Lessons Learned From Teammates and Patients

Our concierge shared with us her adventure to Battle Creek, Michigan, to visit her mom. Being from a sunshine state where we miss fall foliage, it was fun to hear about how cold and rainy those states can be in autumn. However, the life lesson was having someone share what it is like to visit a parent in assisted living. We talked about being sandwiched between the responsibilities of aging parents and one’s own children and grandchildren. Best of all, we got to share a hug and realize just how lucky we are to be healthy. Thanks, Gina!

Our hygienist is in Kansas to run in a very important race, and just sent me a text. “Just managed to finish the marathon in less than 4 hours. Got 2nd place in my age group. Able to raise about $3,500.” You see, Christa’s niece’s son has leukemia and his young life is being seriously challenged. Her energy and commitment are just another way of showing how much our extended office family cares and shares. Thanks, Christa!

I had no idea what twerking was until our assistant showed my wife what her grandchildren had taught her. I was standing outside an operatory when I heard a commotion and raucous laughter. She and Phyllis were trying to move their booties, howling and giggling like middle schoolers. I must have missed twerking in dental school. Thanks, Phyllis!

Two years ago, I got a call from a patient of ours. I could feel the despair in his voice. “Bob I just got a call from my son. He has testicular cancer.” His voice cracked with emotion. “The first person we thought of was you. Can you help us with some info and referral?” I was reassured that all the years of training and treating the overall patient had come to fruition. Jack knew how much we cared about the total patient and I was his go-to guy in this very challenging situation. Within minutes, I had connected him with an MD and with someone who had already gone through the same medical issues. Thanks to all my instructors in my two-year GPR at Brookdale Hospital Medical Center!

I was the chairman of the health committee for the local Chamber of Commerce a number of years ago. Our aim was to give free medical education dinner seminars once a month. The room was packed for our Alzheimer’s seminar. For this seminar, we departed from tradition. One of our committee members, Joanie, role-played the steps of deterioration of communication that occurs in Alzheimer’s. You see, Joanie had gone through it all with her mom. The most important thing to remember with Alzheimer’s is that it is the support system (spouse, relatives), not the patient, who is under the most mental stress. Thanks ,Joanie!

No matter what the challenges in life, with a good support system, it is easier to…

Enjoy the journey,

Bob Oro, DMD, MAGD

Office Closed: Helping Santa at North Pole

This time of year, dental offices decide if they are going to remain open between Christmas and New Year’s Day. Many patients are off work that week and ask to be scheduled during that time. During my early years as a practice owner, I would work that week. These days, I opt to close down and head up north to help Santa after his Christmas busy season. Oral surgeons in my area remain open because kids are home from school and want to have their wisdom teeth taken out while they are on a school break.

I like to have everyone in my office take their vacations at the same time. It is less disruptive to office flow if we are all gone at the same time. So, at the beginning of each year, we pick a week in August for our week-long break. This allows staff with children to travel during summer breaks. Our second vacation week is at the end of December. Again, everyone likes to be home during this time and the kids are off.

When we did keep the office open between Christmas and New Year’s Day, we had no problem booking appointments. In fact, the schedule was quite full. The problem was when the actual day arrived. Early in the morning, the phones would ring off the hook with people rescheduling their appointments. Or people would just not show up. I understand that the intention was there for a dental appointment. However, last minute invitations or store sales kept everyone away from my office.

After awhile, I learned that if I was going to spend that week surfing the Web, I would much rather do it at home in my pajamas.

Of course, I’m available for emergency calls during this time. I rarely get called into the office. However, I will drive to the office if needed. When I do go up to the North Pole to help Santa out, I will have a colleague take my calls. Mostly, though, I’m the one taking their calls to I repay the favors they’ve done for me during the year.

You’ll have to excuse me for this short blog. I hear Santa calling for me. Someone needs to clean up after the reindeer. Guess whose turn it is…

Andy Alas, DDS

‘Twas the Week Before Christmas

‘Twas the week before Christmas and all through the ops
Patients were requesting last minute spots.
The stockings were hung along the front desk counter
In hopes that elves this way would saunter.

