Investing

I want to talk to you about a patient that came in the other day. He is a successful nurseryman and has been a patient here for about 15 years. We live in a medium-sized town that was built on the business of indoor foliage. What? People around here grow plants. There are one-acre facilities and 50-acre facilities, all greenhouses. And when he was making money hand over fist, he invested in a bank (I know because he was telling me about it).

To me, bank people were always a different kind of investor. But when he was here, he asked me if I wanted to invest in a small hometown bank. Remember back in '06 when there were tons of small banks starting? They all had the notion that if they get enough accounts, one of the big banks would them. I opened account with Southern Community Bank because I knew the owner. Then it became Florida First Bank, then it became 5th 3rd. Everyone who owned a bank was rolling in it.

He wanted to talk to me about investing in a bank, and this always perplexes me. I really think most of my patients think that I go home and roll around in the cash that I made that day. What part of the fact that I am driving in an 11-year-old car don't you understand? I told him he was asking the wrong guy because I don’t have any money.

Don't get me wrong: I know I make a great living. But saving? I max out my 401k and, uh, that is about it for savings. All the money I make gets put into educating my children or debt reduction. I just bought the second half of a practice when I still owe on the first half.

Looking at the numbers for the week, they seem okay. I look at the numbers for the month and I take a deep breath because I have a little money in the bank. But I am only six months past the last time I had to dip in to my equity line so I could pay my staff. I look ahead and see that Christmas is right around the corner and I know I am going to be taking 10 days off and then there’s the Christmas party. And now I start to sweat again.

What business do I have investing in a bank?!? Right now I am investing in myself and, quite frankly, I don't know if that is such a smart investment. But I am all I’ve got.

Do I see where one day I might be out of this huge hole I have put myself into? Yes, in 7-10, years I am going to be in great shape. But you also know what happens in 7 years? I will have two kids in college and one kid in the 10th grade. Okay, not so great shape?

I told this guy to hit me back in 15 years when I will only have one kid in college and three kids out of the house, have no debt on the office, and will own my house. FIFTEEN YEARS!!!! I will be on easy street then. OH YEAH!!! Oh my gosh. I will be 58 years old. Holy crap.

You know what? In 15 years, I hope the economy is back because then I will be ready to invest in a bank and maybe I might be ready to buy a new car. My poor truck will be 26 years old, but at least I will have one of those cool "antique" license plates. Have a great day!

john

The Great Debate

I hate to keep saying this, but my life is crazy. Trying to run a business and live my life is hectic, to say the least. Now I am getting a loan from the bank across the street to pay for the first half of the practice. This was originally paid with the equity line on my house. I am going to pay off the equity line and move everything over to the office.

In order to get the awesome rate that I got, I agreed to move my banking from one of the BIG banks to this small, service-orientated bank. We are moving all the deposits and credit cards to this bank. What a huge undertaking! I never knew it would be this complicated. Any automatic withdrawals have to be changed and we have to leave a little money in this bank just in case things come in. We have to get new checks. Ugh. But this will free up equity in my house so that I can refinance it. I know this is a good thing, but it is making my life crazy.

I want to talk about politics today. I am not going to try to sway you to a certain way politically, but it is something that affects us. I have a free-standing building on a corner lot. My lot would be an awesome place to put a sign endorsing a candidate, but I have reservations about that. Listen, I live in a staunchly republican small town. They did a political hobnob here, sponsored by the Chamber of Commerce, complete with a fake election. Romney won with 86% of the vote. I wasn't kidding when I said staunchly republican.

I try to stay away from using my property as space for signs. I want to be neutral about this stuff at work. When I was younger, I did not have any problems talking about politics, religion or sex in the office. Now, I shy away from it. I don't want to offend anyone. Listen, I am a person that can help you with your teeth. I don't want to turn you off in anyway. I don't even have any college affiliation stuff around here because people get sensitive about it. In the south, if I put Gator stuff all over, I might just turn off a Seminole fan or an Alabama fan (I don't really care if I turn off any Miami or Georgia fans).

