Teeth That Bother Me

Wisdom teeth. Third molars. The back teeth. Whatever your patients like to call them, they are the ones that I absolutely hate. Every time I see a new patient’s X-rays and I see these guys— whether they are impacted, partially impacted, or fully erupted—I always make the same suggestion: I recommend that you please schedule an appointment with our oral surgeon to have them removed or, at the very least, have a consultation to determine the risk factors.

Some of you may not agree with me. If the teeth are not bothering the patient, why have an unnecessary procedure? In my experience though, I find that, eight out of 10 times, these teeth are destined to be extracted. It could be when the patient is 25 years old, or 55. It could be when they schedule the procedure in advance and plan time to recover, or when the pain flares up right before they are scheduled to travel.

Let’s look at some of the pros and cons of keeping these teeth, which is a conversation that I frequently have with my patients.

Pros (of keeping them): 

1.      More surface area of teeth to chew with. Better digestion, maybe? Not sure if this has been studied or is clinically significant, but why not?

2.      Extra tooth to possibly replace missing second or first molar or serve as a bridge abutment. Except as a cantilever. Please don’t cantilever off a third molar.

3.      Less risk of nerve damage. This one is important.

4.      Potential for more dental work in the future. This is more for the dentist, I guess, than the patient. Who doesn’t love redoing fillings and filling cavities on wisdom teeth? I personally refuse to do so unless the patient is desperate, but I have seen some root canal treatments in third molars. That must have been one hardworking dentist!

Cons (of keeping them):

1.      Risk of infection and pain occurring when the patient has other plans, typically vacations, weddings, and holidays.

2.      Risk of bone loss around second molars. This happens frequently on the distal of those molars that we actually want to keep and compromises their longevity as well.

3.      Risk of decay on the distal of second molars. I have seen this happen, and I am even attaching a photo as evidence.

4.      More teeth to clean. This one isn’t that serious, but those hard-to-reach areas can become a big problem, leading to the issues mentioned above.

5.      Potential for more dental work. This can be a pro or a con, depending on what you are into.

So, who is with me in the quest to eradicate third molars? Except when they are close to the nerve, of course.

Have a great week!

Lilya Horowitz, DDS

‘I Thought You Said This Was Permanent’

I don’t know if you all have been reading my posts for a long time, but I used to give you book and movie reviews. 

I haven’t seen a movie in a real theater for a long time, but my kids wanted to see “Jurassic World,” so I relented. (We go to the dollar theater all the time, but that doesn't count, because all those movies are already out on video.)

The movie was fantastic, by the way. While waiting for the movie to start, we saw a trailer for “The Martian.” It looked good, so I borrowed the book (can you see a cheap theme in my life?), and I just finished it yesterday. Other than some slow parts in the middle, I thought the book was very good.

But what amazes me is that this was the author’s first novel, and the funny thing was that he initially was giving it away for free on his website after several publishers rejected him. One of the author’s friends said that the website download was too slow, so he put it on Amazon for the lowest price it would allow: 99 cents. Shortly after, he sold a bunch of copies at 99 cents each, and publishers started to notice. Next thing he knew, he had a book deal and a movie deal!

The movie comes out on Oct. 15. I am looking forward to 10 weeks after that, so I can see it at the dollar theater.

Anyway, to the topic de jour:

I have a 75-year-old patient. My father did a full mouth reconstruction on her about 14 years ago.

Today she came in with No.10 broken off at the gumline. I told her that we can save the crown if the margins are intact. But first we would have to do a root canal and a post and reverse core. 

She then got that confused look on her face. She said, “I thought your dad told me that this work was permanent.”

Hmmm… I was blown away by this. I was shocked that someone would think that dental work could be equated with forever. I was put into a position to talk to her about the difference between “permanent” cement and “guaranteed for life.” 

But this might be a great forum to talk about what to do when something fails. Man, this is a tough one, and I know that we are all different when it comes to this topic. We all have different philosophies when it comes to running a business. And, yes, this definitely falls in line with how we run our businesses. 

I know some of you are the strict type. You run your practice like it is a business (that’s funny to type). Everything is black and white. The fee is the fee, and if you don’t like it, then you can go somewhere else. You say things like, “This is our policy.”  

I, on the other hand, don’t do anything by the book. 

I don’t run my practice like a business. And, what I mean is, I am very loosey-goosey about policy, because to me it’s more about the relationship than it is about sticking to the policy.

On a side note, this is a business model; it just doesn’t always look like you’re running your practice like a “business.” Am I making sense? Because I give stuff away like crazy and my business is flourishing.

