Biologic Dentist?

“Are you a biologic dentist?”

In more than 20 years of practice, I had never been asked that question. Last week, two patients asked me this very question. That always grabs my attention.

As the younger dentists in our audience will soon discover, dental stories in the media tend to run in cycles. It seems that every seven years, you’ll get stories about how bad amalgam is. Every 10 years, you’ll hear that someone is developing a vaccine for caries. We recently dealt with stories about how bad dental x-rays are. You get the idea.

Every time one of these stories airs, you’ll find yourself fielding some questions on that particular subject. When two different people asked me the same question I had never heard before, I wondered which news program I had missed.

Biologic dentistry is also referred as holistic or alternative dentistry. I have never referred to myself as a biologic dentist, and I have never claimed to be a holistic dentist. I was very curious as to why people were asking me about this.

Before I go on, let me just say that my blog is not about whether the concept of holistic (biological) dentistry is good or bad. You can decide that for yourself. My goal is to illustrate how I handle such inquiries. You will be asked such questions in your career. The most common variants involve cosmetic and family dentistry. They are different questions, but the same concept.

In answering these inquiries, I simply ask, “What is it that you want done?” I inform the patient that I may just be the dentist they are looking for. Or, I may not.

In this case the patient stated that she had old, broken silver fillings and wanted a dentist who could replace them with white fillings. That sounded simple enough. However, I was the third dentist she had visited. One dentist informed her that he only does silver fillings and the other said that he does both but prefers amalgam. I let the patient know that I haven’t placed a silver filling in about eight years, mostly because people want white teeth. Amalgam fillings are fine by me, but I do not have the ability to make them white. That was perfect for her; she had found her “biologic” dentist.

I have learned to ask what the patient really wants done. I’ve had patients ask me if I was a cosmetic dentist. Upon asking them what they meant, I found that most people wanted a dentist who could do white crowns and fillings. On those rare occasions when patients actually need a full-mouth rehabilitation, I refer to my local prosthodontist. It is just a matter of asking.

Maybe, just maybe, I am a biologic dentist after all.

Andy Alas, DDS

"Family" Dentistry

As a new business owner, I’m finding out that some of the most loyal patients I have are my family and close relatives. As I start working on their complex oral health issues, I find myself dwelling on the boundaries of ethics.

I have been under the impression that, as a health care provider, it is legally acceptable to work on family and friends. However, it’s not the most ethical decision, as the relationship that you have with them personally may influence your decision-making as a provider.

I’m beginning to realize this as I get deeper and deeper into treatment with them. I’m also finding out that their reactions to my treatment and instructions are different than they were when their provider was a “stranger.”

I’m the youngest professional in my family so far. I feel like my confidence is affected when I stand above a relative who has known me since I was born, and I feel restricted in what I can and cannot tell them. It may also be a cultural issue, as I was raised to be advised by the elder relatives and not vice-versa. This makes me wonder if I can perform and guide them in treatment as well as I can a patient with whom I don’t have that connection. This is becoming more and more of an internal issue for me and it would be interesting to know if this is something other providers have experienced. Have you experienced this, or is this just a byproduct of being a new provider in the family?

Mona Goodarzi, DDS

Medical vs. Dental Teamwork

I am three months into my AEGD residency, and it’s going well. I’ve picked up speed, become more efficient, gained confidence and made new friends. Oh, and I’ve also done more molar endo than I did in all of dental school, got ACLS-certified, completed a subepithelial connective tissue graft, and started my IV sedation requirements.

This week, I have spent my mornings at a nearby hospital surgical prep department observing and starting IVs on patients. It’s been humorous introducing myself as a dentist at the hospital to patients and other medical professionals. They stare at my nametag for a minute reading “D-D-S.” They look at me confused and say, “You’re a dentist? What are you doing here?” After my explanation, they are intrigued to know more about the residency program and how they can help me with my experience at the hospital.

I have noticed some differences between the medical environment and the dental environment while at the hospital. Here, patients are moved from department to department – checking in, surgical prep, pre-op, operating room, recovery, rehab, etc. And there are different doctors, nurses, and staff overseeing them at each place along the way. Each member of the team specializes in their specific area, completing their duties and monitoring the patient along the way. This is efficient and should provide a high level of care, given each person’s strengths and responsibilities. Yet it demands precision in the coordination and communication between the different specialties.