I had a guy come in today who said that he is moving. He is 80 years old and he said Florida is too conservative. He said Florida doesn't care about the poor or education. He dropped off his lawn mower at his normal mower place and when he went to pick it up a couple weeks later, they had a big sign outside endorsing a guy he doesn’t agree with. He picked up his mower and told the owner that this would be the last time he did business there. This is what I am trying to avoid. Maybe I am at an age where I need all the patients I can get. I can lose patients that like me; how easy would it be for them to leave if they didn't like me? I don't talk about politics or religion at the office any more. I am not putting a sign up endorsing any candidates this year.

Maybe I won't care about pleasing everyone when I reach my dad’s age. Maybe I won't care about people leaving and the days of me wanting to please everyone will be gone. Maybe I will even stick a huge endorsement ad on the corner where everyone can see. But today, this empty spot on the corner is advertising me.

What do you guys do? I know you care about the election, but do you care about it enough to throw a sign up?

I have pretty strong opinions about the way the country should go. I have to admit that, if I went to a place of business that endorsed the "other guy," I might consider not going back there. When I drive in my neighborhood and see people who agree with me, I give a little tap on the horn. When I see people with opposing signs, I pretty much lay on the horn (because that might change their mind). But my business is sacred, and I leave it alone. How about you?

Have a great Wednesday.

john

More Questions Than Answers

FRIDAY! Nice, huh? I have big weekend planned; I’m taking my boys to the Gator game on Saturday. Hope things are well with you.

I still really love Shark Tank. I think it is a Friday show, but we watch in on Wednesdays because that is a day we are usually home. This Wednesday, we ate dinner and then everyone piled into the van and went for ice cream. Then we came home and watched Shark Tank as a family. We talked about people's ideas and about how mean the Sharks were being to the people and to each other. We talked about what it takes to make a small business happen. I think it is good for my kids to see something like this. It definitely gets their entrepreneurial juices flowing.

I want to talk to you today about having associate. As you know, I am the sole owner of the practice and my father is now my associate. This has brought about some challenges that I want your advice on. I know I am not the only one going through this. If you are not going through this, make sure you listen because you may go through it in the future. I my case, my father says he wants to work one more year. At first, this seemed like a long time. It isn't.

You might buy out a dentist who is late in their career. It is a great practice and you want him/her to work there for a year or two to not scare off the staff and the patients. Or maybe you plan on bringing in a young associate.

Let’s say a new patient calls. This patient hasn't been referred to your practice. He is a father who just moved into the neighborhood and keeps driving by. He has a wife and three kids. Do I let the associate see them, knowing he is leaving in a year? Would you have a young associate see them? New to the practice, just getting his feet wet, you don't even know if this young dentist is going to work out.

What about the older patient that was referred by a friend to my father? Slam dunk. My dad will see him. The guy is missing a couple teeth and wants to get implants. He needs a bone graft then implants placed. By the time the implants are integrated, there is a good chance my dad is going to be gone, so I might be finishing this case up. But my dad uses a different periodontist than I do. I don't even know what implant he uses.

These are valid issues. We talked this week about him sending his patients to my periodontist. It is not that I don't like his periodontist. I just like mine better. I have a relationship with him, and I know I can just pick up the phone and talk to him. It is the same with my orthodontist.

This is no different than if a middle aged dentist were to bring in a young guy. Does the young associate only get emergencies and their family? Remember, the associate, regardless of age, is working off of production; they want all they can get. But is it right for the patient to get used to a dentist and then have them leave in less than a year? Is it right for the health of the practice?

As I write, this I am thinking about the future. Does the patient come to a practice because of the dentist? I know all of us think they are there because of us. And I agree with you, kind of. How many times do you hear about a patient following a hygienist? How many times do you hear that a patient liked the dentist but left because the front desk was terrible?