The assistants were nestled all snug in the breakroom
While visions of sugar-free gum in their heads loom.
And I in my scrubs and gloves and mask
Had just settled in to finish my task.

When out in the hall there arose such a clatter
I sprang from my chair to see what was the matter.
Away to the doorway I flew like a flash
Threw open the door and fell with a crash.

The fluorescent lights shone, the tiles all aglow
Giving a luster of bleached teeth whiter than snow.
When what to my wondering eyes should appear
But a delivery of treats from colleagues far and near.

I picked myself up and brushed off my shame
And to my staff I called by name.
Oh Mary Kaye and Margaret and Irene, too
Richard and Lindsay and Matthew… yoo hoo!

Holley and Chelssey please come and look
At all the treats that were left for our little nook.
‘Tis the season to give, ‘tis the season to share
Let’s show our gratitude to folks everywhere.

And then in a twinkling I heard sounds of glee
As the staff began to plot a giving spree.
And I knew in my heart that very good things
Were going to be happening.

Let’s bring these treats to those who have less.
Let’s bring goodwill and glad tidings to reduce stress
Of neighbors and friends who may be in need.
And I know in my heart it will be a very good Christmas indeed.

We gathered together to spread good cheer.
And in the distance, faint to the ear,
Were words from our staff heard through the night.
Merry Christmas to all and to all… smiles bright!

Claudia Anderson, DDS

For Good

Some days, I really hate my job.

Don’t get me wrong. I know that I am extremely lucky to have secured an associate position in a thriving private practice in one of the most beautiful cities in the world. I’m fortunate to have a steady paycheck that keeps a roof over my head, clothes on my back, and food on the dinner table. I have a lot to be thankful for.

But there are always those days, those patients, those supposed-to-be-straightforward appointments that make me seriously question my decision to enter the dental profession.

I first considered becoming a dentist when I was fourteen years old. I had just completed a rudimentary assessment at school designed to extrapolate the desired qualities of my ideal future profession. For twenty minutes, I answered a series of questions such as, “Do you consider yourself an honest person?” and, “Would you be comfortable working with blood?” and, “Are you able to remain calm when provoked?” I started to suspect that my guidance counselor was less interested in helping me identify my life’s calling and more interested in sniffing out any potential psychopaths and serial killers in my class.

Presumably because I had answered that I did believe in helping people and I was open to working in healthcare, the results of this questionnaire listed “Doctor/Dentist” as a suggested career path for me, much to the delight and relief of my parents. After all, at fourteen, the only definitive plans I had made for my future involved marrying a Backstreet Boy, getting my driver’s license, and eventually making the leap from glasses to contacts, not necessarily in that order.

Now, almost two decades later, I’m doing exactly what this little survey told me I am supposed to be doing with the rest of my life. But every now and then, some days are really tough. Some days I give 100% and it’s still not enough. Patients complain that they’re not happy. They express zero confidence in my knowledge and abilities as a professional. They demand favors and free work, refunds and re-dos.

Though I’ve endured my fair share of criticism over the years, I would be lying if I said that this does not take both a physical and emotional toll on me. Some evenings, I drive home in tears or cry myself to sleep because I can’t shake off a disgruntled patient’s particularly nasty remarks and my failure to meet their extremely high expectations. At the end of the day, all I want to do is be able to do good for others.

Realizing that there was little I could do to alter the reality of the less enjoyable aspects of working in private practice, I began looking for ways to increase my enjoyment of dentistry and to rediscover why I chose it in the first place. I turned to volunteering, knowing that somewhere out there, my skills could be used to make a contribution for good.

This past weekend, I had the privilege of taking part in the California Dental Association’s CDA Cares event in San Diego. This is a program that brings together volunteer dental professionals and members of the community to provide free dental treatment to more than 2,000 patients each time it is held. As an estimated 10 million residents of the state of California experience barriers to dental care, events such as these are desperately needed to provide dental services to the underserved, as well as to raise public awareness of unmet oral health care needs.