When a patient comes in to surgical prep, IV placements are dictated by the specific surgery site, surgical needs, and to ease patient recovery. For example, for a patient needing to use a walker after surgery, it’s nice to avoid placing IVs in the wrist. Then the anesthesiologist comes in and discusses the method they will use and how this coordinates with the operating doctor’s and patient’s preferences. With so many different players on the team, it made me wonder who is coaching it all. Who has the bigger picture in mind? Is it the cardiologist, the orthopedic surgeon, the primary care physician, or someone else?

In comparison to dentistry, I can see clearly that the general dentist is the coach - and the captain, the goalie, the referee, the scorekeeper, etc. We are the primary care doctor, surgeon, radiologist, neurologist, pharmacist, psychologist, and more. We have a lot of responsibilities. Yet we have the ‘dental team’ behind us. Given all the requirements a general dentist has, utilizing dental hygienists and assistants to their fullest capacity without compromising care for the patients should do a lot for the efficiency of the office and the stress of the dentist.

AGD members, do you have any advice for utilizing the dental team? Is it difficult to give up control on some things? Do you find you are able to be more efficient? How do you ensure the dental team has adequate training in what they are being asked to take on?

Thanks!

Katie Divine, DDS

Practice Transitions

I recently attended a local day-long lecture presented Dr. Jeff Rouse, from San Antonio, Texas. He titled the subject “Airway Prosthodontics.” It was a great lecture, but this blog is not about that subject.

I sat beside my colleague and fellow AGD member Gene Dalla Lana, DDS, FAGD. Gene has always exemplified a quality, professional GP dentist. He told me that he has enjoyed The Daily Grind blogs and asked when I was going to tell more about my upcoming office move. I was flattered that someone was actually reading these blogs (as an author, I have no idea how many people these blogs reach), and felt it was time to get back to my own daily grind.

There is an old Chinese curse that says, “May you live in interesting times.” My last few years have certainly been that. I purchased my 4-op 1,500 sq ft practice in 1994 from a colleague who retired after 44 years of practice. He built a thriving, growing practice. In the early 90s, he was still doing full-mouth rehabilitations, placing implants and more. It was big and it was busy, and our personalities matched well. Roy was almost 69 and he wanted to walk out the door and let me walk in, with no transition. We worked hard on the relationships with the team, our patients, our labs, our dental suppliers, and more. I went from no hygiene days per week (he employed four assistants but no dental hygienists on a five-day work week), to three hygienists and nine hygiene days in a four-day work week.

My practice is incredibly busy. We have created a culture that matches the value systems of me and my team, as well as the patients we have the privilege to treat and care for. And then (as I discussed in a previous blog) I picked up a side, niche practice of independent dental examination consulting for orofacial and TMJ injuries. That put my work into overdrive and I did not know how to get balance back in my life.

Working with my business coach, we decided I should open a new office, build it the way I desire with the culture of my team built into a bigger space, bring a dentist or two into the fold, and get them to buy in. They could work the general dentistry stuff full-time while I focused on the consulting work part-time. It sounded like a win-win business plan and I went to work on it.

I hired a commercial realtor/lease negotiator to help me find a new space that was within walking distance of my office. In a relatively short time, we found a great place. It is 4,200 sq ft, above a drug store, with great visibility, underground parking attached to the building. It is just four blocks from where I am now. The landlord was slow to respond, but over the next 12 months (yes, it took almost 12 months), we negotiated lease terms, rental rates, operating costs, renewals, parking and more. We were stuck with the fact that the landlord had to do some exterior renovations before we could build on the interior, and they did not have a development permit from the City of Calgary. We waited, and we waited. Then, in June of this year, they cancelled the deal stating the drug store, which had first right of refusal for the space, stated they only wanted physicians in that space because they write more prescriptions. I was floored.