I think people come to my office for a lot of reasons. There are friendly faces when they walk in and a warm reception area. We don't make you wait. The hygienists are sweet and gentle. People like the way we handle the checkout. We call the next day to see how you are doing. It is the whole experience.

The dentist is part of it, whether that is me, my dad, or an associate. If my dad meets a new patient and a I slip in after a year, only one of the many good things in our office has changed. I think this is what I am going to go with. My dad still sees new patients, but I try to make sure they see me. I will walk by his operatory, introduce myself, and welcome them. I poke my head in and ask them if everything is okay. I make a joke and then move on.

What do you think? Have you had an associate? Have you been an associate? What were the arrangements?

Have a great weekend.

john

P.S. Go Gators!

P. P. S. On Monday we are having a team-building experience. I am taking all my staff to a local gun shooting place. They have virtual shooting ranges, with bad guys popping up and stuff. They use real guns that have kick but only shoot lasers. Then we are going to have lunch. I am so looking forward to it. It should be lots of fun.

Passing the Buck

Good Wednesday to you,

Hope things are going well for you. Things are pretty busy here. I have been reading the same book for about a month. Every time I get back to it, I have forgotten everything I have read. Netflix is making money off of me like crazy. I get two movies in and they sit there on the TV cabinet for a couple of weeks. I finished watching a movie on Sunday. The problem is that I started it the previous Monday. Life is crazy.

It has rained a lot lately, so baseball games got cancelled and rescheduled. This is the reschedule week. We have three baseball games, a football game, and two piano practices. My marathon (NYC) is in two weeks, which means I am not able to slack much on my runs. I went to a game yesterday, then straight to my Seattle Study Club meeting, got home at 9 and then went out for a run. AND let’s not forget that the Gators are on fire! There is a lot of buzz around these parts, so I am going to take the two boys to the game on Saturday (after a 16 mile run). My daughter told me that her birthday is only eight days away. I said, “Oh yeah!” But I knew good and well that I had forgotten this very important date.

And if you think this is not enough, next Saturday I get on a plane to speak in New York City. I fly in on Saturday to speak on Sunday morning. I will be home by 6 p.m. on Sunday night. I will work for four days before I get on another plane to go back to New York to run the marathon. Man, I love my crazy life.

Okay, let’s not have this be all about me (as much as I like that). I want to talk to you about warranties. I have a specialist in town that I really like. She does very good work and she gets my patients in right away. She claims is that if she works on a tooth, she takes responsibility for it. A guarantee, per se. I like that. She is a specialist who takes responsibility for her work.

I do this. I have an unwritten guarantee on all of my work. We have spoken about this in the past. If a filling is less than five years old and it fails, I will repair it or replace it at no cost. If a crown is less than, say, eight years old, the same rule applies. I am a consumer and a small business owner, and I try to run my practice the way I would want to be treated.

I sent a patient who was hurting and swollen to this specialist. To her credit, she saw my patient right away. I think there were some antibiotics at first and then they rescheduled for a procedure (I am being very vague on purpose because I have been told in the past to watch my rhetoric). The procedure was tough for the patient but she was relieved to be out of excruciating pain. But after the completion of the procedure, she never was without pain and couldn't bite on the tooth. She went back to talk to the specialist and discuss her pain. She was told that everything looked good and left with a $100 exam bill. The patient came back to me and told me that she hasn't been able to chew on this tooth ever since the procedure. It has been about a year. WHAT?

I know this specialist and she claims that she won't do anything that won't succeed. I called and left a message that was never returned. When I saw the patient on the schedule again and realized that the issue wasn't resolved, and emailed the specialist. This email also went unanswered. Sound fishy? I thought so too.

I called again and finally got the office manager on the phone. When I call to talk to the doctor and the office manager gets on the phone, I feel like the doctor is blowing me off. She is telling Sally to talk to me because she doesn’t want to.

Look, we all have teeth like this. We have all worked on teeth and thought we did an awesome job, only to find out that the tooth still hurts. We all do fillings that are shallow that somehow hurt people so much so that they need to have a root canal. We all have teeth that fail that we don't know why. So why is talking to another dentist that knows failure such a big deal? I didn’t think it was her fault; I thought maybe the tooth was cracked.