I awoke at 4:30 a.m. to pick up my assistant and drive to the Del Mar Fairgrounds, where hundreds of people were already waiting in line to be seen. Many patients had traveled several hours by public transportation to camp out overnight in the rain for a chance to receive dental treatment that would otherwise be impossible for them to obtain. I chuckled to myself, thinking about all the times a patient in our practice had complained about having to wait ten minutes while seated in one of our white leather reception area chairs or helping themselves to a freshly brewed coffee from the Keurig machine. It was clear that things were going to be quite different today.

The doctor who led our clinical orientation concluded his presentation by saying, “For some of you, this will be one of the most life-changing experiences you will ever have.” He could not have been more right about that. Despite the cold and dreary weather, there was an unmistakably high level of positive energy in the air. There is something truly magical about thousands of people sharing in the excitement of coming together to help others.

From the moment we arrived until my last patient threw his arms around me in a big bear hug of gratitude, it was smiles all around. At times, it was hard to tell who was more thrilled to be there, the patients or the doctors. I realized that I had not heard this many people thank other people so emphatically and enthusiastically in a long, long time. It was incredible.

Since being appointed to the faculty at the University of California-San Diego School of Medicine earlier this year, I have had the opportunity to take part in the UCSD Pre-Dental Society’s Free Dental Clinic. This is a student-run organization that provides dental services to underserved patient populations in the San Diego area. It was refreshing to see so many of the students I work with eagerly volunteering to serve six-hour shifts as chairside assistants, runners, and translators on a weekend that fell right in the middle of their final exam period. If there are any dental school admissions officers reading this, I want you to consider that the GPAs of your applicants from UCSD probably could have been a little higher this semester had they spent their Saturday and Sunday holed up in a library gripping a textbook instead of a suction tip or a patient’s hand.

Perhaps the most encouraging thing I learned from my experience was that the large majority of the dental professionals who participated in this event have endeavored to stay actively involved in dental outreach missions and initiatives throughout their careers. Though there were plenty of first-timers like myself, most of the people working around me had been going to similar events multiple times a year for ages. They live for this and keep coming back for more.

I learned that it takes a certain type of healthcare professional to sign up for this kind of humanitarian work. When many of the typical motivational trappings of volunteer work—self-promotion, resume padding, increasing chances of admission to educational programs—are no longer applicable, it’s not easy to find a licensed practitioner who will voluntarily give up precious days of rest, vacation, or production in favor of performing free treatment for patients whom they will likely never see again. It would be so much easier to just send a check in the mail, make an online donation, or host a glamorous charity dinner to collect money to support and celebrate these efforts from a safe distance.

But that isn’t good enough for me. I need to be right where the action is. The dentists I met through this experience showed me that it is not only possible to strike a balance between a lucrative dental practice and a commitment to outreach, it is absolutely essential to achieving career satisfaction if what lies at the heart of your work is doing good for others and, in turn, being changed for good.

Diana Nguyen, DDS

To Which Continuing Education Cult Do You Belong?

Back when I was in dental school, I was pretty sure I knew how to do everything. I had no issues finding patients, diagnosing and treatment planning by the book, and making sure my clinical requirements and production goals were completed on time. If I ever ran into a problem treating a patient, I would hunt down whatever specialty or general faculty I needed at the time, and they would calmly and patiently assist me. Toward the end of fourth year, with my requirements behind me and little left to do, I spent my clinical hours finishing my remaining cases, chatting it up with fellow students, and basically doing as little dentistry as possible. I was done.

Fast forward to several years later. The majority of the dental work that I perform in private practice I NEVER did in dental school. Invisalign, bonding all ceramic restorations, digital impressions, anterior composite layering techniques are all things I learned after I graduated. I know everyone is different in terms of the scope of their practice, but I shudder to think about all the time I spent learning how to wax denture set-ups when my hands have not come in contact with a denture in more than a year. More importantly, I learned how to do all these things through attending live CE courses and national meetings, reading dental journals, and watching videos on the Internet. Let’s also keep in mind that this was all done with my money and my time (which technically is more valuable than it ever was now that I have this expensive degree). This is time that I COULDN’T wait to have back in dental school to sleep, exercise, bake, watch TV, travel, and do whatever it is you daydream about doing when your are stuck in a marathon study session at the library.