At this moment, another space came available, also four blocks from my office (in a different direction). Again, we negotiated all the terms with their realtor representative. Then that landlord handed the deal off to his son to finish negotiating and he wanted to change everything, to considerable detriment to me and my plans. They got greedy and I had to walk away.

By this time, my practice was growing ever busier and I had no place to move to. Stress was building as I was putting in 60+ hours per week in the two businesses. I was growing increasingly unhappy. I had to make a change and decided I needed someone in my current space with me now. We could expand our hours, the new person could work full-time and I could go part-time. We could find a way to make it work in our tight space. So I called a local practice broker/transition specialist.

He told me that the timing was perfect. Apparently, the economy for dentists in Ontario is not that great; there are many young dentists looking to buy practices in Alberta, and Calgary specifically. Demand has increased greatly, but supply has not. I had my practice valuation done three years ago to take advantage of some professional corporation taxation changes and bring my wife in as a shareholder. The broker told me that my practice value had increased 50% in three years! And with the taxation changes we implemented, most of it would be tax-free. So, I have decided to sell. At nearly 55 years of age, I will let it go. I am told it may happen and be completed all before Christmas. Depending on who purchases the practice, I could stay on to help with the transition and work-part time, or I could leave and rent chair space from someone. (Do you have room, Gene?) I could do my independent consulting, or I could open a small practice close to my home and limit it to the orofacial/TMJ stuff as part of my independent consulting.

Even though I am working too hard now, there is a light at the end of the tunnel. I want to work less and spend more time with my family. I want to emulate Dr. Bob Oro and give my wife the gift of a husband with a new body. There are a lot of things I want to do, and it all may happen very soon.

We sure live in interesting times. As my days grind on, I’ll fill you in on my progress.

Thanks, Gene, for telling me that you read these blogs. It’s nice to know it’s not just all the authors reading them.

Warm regards,

Larry Stanleigh, DDS

The Feet of Mr. Lincoln, The Words of Dr. King

The view of our nation’s capitol teeming with people from all parts of the world made me button-popping proud to be an American. It was the summer of 2011, and the messages just started flowing.

Our summer vacation plans were dictated by our child’s educational needs. Sound familiar? You see, he was moving to Washington, DC to pursue his graduate education. As usual, his mom wanted to okay his student housing and make sure he wasn’t going to die of malnutrition or major OSHA violations.

I had just walked from the Washington Memorial past the Vietnam Memorial, on to the reflective pool. There was no water in it as preparations for August 28 had started. That is, August 28 as in 2013, a full two years away.

When my son, Debbie and I got to the Lincoln Memorial steps, it was entrancing. We stepped into another plane where the quiet was deafening as people from all over the globe wandered the massive monument to pay homage to this great man.

My mind was racing as we approached the magnificent entryway of granite steps. And then I heard him speaking. Yes, this was the monument to Lincoln. But make no mistake; the event that took place on August 23, 1963, was in full display.

I turned to Debbie and said under my breath, “Debbie, I can actually hear MLK giving the famous March on Washington speech.”

Softly she replied, “Bob, you silly goof. Look over there. See the podium? See the speakers? Yes, they are playing the speech, loud enough to hear clearly if you are close.”

Almost 50 years. Hard to imagine!

When I got to the top step, it felt like I could say hello to Abe and then sit and see what he sees as he looks over the world today. With the speech of Dr. King as the backdrop, it was easy to see the connection to the White House, not that far away.

One hundred and fifty years ago, Mr. Lincoln was part of the evolution of the United States. Fifty years ago, Dr. Martin Luther King, Jr., was part of the evolution of the United States.

To those of us baby boomers, there may be a yearning to think about what we have learned in the past 50 years. Surely, each one of us will have a personal story as unique as our own individuality.

If you get a chance to go to our nation’s capitol, be sure to make time to sit at the feet of Lincoln and contemplate the words of Martin.

Enjoy the journey,

Bob Oro, DMD, MAGD

The Other Dentist

I recently had an interesting encounter with a patient. She was in for her clear aligner checkup, and asked about a spot on one of her teeth. I asked if she had recently been in for a checkup with her dentist. She said that she had not, and then asked if it was possible to come to our office for that service. I double-checked with her that she did not already have a dentist she was seeing. She replied, “No, I’m monogamous.”