I didn't want to take the tooth out without consulting her first. But I get to talk to her office manager. She told me that she has everything on this tooth documented and that on such and such date they told the patient that they didn't find anything wrong with the tooth. They referred her to a facial pain specialist and that they were happy to make her new patient appointment ($650) with this doctor, but the patient declined.

This dentist is not taking any responsibility for this person’s continued pain or for punting her. They are claiming it is not the tooth at all and classifying her as a facial pain patient. Listen, I refer to this specialist and I think this guy is the smartest dude there is in town, but this thing is starting to look and smell and feel like a duck.

If it were my patient that was in pain, I would take responsibility for this tooth. I would have an arrangement with the other doctor that he/she would see my patients and if they thought there was something that I missed, their exam is on me.

What do you think? Is someone skating on their responsibility? Am I being too cynical? Have you ever done a root canal that failed? I have. It is rare, but it happens. I call my endodontist and ask them to help this patient for me and tell them to send me the bill.

To me, that is what it looks like when a guy takes responsibility. Am I wrong? Let me know.

Have a great Wednesday,

john

You Stink!

Well, I have been a bad little blogger. I have been busy and out of fresh ideas lately. I guess it is that thing they call “writer’s block.”

I have been lovin’ the football season. I have been pleasantly surprised by what the Gators have been doing this year. Seeing the Seminoles choke to NC State and then the Bulldogs get their tails spanked by old coach Steve Spurrier was fun.

My house has been full of sick people lately. Two kids and the wife with fever, cough, etc. Just picture the scene from the movie Outbreak when they walk into a room and everyone is lying around moaning and acting like death warmed over. I had to have a repairman over to the house, and he nearly went running out of the house in fear for his life. Everyone is better now, thank goodness.

A new patient came in. Let’s call him Frank. He came in for a second opinion on a crown that was done at another office. You know the tone of voice and certain words they say when they are unhappy and blame the other dentist for something. I always tread lightly with these situations, especially if I know the previous dentist has a good reputation and does good work. I addressed his issue and he seemed happy. He asked how he could get established and get a cleaning. I informed him that the front desk would be more than happy to assist him with his request.

We have a new patient policy. At our office all adult patients must see the doctor first for a comprehensive exam and proper diagnostic radiographs. We typically like a full mouth series, unless we suspect third molar issues (then it is a panograph and bite wings). According to Florida state law, prior to being seen by a hygienist, a patient must have an exam by the dentist to authorize by indirect supervision prophylaxis or other hygiene services. As a military man, I follow the rules. I know many offices let new patients schedule right into hygiene. But from my understanding, this is not allowed.

What is not very clear in Florida dental law is the requirement for radiographs. It is a grey area. What it says and how all the attorneys I have spoken with interpret it can vary. The attorneys say that the Florida Board of Dentistry and Florida law do not strictly mandate the need for radiographs, however, it is viewed as normal and customary to have radiographs to review as part of a thorough and complete exam. It is a general liability issue as well. So, in a few words, the law says, “You need to take darn x-rays!”

A few weeks had gone by when one of our hygienists noticed Frank on my schedule and on her schedule immediately after for a prophylaxis. The note in the appointment stated that the patient did not want any x-rays. My hygienist knew this would not go over well with me. She called the patient several hours prior to the appointment to inform him that radiographs would be needed.

Boom! Frank exploded, ranting about how he should not have to take x-rays and his other dentist did not take x-rays. He asked why we would need to take them, and my staff told him it is required by law; he called us liars and asked if we were saying his other dentist was breaking the law. [No, but maybe he wasn’t very thorough if he never consulted radiographs]. Frank went on to say that if we would not give him a cleaning without x-rays, then he use the internet and tell everyone that we “suck.” Then he hung up.