So yes, you are reading correctly, I actually enjoy spending my free time learning about dentistry, well after graduation. When I first found myself in private practice, I realized just how little I knew. I hated not feeling confident when I discussed treatments with patients, and I hated the anxiety of performing new procedures for the first time without anyone being there to hold my hand. I tried to contact some local dentists through the AGD and other organizations to see if they could help me out with my many questions. Some were extremely welcoming, responding to all of my emails and inviting me to their offices to watch them in action. Some simply ignored me. I was part of a great study club for about a year, but they were unable to get enough members to maintain it. This all helped, but I needed a more structured, foundational approach.

It is funny how I was never as excited to learn about dentistry in school as I am now. There are so many different reasons, but I think the main one is that I can see direct results of my knowledge the week after I take a new course or study a new technique. I am approaching my second anniversary at my job and am feeling a sense of stability. I am slowly starting to become comfortable with more challenging dentistry and patients. But, I understand that I need some kind of foundation, some kind of support system in order, to confidently and predictably treat patients that may need more comprehensive work. That’s where the cults come in.

When I say “cults,” I do not mean to confer a negative connotation. I have a great amount of respect and admiration for many of these organizations, but I cannot help to draw certain parallels. They both have well-known leaders with significant influence. The dental cults have large scale education centers located throughout the country, along with a group of devoted followers. In addition, you can find many of their well-known speakers at various meetings across the country, giving inspirational speeches about having the practice you always wanted and offering you paths to reach your goals. Unfortunately, these paths come with quite a hefty price tag.

I recognize the value of spending money on these courses. The ones that I have attended have proven to be extremely valuable in increasing my clinical skills. My dilemma lies in making a choice as to which organization I want to spend my time and money on. From what I understand, most of them actually have more similarities than differences, and no methods that any of them teach will work for you 100 percent of the time. What is apparent is that each one has a specific track they want you to follow and tools they want you to use, making it pretty unrealistic spend time at more than place. What are the pros and cons, and what made you decide to stick with one, if any at all? In a recent The Daily Grind post, Dr. Lavigne wrote about her great experience at the Spear Center. Have any of you had similar experiences there or elsewhere that have won your allegiance? I would love to hear from you in the comments.

Have great week and enjoy the holiday season!

Lilya Horowitz, DDS

It Is a Great Time to Start Placing Implants

I wonder what was holding me back from placing implants in some of the ideal cases that I’ve come across. Today, we have well-defined guidelines and protocols supported by long term evidence. We have many tools, including CT Scans, surgical guides, simplified implant kits and more. Maybe, I just need to get the necessary education, follow the stricter-than-ever protocols, and know my limits.

Once implant dentistry became more restorative-driven, it paved the road for general dentists to consider placing implants. Recently (or finally), I made the decision to pursue implant dentistry and I am very excited!

Find the right course and the right instructor
I have attended bits and pieces of implant lectures over the years, both surgical and restorative, and I have been restoring implants since I started practicing 10 years ago. But getting to a position where I can surgically place a single implant in an ideal case required a comprehensive and well-organized implant course. It started with a lecture, then moved to placing implants in pig-jaws. After watching live surgeries, we finally placed an implant in a patient’s jaw under the close supervision of an instructor.

I wanted to stick with one instructor initially throughout the whole course, from lectures through hands-on. I looked for an instructor who would encourage me, but would also set limits for me, and be open to meeting my specific needs as long as they were within reason. I openly expressed my expectations at the beginning of the course.