As excited as I was to hear that my patient wanted to go steady with me, I started thinking about all my other patients that continue to “see other people.” Sure, I was a little jealous. But I was more concerned that they are not getting the same level of care that I would provide (that’s what we all say, right?).

The practice I currently work in is heavily focused on clear aligner therapy. Many patients that come here for orthodontics may already have a dentist that they see for cleaning and restorative work, but that just does not offer orthodontic services. I know many of these patients choose to go to another dentist because they have an established relationship with them, but it’s usually because they want to see someone that is in network with their insurance.

Typically, my orthodontic consult involves asking when the patient’s last cleaning/checkup was. If it was within the last six months and their x-rays look good, I trust that they are in good hands and proceed with my treatment. However, if I get a blank stare when I ask this question and I see pathology on their x-rays, I ask that they schedule a cleaning and new patient exam, either in our office or wherever they would like. I would say half the time they come to us. But if we do not take their insurance, they see someone who does. I honestly do not have a problem with this. My main pet peeve is when they return from their dental provider after an SRP or even a “cleaning,” and there is still so much plaque and buildup on the teeth that I cannot even take a proper impression. I have patients that come back complaining of sensitivity after a mouth full of freshly-placed fillings. The best was when someone had brand new ceramic crowns placed on teeth that clearly had failing root canals and periapical pathology. This patient assured me that their dentist told them everything was fine.

I know it is a huge taboo to bad mouth a fellow dentist. It does not make our profession look good and it is highly discouraged in our community. In the case of the failing root canal, I attempted to personally contact this dentist, only to be ignored after leaving several messages. I try my best to inform the patient about the state of their dental work. I try to avoid saying anything bad about the other dentist, but it is difficult when I have to inform them of the reasons I cannot perform my treatment. When I have a patient that complains because they are unhappy with work that I have done, I make every effort to correct it or redo it because I want to make sure they have a good experience. If they ever ended up in the hands of another dentist who questioned my work (my worst nightmare), I would feel terrible!

I do my best not to judge. I know we have all had difficulties and you can never truly understand the situation unless you have experienced it firsthand. But I seem to find myself presented with these scenarios more often than I would like. Have any of you ever had these types of experiences? If so, how do you handle them? Do you demand monogamy from all your patients? When I develop a relationship with a patient because they see me so often, it’s hard not to feel jealous or protective if I learn they are getting other dental work taken care of somewhere else. I guess I just have to hope one day they will realize what they are missing out on!

Lilya Horowitz, DDS

Goals and Babies

I've been thinking a lot about goals lately. My dad recently retired from the Navy. He put in 25 years as a physician and now he has had to try to figure out what he really wants to do for a living. Or, when he grows up. He wants to open his own practice. He wants to go to Africa to help the people there. He wants to do a lot of different things. The thing is, all he needs to do is decide and he could probably do it.

I have thought about what I would do in that situation. If I had my needs met already, possibly didn't have to go to work, what would I love to do? Would I still go to work every day, just because I like it? What would change? Would I still see all the same patients, or keep the team members I have? If the fear of failure was taken away, how would I operate? Why couldn't I do the same thing now?

I thought about these questions, and thought to myself, “Why not?” I get to choose what I do with my life, who I work with, how many days I work, how big a house I have to pay for...

My wife was due with our sixth baby last Saturday. We are still waiting for our now-overdue baby to come. So I have another reason to revisit my priorities. Kids grow up fast, and if you are not intentional, you might miss out. I want to be more intentional, so I have thought about some more questions.

What is most important to me? Who is most important to me? If I could accomplish one thing in the next month, what would it be? Even more thought-provoking is the "What if I had one month to live?" scenario.

I think sometimes I get caught in the current of life. I get swept away because something is urgent, or somebody asked me to do this or that. If I don't watch out, I will end up missing out on something I know is important, like my life.

Michael Lemme, DDS

She Wasn't Crazy...