My office manager called him back to try to explain again. She offered to fax over a position paper from the Board of Dentistry that explains why x-rays are needed. Frank would not hear anything about it. Instead, he just went on and on. The office manager listened patiently before she asked, “Sir, can I say one last thing?” She told him that we are sorry we cannot help him, but if we discover that his making or writing libelous or slanderous statements about our office, he would be held responsible. Goodbye!”

Today, a discharge letter and the position paper info sheet on radiographs are being sent to Frank.

How else do you deal with this type of character? I know there is no way I want to treat this person after this encounter. We strive to meet people’s needs and desires, but this was a no-win situation. What else could we have done? I know my staff is not rude or hostile to patients. I just do not see how this could have been avoided. Any ideas?

Have a good week,

J.J.

Bad Crowns

Happy Friday. I forgot to mention the Gators in my last blog. I have a bit of a bounce in my step this week because we beat the #4 team in the country. I was in the third row on the 40-yard line for that game. What a great atmosphere. But what is even going to be better is if South Carolina and the Gators can take care of business this weekend: then next weekend will be Battle Royale in the swamp. I already have my tickets to that #3 against #4 game. And basketball media day was Wednesday. Oh my gosh, I am so excited about basketball!

I want to talk to you about something important. I don't know if you know this or not, but I have been the blogger for The Daily Grind for almost four years. I told the AGD that I will be retiring from blogging at the end of the year. I have a lot of irons in the fire right now. Most of the time, I am going crazy trying to get everything done. As the new 100% owner of my practice and trying to get this speaking thing off the ground, I feel like it is time.

I am totally going to miss it. It has been a huge part of my life for a long time. I don't know if I will continue to blog, but I just can't commit right now. It has been four years and about probably close to 600 blog posts. Wow. My fingers hurt just thinking about it. The AGD promises some new and exciting writers for The Daily Grind.

Today's topic is bad crowns. In the last two weeks, I have had the same thing happen twice. One was an old patient that decided to go somewhere else to have an implant restored. I don't know why. But when the implant crown came off after 3 months, she decided to come back. The other was a new patient that was unhappy with an anterior crown that was done just a few months back.

The old patient had an implant on #30 restored and it was a mess. The implant was great but the abutment was too small. There was plenty of room but the abutment was taken down too low. The crown looked like a tabletop with no anatomy. I told the patient that I could put this back in but it wasn't going to stay. I told her that she really needs a new abutment and a new crown.

She has insurance but, as you know, the insurance is not going to pay for a new abutment and a new crown. I told her that I felt bad for her and I might discount the stuff a little bit, but it is going to cost her about $1,500. I am not upset that she went somewhere else, but I am still a little shocked sometimes when I see crap dentistry like this. But what am I supposed to do? It is what it is.

I told her I am not going to get involved, but if someone wrote me a letter and told me that something I did failed and was going to have be done over, I would give them their money back. Now, between you and me, I don't know the scruples of the other dentist but to do substandard work tells me a little about this guy. If I were to get this letter, I wouldn't be concerned about someone suing me or anything because my stuff is good. But I would think that someone is doing this kind of work may fear some legal ramification. This letter would maybe make them want to write a check for it to go away.

The second woman came in unhappy with the new crown she got on #8. She has veneers that are about 10 years old One of them broke and a dentist redid this one to match the others. I am not saying this is easy; I know it isn't. But this tooth looks like a Chiclet next to her other teeth. If I was her, I would be unhappy too. I told that I would need to redo this tooth to make it look like the others. What else could I do?

She has the same issue with her insurance. I told both of these patients that they could go back to the dentist who did the work; neither of them wanted to. It looks like both of them are going to pay me (without insurance) to redo some very new work. This just baffles me. If I paid $1,000 for something and it wasn't right, you can be sure I would go back there and get it done right. I do understand losing confidence in someone. But the first one went to another dentist to save money (I am assuming), and now she is back and going to pay twice. If she has the money, why didn't she just come here in the first place?