I am a very aware consumer. I go into a place and I think about what the ownership is trying to do. Is the staff friendly? Do they care about me or about themselves? How is the product? How is the execution? How do I feel when I am paying? Do I feel ripped off? Do I feel happy about giving them my money? Will I tell my friends about this place? 

And the question that I always ask myself (and what all your patients are asking themselves) is: Will I come back? 

All of these questions are running through my mind when I think about the way in which I run my business. 

I want people to like my place. I want people to feel like family when they come in. (We take photos of everyone when they come in so the next time we see them, we can greet them and call them by name.) I want them to not feel ripped off (even though dentistry is expensive). I want them to tell people about us and I want them to come back. 

So what do you do when a person who has been in your practice for 15 years breaks something that is 14 years old and says, “But I thought this was permanent?”

For me, it is to try to make the patient feel heard, try to educate her, try to make her take some ownership of it, and try to make her feel not ripped off. 

My loose policy on my work is that most of it is guaranteed.  

I think that I have told you this before, but if any composite restoration fails within five years, I do it again for free (I fully expect them to last for 15 to 25 years.) 

Now crowns are a different story. I think crowns should last a long time, more than 20 years. I usually will do crowns again for free if something fails within seven years. (Oh, my lab will also do it again for free, too. He also has a replacement policy). Between seven and 10 years, I will usually do it over for half price.

I know this might sound crazy, but I rarely do things for free. I will usually do one crown a year for half price (and sometimes less than that).

Things don’t really fail. I am not saying that I am all that. I am just saying that materials have gotten pretty idiot-proof and very strong.

But when they do fail, I just do it again. It’s the price of doing business.

I run my practice like a business—but it is my business. 

I sat the elderly patient who thought the work was permanent/forever and educated her on what those words mean (and I also told her “nice try”). We talked a bit more about how I was going to try to be conservative and save her some money, and we did the work. She was heard, she understood what we were doing, she was comfortable moving forward, and hopefully she was happy with the work and OK with paying the fee. 

Now that is a business model that will be permanent and hopefully it will last forever (see how I did that... bringing it around full circle?). 

How do you handle work that breaks? Do your patients think your work will last forever? Let me know your stories.

Have a great day, 

John Gammichia, DMD, FAGD

Hire That Older Applicant!

When you hire someone, how long do you hope she or he will work for you? How many years of service would you be happy with? Two years? Five years? Ten years? How many people currently working for you have been with you for more than five years?

My friend Doris just lost her job. She is a geophysicist and she works in the oil patch here in Calgary, Alberta. With the current global oil glut, Calgary alone has seen more than 40,000 people lose their jobs. Doris, a married mother of three (all mid-to-late teen boys) who is the primary income earner for the family, finds herself in her mid-50s with no job, no income, and a bleak future. Why? She is experienced, smart, capable, hardworking, enthusiastic, a solid team player, fit (she runs marathons in her spare time), loyal, possesses no sense of entitlement, and more. She would be the ideal employee, as far as I am concerned. But she tells me that people have been citing her age as a barrier to future employment.

I am astounded by that statement. I revisited all of the questions listed in my first paragraph above. In the oil patch, an employee who works for one company for five years is considered a veteran in that company. So with 10 to 15 years of useful productivity left in her career, why is her age a barrier now?

Carol applied to my office to work for me on my administration team (many of you call it a reception position). She was 57-years-old with 30 years of experience. She was experienced, knowledgeable, a good team player, loyal, married with an adult child, possessed no sense of entitlement, and more. Her personality testing showed her to be a great candidate with leadership potential. Her salary requests were reasonable. I hired her.

We recently celebrated five years of working together and to mark the milestone, I gave her and her husband two nights and dinner with wine pairings at a luxury hotel in Banff (a 60-minute drive from our home…we are so fortunate to live where we live) as a thank you for the five years of service, and hopefully many more. She has never called in sick and she’s a great team member.

When people heard that we had been working together for five years, they were surprised, because so many dental offices do not retain staff for that long. I was surprised to hear that, since I have lots of long-term members on my team…one at 19 years, two at more than 15 years, and so on. I have eight staff on my team and their ages range from early 20s to early 60s. Although all female, my team members are of four major religions: Christian, Jewish, Hindu, and Muslim. I love this team who I get to work with every day.

So don’t overlook the older applicant. How many years do you hope she or he will work with you? Can that older applicant fit the bill? Can she or he fit into your office culture and practice philosophy, which is way more important than age anyway?

Think about it, and share with me your older applicant stories.

Warm regards,

Larry Stanleigh, BSc, MSc, DDS, FADI, FICD, FACD

Diving Into the Deep End…of Your Community

I’m going to give you a little bit of backstory before I dive into the deep end of my message today.