Dr. Bauer wrote a post a while ago about “crazy patients.” I really enjoyed the blog; the moments he shared definitely reminded me of a lot of the patients I see. A commenter said, “You aren't going to always know everything about every patient and their problems when they walk through the door. This doesn't mean them crazy or make you a bad dentist. The key is to stay patient, keep calm and try to sort through the mess to the real issue at hand.” That comment truly struck a chord with me. A patient of mine recently showed me just what the commenter was getting at.

My patient had always seemed a bit different, but I couldn’t ever narrow down just what was happening. An hour after speaking with her to schedule our next appointment, she would call me to schedule our next appointment. She wouldn’t have any recollection of our previous and would frequently become very emotional on the phone. When she was in my chair, she would often make inappropriate comments. On several occasions, my classmates asked me if there was something not quite right with her.

She had presented with recurrent caries under a crown, and not long after developed a toothache. We discussed the options and she elected extraction. She experienced significant prolonged bleeding following the extraction which required her to return to the clinic for debridement and placement of hemostatic agents. A week later, she called me in tears and in her voicemail she reported significant bruising. She asked if she could come in to be examined to determine if the bruising was from the extraction or from her husband slapping her on her face the night of the extraction.

I was rattled to hear that she was being abused, but it showed me what that commenter already knew: there are things about your patients that you do not know. They aren’t crazy and you aren’t a bad dentist. You just have “to sort through the mess to the real issue at hand.”

David Coviak

When a Trend Becomes a Rut

Several years ago, we began something had been heard of but was not yet a trend. We bought back Halloween candy from kids in the community (with a max on the cash paid), then boxed the candy to send it to our men and women in the military. Over the years, it became popular with many other organizations. And, like many things that begin as a reward, it began to be expected. The luster and enthusiasm was lost. Lost. I believe, on the patients, the community, and the team.

We would ask patients for addresses of soldiers overseas to send our candy to, but struggled to have enough addresses. We found it difficult to get staff to volunteer (other than the faithful few that are always there to support office events). Last year, we found a national program called Operation Gratitude that organized, in a mass effort, the very same program we were feeling quite lost in. We have continued our program and will again this year. This event like, so many things we experience in life, needs a bit of a kick start.

A relationship is constantly evolving and needs to be nourished to thrive. Our relationships with our team need nourishment, as well. What are you doing to nourish your team? We have instituted different bonuses for the team. I call them “moments of appreciation.” But I fear that because it coincides with a date on a calendar rather than a purposeful unplanned moment, it is less meaningful (or worse yet, expected).

I always appreciate a gift or card in association with a birthday/holiday, but I seem to really enjoy the unexpected ones. Why is the team or our patients any different? I feel the burden of the team feeling under-appreciated because myself and my partner can’t catch every good moment. Like many, we aren’t the best at seeing the positives in the first place. Although, is it a one-way street? Does our team thank us for working that extra patient in? Do they thank us for paying them when we say we will? Of course, being the bigger person—giving and not expecting anything in return—is the golden philosophy. But is it endurable?

I am not proposing that I have the answers. I am simply asking the questions so that you can self- reflect and see where you fall in the spectrum. What kind of employer are you? “Send this lab case,” is different than, “I need this lab case sent, please.” Both are statements of direction and intended expectation, but one is with common respect for the other human being.

Not all statements can be sugar-coated. But maybe your tone could be tweaked to encourage a positive reaction. Also rather than planning yearly rewards during Hygiene Month, Assistants’ Week, and Business Administrators Day, maybe it could be spontaneous (or at least appear to be). Shuffle the names of your team and scatter the same reward that would be given normally in conjunction with the calendar date at random instead, making sure each is recognized throughout the year.

You could plan two years ahead and choose a different charity to participate with, in lieu of Operation Gratitude. Maybe an Easter Candy Buy-Back and to benefit a local soup kitchen. Then, the following year, choose the local service club such as Kiwanis or the Lion Club to work with. Mix it up to avoid ruts. Nourish and flourish!

“Make it a habit to tell people thank you. To express your appreciation, sincerely and without the expectation of anything in return. Truly appreciate those around you, and you'll soon find many others around you. Truly appreciate life, and you'll find that you have more of it.” —Ralph Marston

Colleen B. DeLacy, DDS, FAGD