system set up? Help me get better.

Have a great weekend.

john

P.S. I’ve got a big week next week. I am speaking at the FNDC, which is our state,s meeting. I think a lot of locals are coming to see me. Scary. There are 150 signed up for one of my classes. So I will probably not write a blog next Friday because I will be having a nervous breakdown.

Encouragment

Well, Luke is officially 13. We had a surprise party for him on Friday night. He had told me about two months ago that all he wanted was for me to take him to a PG-13 movie. As the big day approached, he started talking about how maybe he could have some friends over. But we kept telling him that he would hurt his dad’s feelings if he told me he didn’t want to go to the movies with me.

We had 7 of his friends meet us at the pizza place attached to the theater. I asked Luke if he wanted to get a bite to eat before the movie, and SURPRISE!!!! Everyone was there. Then we all went and saw Snow White and the Huntsman together. [It was just okay, especially with seven 13-years-olds. The wicked stepmother has to suck the life out of a young woman to stay young and she eats bird hearts and stuff like that.] All in all, it was a great night. On Sunday, we had the family over to again celebrate. He felt special.

Today I want to talk about encouragement. This is a topic that comes up in our office a lot. Let me back track and tell you that I am a dude. Dudes, by and large, are not good with feelings. I work with 7 or so girly girls.

And along with being a dude, I am a perfectionist. Being a perfectionist is sometimes good and sometimes bad. I am not happy with about 99% of the things I do. I am not the only perfectionist out there. You know what I am talking about.

I put in a crown: the color matches perfectly, but the MB margin has just a smidge of an overhang. I put in a filling: the anatomy is so sweet and then the contact is a little light. I put in veneers: they look awesome, so I sit back and wait for them to fail. This happens with everything. It is not the success that drives – me it is the limiting of the failure. This is a profession where things fail. So there it is.

If I looked over the whole of my practice, I would see that it is pretty great. I have great patients. They are really nice and they really like me and I really like them. I have done some really nice work, I know that. I know in my heart of hearts that I am pretty good at this. Pankey used to say, "Strive for perfection and settle for excellence." But if you are striving for perfection and you settle on excellence, it is kind of like you are happy with 2nd place.

Anyway, enough about my craziness and the reason why I am going to have a heart attack at 52. I was sitting with one of my assistants the other day and she told me that it makes people feel good when they are encouraged. She told me that my father used to end the day telling everyone what a good job they had done. She said that was so nice.

Look, I know people like to be encouraged. I am just going to come right out and say it. I am not a good encourager. In fact, I suck at it. And I think it goes back to me being a perfectionist. If I am not happy with something, albeit maybe just 1% of it, it is hard for me to choke up a compliment.

Now, it is just me. I like the women I work with. I think they all bring a lot to table. think they all make this office great. I think they are all top-notch. I just don't tell them that.

Let me clarify. I don't sit them down and tell them how awesome they are. I told you, I am a dude. At the end of the day, when they are leaving and they say goodbye, I always thank them. I get in trouble at home with the same thing. If you think I am critical at the office, just wait til you see me at home. I am almost to jackass level.

For me, if I tell you I love you and we just go through this tough thing called life together, I am telling you something. But apparently this is not enough. Same at the office. This may sound bad: if you get invited to the Christmas party and I pay you every two weeks, is this not enough? If I tell all the patients you are the best and when you come back from vacation and I tell you we had a hard time without you, is this not enough? When I tell you, "There is no replacing you," this is me telling you I think you are great. This is me telling you that I think the practice wouldn't be the same without you. Why do I have to come out and say it?

I understand people need encouragement. Heck, I need it. But I get it when people come back. When people make an appointment, they are telling me they like me. They don't have to say it. When they refer their friends, they are telling me that I am good. Maybe I am reading all the wrong signals. Maybe I am just the guy up the road and I am convenient.

What do you think? Dudes, perfectionists, do you feel the same? Do you need verbal encouragement? Or am I the only jerk out here?

See you tomorrow.

john

This Patient Walks Into Your Office...

Happy Friday.

I hope things are well. It is June 1st. My oldest son turns 13 today! These are just crazy times for my wife and I. We have a 13-year-old now and we are still chasing around a 2-year-old. And we love every minute of it.

I had a tough new patient exam this week that I want to share with you. This is a paralegal at a downtown law firm. She claims that she has worked hard to get where she is but she is around some high-powered people. She wants to be able to smile or talk to clients without being self-conscious.

The anteriors are decent, but she has major perio problems in the posterior. Basically, most of the upper right molars have to go (I think we could save #3). So we are left with anteriors and one molar; #12 has major decay, and it needs a root canal and a crown. As a Pankey grad, I started thinking we just remove the bad teeth. We have to get her gums back into shape. Surprisingly, she still has bone around the teeth (she has never had her teeth cleaned). Then we do a bit of ortho and move #11 back into place and get her into a solid occlusion. Then veneers across the front and implants in the posterior. In the lower, all the teeth can be saved. We can either do a Precision Partial or put some implants in all the empty spots.

Remember, her chief complaint is that she wants to smile again. Also, this is not a wealthy patient. I know I am not supposed to think about that but, I do. I was educating her on implants she said that would be out of her price range. I had to take a step back. The treatment plan I had in my head was about $25,000-$30,000 just for the upper.

I had to think of another option. She has very ugly teeth (the picture doesn't do them justice). They are very dark. If I only straighten them, they are just straight ugly teeth. Veneers are the only way to improve the look of these teeth. #11 has to be moved or taken out. How do you do that without a lot of money? You can't. Let’s say we didn't do implants on the top and just made them a partial. That is still very expensive. I think about $14,000, and that is just for the top.

I don't know if taking these teeth out is the best thing for this patient. Saving teeth has been something that has been ingrained in my being since I got out of school. This is a hard concept to get my arms around. Sometimes taking teeth out is the best thing. Hmmm. I just don't know.

What if I put two implants up there and then did a denture? It would be about $1,200 to take out all the teeth and $1,800 to make a denture. If she wanted the palate out of the denture, we could put in a couple of implants. We are talking $5,000-$6,000 for a rock-solid result that looks great.

This might be the first time that what the patient needs goes against what I try to do. I want to make the patient happy and healthy. I guess I would be doing this, but without teeth.

And we still haven't talked about the lower. If the lower costs a couple grand more, we are just making this patient's dream more of a burden. You know how that goes. You bring them in for "the consultation," you deliver the $32,000 treatment plan, and they can't run out of your practice fast enough.

I am not saying that we should put our principles aside. I am not saying that saving teeth isn't an awesome precedent to set. But, I think I want this patient to be happy. And if taking her teeth out will let her smile again, then I am going to do it.

What do you think? Let me know.

Have a great weekend.

john