I grew up in the country. I mean country—three stoplights in the entire town. When the McDonald’s opened, it was the highlight of an entire year of our childhood (ain’t that scary?), and we had one elementary, middle, and high school. Needless to say, everyone knew everyone. It was a tight-knit community.

Fast-forward to college in a bigger town and dental school in a major metropolitan city. Nearing dental school graduation, I weighed my options and decided to return to the city closest to where I grew up, only I wanted to be in the middle of the action. Young, single, and enjoying life, I chose to live in a downtown loft, five minutes from the social scene, 60 minutes from work. I enjoyed the city life and all that comes with it, but I was missing something with my patients. I was missing a connection with most of them that I didn’t understand until much later, when a lightbulb went on—I was missing the community connection.

I remember growing up, playing baseball seemingly every day for eight months out of the year, from ages 5 to 21. Dad was always the coach, and everyone called him “Doc.” I shook it off as nothing, but now I get it. He wasn’t just there just for us; he was there connecting with the dads/moms/kids/grandparents of his community. And he did it well. He’s run a bustling practice in that little old town with one McDonald’s (we have a Bojangles’ now—whoop, whoop!) for 30 years, and most of his patients know him from the ball field, grocery store, church, or gym.

There’s something different when patients get to know you outside of the office. It brings about a deeper level of confidence and trust in you as a practitioner, doctor, and friend. It’s a great way to build a patient base, as well as to do good for others around you. You just can’t beat it.

So my wife and I recently decided to dive in. We are making the move out near the country. It’s a big change, but I am excited to get involved with the same patients to whom I’ve said, “Hey, how’s the weather?” for years. (That’s my go-to question when I don’t have anything else to say to a patient.)

I’m excited to see people on the weekends and have them crank open their jaw, point to No. 18, and ask what I can do for it.

We have an awesome job. We really do. People always will need dental care, but, more importantly, we do some great work for people in pain, in need, or in desire of a beautiful set of chompers.

I’ve made the plunge, and I’m headed for the deep end. Hopefully, I don’t drown!

Donald Murry III, DMD

Did That Really Just Happen?

Have you ever had one of those moments where you pause and ask yourself, “Did that really just happen?” I am referring to the moments in the office that make you want to smash your head onto the desk, and also those moments that leave your side hurting because you’re laughing so hard.   

There are, of course, those times when you haven’t even recovered from the two-week notice of one staff member and you are hit with another who is moving on to something else. You sit there silently, because there is nothing you can do to change the situation and yet you have no time to deal with it either. [insert head smash]  

Or, what about that moment when you see that patient on your schedule, the one who has fallen out of treatment and was a nightmare to work with previously. You already feel your stress level rising and the patient isn’t even due to come in to the office for two weeks.   

Of course, intermingled amongst the downs of the day, are the ups. I am very pleased and lucky to say that laughter is an ever-present sound in our office. We like to have fun with each other and our patients.

Some of the moments of laughter arise when you walk by a treatment room and you overhear your assistant teaching a patient who was concerned about her speech as she transitioned from a long-term complete upper denture to an open plate implant-retained denture. You hear the assistant teaching her a tongue twister to practice but you’re unfamiliar with it… then you hear it. “I slit a sheet a sheet I slit…” and the patient is laughing, because every other word is clearly not “sheet.” Between the laughter and the giggles, you can hear the improvement and confidence the patient is gaining in her speech. [insert full-belly laugh]

There also are those times when you can hear patients interacting across the hall during their hygiene visits and laughter resonates throughout the building. Those are the moments that keep you from smashing your head onto the desk at the end of the day. 

I also enjoy those times when the team shares the funny stories of family life that has everyone giggling so hard that no one can catch a breath. These are the moments that save us time and time again—those stories that you just have to question if they even really happened, because they were so funny you barely believe that your career can be that much fun!

Be the reason that someone laughs today—just try not to do it at your own expense!

Colleen B. DeLacy, DDS, FAGD

Pet Peeve

Pet peeves—we all have them. The good thing about pet peeves is that they are kind of like pets. We all love our pets, but every now and then, that loveable pet will chew the toes off your favorite eel-skin boots, or do its necessary natural elimination on your favorite rug, or run away for days but then return like nothing happened.

Owning a practice is like owning a pet. Most of the time, I love it! It gives me great joy to make my patients feel comfortable and happy. I love the challenges of learning new technologies. I have a great, supportive staff, and we all work together wonderfully. However, like every dentist, I do have those moments when things don’t go as planned, patients fail to keep appointments, production drops, and “burnout” lifts its ugly head.