I asked the instructor to give me a detailed protocol from the initial assessment to the final follow-up. I asked for the black-and-white, not for the gray. At dental school, I only did things one way, the way my instructors told me to. This provided me the ability to perform predictable and successful dentistry with confidence and without confusion. After finishing school, I was hit with lots of gray and an abundance of options. But by then, I was equipped to make reliable choices for materials, equipment and techniques. There is nothing more confusing than attending a course where multiple options are presented and you are told to choose whichever you are comfortable with when you are just starting. That works well at intermediate and advanced levels, but not for beginners.

My goal was to finish the course with adequate basic knowledge to place single implants in ideal cases. For now, I will stick with the black and white, and later venture into the gray. The fact that my instructor is within an hour of my office is an added bonus. By default, he will probably become my mentor.

Find the ideal first case
This took me back to the days of my board exam. My patient was very healthy and the implant site had plenty of hard gum tissue and bone. I planned the implant placement on a CT scan, and planned my incision on the model. Consequently, the surgery went very smoothly. I did not have a surgical guide, but I cannot even imagine how much smoother this could have gone if I’d had one.



Finalize the commitment
Purchasing the equipment finalizes the commitment. There are many implant companies out there and they should be evaluated thoroughly. In addition to the well-known criteria of effectiveness, efficiency and safety of an implant system, I need regular access to the local rep. Fortunately, I had the chance to know him closely before committing to his company because he lives in my small town.

Keep the momentum
Signing up for a comprehensive surgical implant course did not mean that I would start placing all kinds of implants on Monday! I did not have a line of patients waiting for me. I did not even start looking for the surgical case for the course until I attended the course lectures because I was not sure of what to expect. I was not discouraged or concerned at all, but I knew that I needed to move slowly initially so I would feel comfortable and safe.

I will not let the excitement fade away. I am on a mission to identify these simple implant cases. This will also be a lifetime commitment to CE.

Implant complications and undesired outcomes can happen even in the hands of the best surgeons and even when ideal protocols are followed. But they mostly happen when something is overlooked, either by us or by the patient. That is why sticking to protocols is of the utmost importance. However, I believe that it is more about how often complications happen and what I will do to make it up to my patients when an undesirable outcome arises

Samer Alassaad, DDS

Where’s The Instruction Manual?

I recently attended a dinner put on by a group of dental business advisors. They talked about the usual: how to choose a practice, how to get a business loan, what kinds of insurance you need. But, like most of these talks, there were few specifics given. Essentially, any question that asked for numbers went unanswered.

For example, many graduating students want to know how much money they should allocate for a retirement account, an emergency fund, and payments on student loans. The response was always, “It depends on how much your living expenses and what your interest rates are.”

“How much should disability insurance cost?”

“It depends on your age and gender!”

I understand that no two individuals or practices are the same, but there must be some rules of thumb or examples that can be given. There must be better answers to all the questions that arise as we transition into our careers. It sure would be nice if a dental school diploma came with an instruction manual! There are, of course, many great resources out there, including the AGD Graduate Transition Manual, but no resource will ever come close to covering all there is to know.

This is going to be my last post for The Daily Grind. I’ve enjoyed being a part of it, and I want to thank you for reading and especially thank those who have posted comments. I want to encourage you all to stay active in this online community, as I believe it is vital to our success as individuals. Please remember that our educations do not come with all the answers and that your knowledge and experience can help future generations avoid the same mistakes that you have made. Together, we can continue to elevate the profession and make the daily grind just a bit more enjoyable.

Dave Coviak

No More Polish

I intend to write a more scholarly article on this subject and get it published as an opinion piece in a peer-reviewed journal, and have been sitting on the idea for a long time now (years, I am sure). I just need to get it off my chest and get the ball rolling. Right here, right now.

As usual, we have done it to ourselves. We created the language that has resulted in dental benefits companies and our patients devaluing a critical health care service that we provide for all of our patients.

I am not completely versed in the coding for dental procedures and the descriptions of those codes. In Canada, when we provide basic oral hygiene care for our patients there is scaling, root planing and polish (formerly called rubber cup prophylaxis or prophy). I am ranting about the last term here.