When I do something, I am my own worst critic. I send stuff back to the lab even after my patient says they love it. I will not stop until everyone is happy. If we are both happy and a couple of weeks later they come back and say they don't like something, I fix it. And if that means doing it again, so be it.

Do you guys get this? I would think that in these hard economic times, people wouldn't be throwing money around like this. Do you just tell them like it is? "Sorry, but it is going to cost you $1,200 to fix." I don't know. Maybe I am trying to save the face of dentistry or to uphold our reputation as a whole.

Hey, have a great weekend.

john

Go Gators.

Are You Up on Technology?

Hey everyone,

Hope you had a good weekend. I got an email this weekend from the organizers of a big meeting. They are interested in my lecture and are planning on reviewing my application, but they had a few questions. They were wondering I have any availability on June 17, 2015. Uh, let me check my calendar. Yeah, it looks like I am wide open. Pretty funny, huh?

I went to Gainesville a couple weeks ago to present a lecture. The night before the lecture, I was able to spend some time with Wayne (I think this is what I called him, but it is not his real name). We had a few beers and talked about teeth. He sees dentistry in an interesting way.

He started asking me questions about my schedule and how it works. He is presently in a two-week class on the business of dentistry. Hilarious. This class on the business of dentistry is probably a total of 10 hours. I am also taking a class on the business of dentistry; it has been going on for 17 years and I am barely pulling a C minus. The class promises to finish in about 17 more years and I am hoping to pull my grade up to a high C.

Wayne is worried about technology. He said that he’s been hearing a lot about CAD-CAM. I told him that I have no problem with CAD-CAM and I think it is an awesome piece of equipment, but our practice just doesn't cut enough crowns to justify having one.

He also asked about digital impressions. I again told him that $40,000 was a lot to make up. It costs $5-$8 per impression and we do 60 crowns a year (that is about 50 impressions). You do the math. It just doesn't make sense for our practice. He started to ask another question, but stopped. “Spit it out, Wayne.”

"But what if people get the impression that we are not up-to-date on our technology?"

Hmm. I had a hard time explaining to him that just because you don't have two of the top three expensive pieces of equipment that dentistry has to offer (CAT scan being the other one, and no I don't have that either), doesn't mean you are not up-to-date. I also had a hard time explaining to him that there is a small amount of people that care more about your technology than about you. up-to-date If your patients like you and trust you, they do not care so much about your equipment. Some do, and I am not sticking my head in the sand and pretending that it doesn't matter, but most patients pay more attention to you than your equipment.

I don't have these pieces of equipment, so market the things we do have. I accentuate the positives. Like in life, if you continue to dwell on the things you don't have, you are going to be a very unhappy person.

I hope to create an environment that values relationships. I have created an office that cares about the needs of the patient before the needs of staff. This office puts service above self. It is up-to-date on the latest CE and does dentistry really well. We are moderately up-to-date on technology, as well. We have digital x-rays and have monitors on the ceiling that impress people, and we have paperless charts. But I am not trying to impress people with my technology; I am trying to impress people with my thoroughness.

This has worked for me for the last 17 years and it is going to have to work for me for the next 17 years. I want people to tell their friends that I was an awesome dentist, that I was friendly and my staff was helpful. I want them to say that this office was so comfortable and warm. Will they mention that we had cool, current technology? Maybe.

Wayne asked what would happen if the guy down the street has a CAD-CAM. I didn’t know what to say. Will I lose a patient because I don't have one? Maybe. I guess I have never really been concerned that I wasn't current enough.

If the guy down the street does have a CAD-CAM, do his patients tell their friends that their dentist hast a one-visit crown machine? Heck yeah he does. And if I had one, I would be marketing the crap out of that thing. But I don't, and I don't care.

I do have a lot to offer, folks. I sound like Stuart Smalley again. "Because I'm good enough, I'm smart enough, and doggonit, people like me!"