That’s the pet peeve that came to light yesterday. Not the burnout, but all of the solutions offered to correct it. Having been in practice almost 40 years now, I have seen multitudes of solutions offered for what can become a very serious problem. I don’t want to discount the issue of burnout, but have you ever noticed that the people offering the solutions come out of the woodwork in the last quarter of the year? This is when we get serious about analyzing our practice for the past year and may realize we’re missing some of our goals, which can be stressful. I think a lot of dentists who are experiencing normal challenges of a dental practice suddenly diagnose themselves as being “burnt out” and can easily fall into a state of depression as a result of a deluge of marketing by purveyors of burnout solutions, most of which are quite expensive.

Also, have you noticed the experience that some of the burnout consultants have? Many are not dentists at all but claim to be able to solve your problems even though the problems are specific to dentistry. Others ran successful dental practices for 10 to 20 years but say that they have found their calling to help other dentists reduce the stresses of dentistry. Almost none are still practicing dentistry. If dentistry can be so stress-free and profitable, then why did they quit?

They quit because dentistry is hard, very challenging at times, and often not as profitable as many had hoped it would be. Because of these traits of the profession, many doctors are looking for a fix to their burnout, so they look to a big market for solutions. Don’t get me wrong, I’ve been there, done that several times, and my experiences were mostly beneficial. I just have discomfort with the existential, touchy-feely approaches.

Personally, I have found keeping my family time and practice time balanced, reassessing goals, and keeping pace with advancements in dentistry to be the best ways to reduce stress and achieve the rewards of satisfaction with a job well done. I also have learned to accept that our profession can be very stressful, but to work through the stress by my own analysis of the causes. Stress is merely one of the challenges we face. Without challenges, new knowledge would not be obtained, and we would not have the advantage of being able to deliver dental health care at its highest level ever.

If you don’t have one, get a real pet.

Terry G. Box, DDS, MAGD

Strange Days

There are days in a dental practice that can feel somewhat routine. This is true of any profession. Luckily, every once in awhile, something happens that is so unusual that you remember it for the rest of your life. Routine days quickly turn into memorable, strange days. Here are some examples from my career:

Have you ever had the police show up to arrest the patient you are working on? I have.

I was placing some fillings on my patient when, suddenly, the receptionist came in and said, “Doctor, the police are here and they need to talk to you right away.”

Since this was new to me, I asked the officers what the procedure would be. They informed me that they did not have the authority to interrupt medical or dental procedures in progress. “Take your time, Doc,” the officers said. “If you need an hour, we’ll wait. If you need two hours, then that’s how long we’ll wait.” The officers said I was to release the patient to them upon completing my treatment.

When I went back to the operatory, the patient knew what was going on since he had overheard the conversation. All he said was, “No problem, Doc.” Once we were done, the patient went to speak with the officers. They escorted him outside my office and arrested him there. I appreciated the fact that the rest of my patients didn’t have to witness the whole arrest procedure.

Have you ever been preparing a tooth for a crown when an earthquake hits? I have.

I was in the middle of a routine crown preparation appointment when we started hearing some rumbling. If you live in California, you recognize that sound. Then, about one or two seconds later, the ground started to shake. The dental chair and operatory light started shaking side to side. Even after having experienced earthquakes my whole life, it still takes a few seconds to realize what is happening. Unlike other natural disasters, such as hurricanes, you get no warning.

All you can do is make sure nothing falls on the patient. You and your assistant reflexively push instrument trays out of the way. The first priority is to make sure nothing falls on anyone. Then you wait out the earthquake. Most of the time that takes several seconds.

Afterward, you check to see if you still have water and electricity. In our case, we did, and my assistant quickly fabricated a temporary crown since, understandably, the patient wanted to go home to make sure all was fine. We also wanted to contact our families to make sure they were fine. Needless to say, that was a memorable afternoon.

Has your office ever called a patient’s parent to collect payment, only to hear, “Wow. That’s more than I charge for a crown in my office!” We have.

I have been seeing my patient since I bought my practice. He was about 5years old at the time. He is 17 now. Over the years, I have done A LOT of dentistry work on him. I’ve seen him grow up. Let’s just say he’s been “dentally challenged.” A year ago, we had to perform a root canal and crown. His mom also has been a patient of mine. When it was time for payment, she requested that we call her husband and that he would take care of it over the phone. That’s when my office manager learned that the patient’s dad is a currently practicing dentist. He was kind enough to inform us that he charges less for a crown than we do. That, of course, brought up a whole host of questions in our minds. He did pay for his son’s crown, though. In his defense, I must admit that my patient medical history form contains no line asking whether one of your parents happens to be a dentist.

Have you had any memorable, strange days? If so, let me hear about them.

Andy Alas, DDS