Polish? Really? Are we shining teeth? Dental benefits companies will often have generous coverage amounts for scaling and root planing because they understand the benefit of the procedure, but the polish, or prophy, is often limited to just once per year. But if we see patients more than once per year (and many are seen three or more times per year for periodontal therapy), our patients will arrive in my office and say they don’t want a polish because it is not covered. Aaarrrgh!

We know that periodontal disease is a problem that involves bacteria, the biofilm they create and the host immune system’s ability, or lack of ability, to keep the system in balance. The resulting tissue destruction could lead to tooth loss and systemic health complications. The vast majority of adults have some form of periodontal disease. And with confirmed links to cardiovascular disease and diabetes (a growing problem in North America), we need to be ever vigilant in keeping our patients informed and healthy to the best of our abilities. We know this.

In treating our patients, subgingival scaling, root planing and surgical curretage (whether with cold steel or via laser therapy) removes the biofilm and their associated bacterial colonies from the sulcular region and from within the tissue that the bacteria have penetrated. But this subgingival invasion started supragingivally. And it is the polish procedure that removes the supragingival biofilm. Without this critical component of our treatment, our subgingival work will fail sooner. Without removing the biofilm above the gumline, the recolonization of the area below the gumline happens in hours or days, instead of weeks or months.

Our national dental associations have created procedures and codes with descriptions that use language that does not support how important this procedure is. We are not polishing teeth. We are not making them shiny. We are removing the supgragingival biofilm.

I propose that we start calling the procedure an SBR, or supragingival biofilm removal. Performing scaling, root planing and SBR, and would be easier to understand and support. All we have to do is convince our national dental associations to change the wording of our procedure codes to support this important facet of our health care treatments.

One day, I’ll write that more scholarly letter on this subject, now that I have it off my chest. I feel better now.

On another note, I had previously written about how busy I was and how out of balance my practice and my life have become, and I had announced my intention to sell my practice. Well, the valuation took longer than I imagined it would, and was finished about three months after I started the process. Within three weeks of my practice going on the market, I have had six interested colleagues and two firm offers. Now I need to sit down and evaluate which offer is best to meet my goals. I’ll post more in my next blog.

Thanks for reading. Now, back to my daily grind…

Warm regards,

Larry Stanleigh, DDS

Gratitude and A New Grad

Thank you for the chance to look back at the year and remember how far I have come. I went to an awesome business class in May. We celebrated many birthdays in my family. I wrote a good chunk of a novel during the month of November. We had a baby in September. What an amazing life. Of course, it is not always happy and easy without problems.

Our kids have been sick off and on, passing it around for the last couple weeks. My lead assistant just got engaged and is likely moving. The new computers at the office have taken hours of setup and debugging. Life is busy. But looking back, we have been blessed, for which I am grateful.

With that in mind, I got a call the other day from a recent dental graduate. His father used to be my dentist in our small town, and our families have been friends for years. He is buying a practice from another doctor in town and he wanted some advice. We are going to lunch tomorrow to talk. I have been thinking about what I will say to him, and looking back on what I would have wanted someone to tell me at that time in my life.

I am excited for him, but nervous as well. I want to help him avoid some of my mistakes. I also want to prepare him for the times when he will make those mistakes, because no matter how prepared he is, he will make them. We all have.

I feel like one of the most important things I can share with him is that he has permission to do things the way he feels is right. When I started practicing, I was defensive of everything. I was worried an employee would sue me for doing something wrong. I was afraid that I might hold on to an employee too long because I was afraid of making them angry.

I was also extremely private. I put as little as possible about myself and family on our website because I was afraid of stalkers or someone in cyberspace finding out about me and doing something weird. I don't know why, but that is what I did. I was keeping potential patients from getting to know me and becoming more comfortable around me before we had even met.

I acted out of fear, but I have learned in the last couple years that I have to overcome that and be proactive. Hire people that I like, and don't be afraid if it doesn't work out. Don't be afraid to open up to people, even online people, as scary as that may seem. That's the only way to connect with them.

Fear not.

What would you tell him?

Michael Lemme, DDS