It just is funny how younger adults see the world. Some of them have never been consumers. They have never gone to a mechanic and felt ripped off or felt helpless because they don't know what they are talking about. I go there and don't care about the machines they have. I just want to know that they know what they are doing, they do it well and they do it at a fair price. I care that they talk to me in a way I understand and I don't feel like they are doing stuff just to make money. It is the same with dentistry and my patients.

Have a great week. I will talk to you soon.

john

I Don't Want an Exam

Well, things have settled down here a little. I think the course went well and it is such a relief to have that behind me. I have another lecture in NYC in three week and another lecture/hands-on in January, but that is all I have scheduled right now.

I did a massive push to get gigs about a year ago and got about 8. It has dried up, so I have to do another push to get gigs again. I was hoping some people would hear about me and call me, but I guess I am not that lucky. The feedback has been very positive but no one has called yet. I have just hired someone to build a website for my lecture so meeting planners can find all the information they need about me. This is a risk, especially if no one goes to the site. But I am trying this thing for a couple of years and we will see what happens. I will keep you posted.

Today I want to talk about the patient that is not very compliant. I have been in this biz for about 17 years and I have seen everything, but still some things amaze me.

I have some friends at my church who go to a dentist near their home. We have gotten to know them well and they both said they wanted to come to my office. The wife came in first for a new patient exam and really liked it here. A couple months later, the husband came in. He has the dental issues. He had braces to try to improve the bite and the cleanability of his teeth and he has been battling gum disease. He has been "keeping it at bay" for about 10 years.

It has been a couple years since he last had his teeth cleaned. You know that a couple years is a long time to wait for perio maintenance. I did perio probings and he had an alarming amount of 5mm pockets and only about 40% of bone on the lower anterior. He has great teeth, a pretty good occlusion and no decay, but the perio is a concern.

I mentioned this and told him that I would put him on a "shorter leash." I want him to come in every three months for a bit while trying to avoid another trip to the periodontist. He said his insurance would not cover that. I told him that his insurance would cover the extractions of those lower teeth. I made it very clear that I recommend him coming to see us every three months for now. He scheduled his next appointment for six months.

I just shook my head. He has been around the block with his perio. He knows what is going on in his mouth and he does not want to spend the extra $170 a year to make sure he doesn't lose his teeth. This kind of stuff baffles me. You are probably thinking that I should not be so hard him because maybe money is a concern for his family. It isn't. I know this couple. They are DINKs (duel income, no kids). The $170 is not the problem.

People are weird. These people are great people. I am not really mad at him. Maybe I am just mad at myself because I must have done something wrong. I must have not educated him enough. I must not have told him the severity of the issue. But I think I did. He knows. He knows what gum disease is and he knows he has it. He knows that being here more often is going to prevent the advancement of this disease. But he just doesn't want to spend $170 out of pocket. This is not my fault.

It baffles me. I know they like it here and I know they trust me. But who do you think is going to have to pick up the pieces when Humpty Dumpty comes tumbling to the ground? You guessed it: me.

What do I do? Do I kick them out of the practice because he won't listen to me? Do I bring it up every single time he comes in and pester the crap out of him? We all know that is why people leave practices all the time. "The hygienist wouldn't stop telling me to floss." Or, “They just kept bothering me at my old dental office." Do I just pretend it isn't there?

I don't know the answer. Do you have one? Let me know what you think.

Have a great weekend.

john

The Patient That Cannot Be Fixed

Sorry about last week. I didn't forget; I just am stressed beyond my ability to handle. See, I gave a lecture on Saturday, but this one was different. I gave my regular lecture in the morning and my first hands-on course in the afternoon. Oh my gosh. Doing a hands-on course is SO MUCH WORK.

When I do a filling, I go into a room and it is all there. I never have to think about how much stuff I really use. I don't have a sponsor, so I have had to beg, borrow and steal products to have on the lab bench for people. I am not getting paid very much to do to this because I just wanted the opportunity. If I spend money on products to give away, I really would make nothing. And making nothing is not an option because it is so much work (did I say this already?).

Triodent donated the models. But the models just have an MO and an MOD on them and I think everyone can do that. I wanted to take the class up a notch by putting in an MOL cusp replacement, an access filling and an MODF build-up. All this for them to think out of the box when it comes to restoring with composite.

There is just one small problem: the models don't come prepped this way. I prepped the teeth on all 17 models individually after work. I have been putting in 12-hour days, cussing under my breath saying, "I bet Frank Spear doesn't have to do this." I know, I know: I am no Frank Spear.

Along with the models, I had to get the resin donated. The bonding agent donated was donated. Twenty Contact Pros were donated. I got tofflemire matrices from WaterPik. I got bands and V3 rings from Triodent. But what about placement instruments or explorers or finishing discs or glazing products? Ughhhh. What a royal pain in the neck.

All participants have to bring their own handpieces (high- and low-speed), composite trays and finishing burs. Does that mean they are going to bring a tofflemire? I don't know. There are 17 participants, but I only have 10 tofflemires in my office.

Four days before the course, the university started sending me paperwork to sign. Oh, and I had to watch a HIPPA video and get certified. What? I have been scheduled to do this lecture for a year and you are sending me paperwork 4 days before the course that I am already stressing about?

And I am trying to run a practice. And I am training for a marathon. And I have a family that wants a piece of me, too. Anyway. That is just a little glimpse in my life. I know I made this bed. But I thought being a lecturer would be cool.

Today's topic (no, that wasn't it) is the patient that can’t be fixed. I have this retired man who has been a patient for a long time. He is an absolutely great guy. We all love him and he loves us.

He has a broken bridge. The abutments are 6 and 7 and the cantilever pontic is 5. I don't think he had 4. Both abutments had RCT and post and cores. The core broke on 7 but he broke the post in half on 6. I sent him to the periodontist to discuss doing some implants to replace this bridge. He said, "No way. They are too expensive. I am on a fixed income and I can't do it." We talked him into doing an implant on 4 and agreed that I would try to salvage the bridge.

I sent him to an endodontist to take the broken post out of the tooth; he said it couldn't be done. I put 3 minum pins in 6 and did a reverse build-up on both 6 and 7. It looked great and we just recemented the bridge. We finished up the implant and things were looking pretty good for about 6 months. Then, it broke off again with both abutments in the bridge.

Hmm. We decided there was not much we could do except try again. Two more reverse build-ups and recement the bridge. Again, things looked good… for about 4 months. By then, he was tired of spending money and I was tired of looking like a crappy dentist.

I told our patient that if he got the post out and we did a reverse post and core, this would be the last time he would pay for this. I was essentially guaranteeing the work. He agreed.

I then sent him to another endodontist to see if he would take the broken post out of 6. No problem. We did the work. I relieved the occlusion the best I could and he was thrilled. I was so proud of myself for fixing him and making him happy again.

Four months. This lasted four months before he broke the post again. I was now convinced this couldn't be fixed.

When the bridge was out, I took an impression for a Valplast partial. I then did some more minum pins and reverse build-ups and temporarily cemented the bridge so it would come off and not break the build-ups.

He was in the next day. We cemented the bridge with stronger temp cement and he was back in 2 weeks. At this point, the partial was made. We took 6 and 7 down to the gum line and put in his new free Valplast partial.

He was happy, but I don't know how he could be It must be tough for a 70-year-old man to get used to a removable partial. But this made me think. Sometimes some teeth, with the present technology, can't be fixed. I thought I could have tried a cast post and core, but other than that, there was nothing else to try. I think he still would have broken the cast post and core and, come to think about it, I think he might have broken the implant too.

So, you know what? I think we did the best we could. The thing is going to flex when he moves on over with his jaw muscles not breaking anything. I am just frustrated that I had to do this five times to realize it wasn't going to work. I want to think that what we do works. I know it does, but once, maybe just one time it won’t work. But you just never know when that patient is going to walk in.

Have a great week. I am probably out for tomorrow because I will be so stressed out. See you next time.

john