Headphones

Fire seemed to follow me around in the early days.

Kate was my first assistant. She was personable and the patients loved her, a real asset for a young dentist starting out.And, although in hock to the devil, I was consummately proud of my shiny new office.

A classmate told me about a new technique he was using to relax patients: headphones connected to a tape player (remember cassettes?) so patients could listen to their choice of anything, from hard rock to classical, to help drown out the drill. I decided to give it a try.

Kate seated a stylish young lady who hadn’t slept the previous night, anticipating her upcoming root canal. “We’ll do our best to make you comfortable,” Kate said, softly placing her hand on Lori’s shoulder. “If you need a break, just raise your left hand and I’ll have the doctor stop.”

“Thanks.” She smiled crookedly, as the anesthetic was beginning to work. She settled down as Kate showed her how to thumb the volume knob; Lynyrd Skynyrd began to blare from the headset.

Kate finished arranging the instruments and laid several alcohol gauze pads on the counter. I lifted one of the ear pads and half-shouted, “You should be good and numb by now, Lori. We’ll go ahead and get started.”

Her hands trembled while she repositioned the bulky headphone. The preparation was uneventful and soon finished. Kate lifted her left ear pad. “Relax, Lori. The worst is over; no more drilling.” Lori’s once apprehensive eyes softly closed as her body slumped, totally relaxed. ♫…Sweet Home Alabama…♪

It was time to seal the canals with gutta percha and a condenser heated over an open flame, an archaic process probably hard to imagine for younger graduates. Safely maneuvering a red-hot branding iron into a small mouth could be a little dicey. A steady hand is the key. I thought about my klutzy classmate, Oleander Jacob, and hoped she referred out.

Kate was afraid to tightly press the match head with her finger to strike it, and an unproductive puff of smoke floated toward the ceiling. I glanced over my shoulder to see what the delay when she failed a second time. She seemed embarrassed and, with renewed determination, struck a third match, which finally lit. Kate fired up the Bunsen burner with a triumphant. Ever the cautious one, she placed the still burning match on a wet cloth—the alcohol gauze—to extinguish it.It immediately burst into flames.

Startled, she knocked into the blazing Bunsen can; it threatened to topple over, but remained upright. “Grab the gauze and throw it into the sink,” I said under my breath. Kate just stared at the fiery brand on the counter. All the while, Lori’s eyes remained closed in detached reverie ♫…Lord, I’m comin’ home to you…♪

“In the sink. Now!” I quietly exclaimed.

Catatonic, Kate blinked back to life and snatched the flaming fabric but immediately let go. It fell short of the sink,onto a dry paper towel. The volatile liquid diffused and spread like, well, like wildfire.

Becoming ever more animated, Kate grabbed the unlit half of the towel and gave a mighty heave. Fanned by the breeze, it traced a fiery arc over the sink and landed against the wall.

Who knew that wallpaper could burn so readily?

As the conflagration licked up the operatory wall I conjured visions of my brand-new office ignominiously disappearing into the shrouds of hell. As quickly, yet calmly, as I could, I got up and brushed the bonfire into the sink, filled a green mixing bowl with water, and splashed it on the wall, a handy lesson learned in freshman lab when Oleander’s hair caught on fire.

With pyrotechnic disaster narrowly averted, Kate looked relieved and a little sheepish. But Lori’s nostrils flared like a sniffing bloodhound. “Is something burning?”

“It’s nothing,” I smiled. “We’re almost finished.”

Thankfully, she drifted off and we closed without further incident. Lori later commented on how much she liked the headphones. “You and Kate make a great team.”

“Thanks,” we said in unison.

Yep, Kate worked out great. And I married her.

Jim Rhea, DMD

Choose Happiness

Are you happy?

Why or why not?

A couple spoke in church last Sunday about happiness. They did an excellent job, and inspired me to think about what true happiness is.

I remember a time when I was an undergraduate at BYU. We had a 6-month old daughter, and she was just starting to crawl and get into things. I always kept my textbooks by my chair so I could study next to the lamp. Well, she was constantly getting into my books, and knocking them down and playing with them.

I was trying to study, and I was getting frustrated. I couldn't concentrate. I wasn't focused. It was a waste of time. And my daughter was frustrated because she wasn't getting the time she needed from me.

I had to make a decision: I could continue to try to study, or I could put it away and spend time with her. I decided to take the time at home and spend it with her. I did the same thing through dental school, as well. If I was at home, I was 100% at home. It made such a difference.

I sometimes stayed late at school in order to study longer. I sometimes went in early. But when I was home with my daughter, I wasn't frustrated about not being able to study. I was able to enjoy the time we had together as a family.

I decided not to be frustrated. I chose to be happy.

I don't always have that attitude, and I have to remind myself about what is most important. I think back to that time at school, and I relax and put my other stuff away.

I choose to be happy.

Michael Lemme, DDS

Feelings About Labs

As general dentists, we enjoy a certain degree of autonomy with our work. When I perform a procedure, I like to oversee all aspects of it and therefore, take responsibility if anything goes wrong. I enjoy being in control of the situation and not relying on an outside party for help with this work.

For example, let’s say a patient comes in with a large class IV composite restoration that was done years ago. It is ugly and distracting, and they would like to know what can be done about it. My first thought almost always to redo the composite. Seems pretty logical, right? It would seem so, although not all dentists would go for this approach. I guess it just depends on what you are into. Some dentists like to spend hours trying to find accessory canals in second molars. My biggest practice time-drainer (but also my most enjoyable patient procedure) is contouring and polishing anterior composites.

What else can we do here? Another treatment option for this patient would be a crown (or veneer, depending on the amount of tooth structure present) to restore this tooth. Many dentists prefer this option because they just do their prep and leave the rest of the work to an outside party: the lab. In fact, many dentists will use their lab for just about anything. I recently went to a lecture by a well-known prosthodontist. Let’s just say he was anything but conservative in his treatment planning and was proudly showing off how he places the tiniest class I and II inlays I have ever seen. He LOVES using his lab.

When I send a case to the lab, this is where my loss of control comes in. Since starting to practice, I have dealt with a fair number of them. I like to experiment until I find the perfect match. The problem with labs, however, is that I have not yet found my perfect match. One day, I will get a back a perfectly fitting crown; the next one will come back with extremely overbuilt contacts that I have to spend time adjusting. For the most part though, I have begun to have better luck with single-unit posteriors. My anterior cases are a different story. Granted, I do not do as many of these cases, but the amount of revisions and back and forth messengering that goes into one case makes it seem like a number of different patients instead of just one.

Who is to blame when you get a case back, and it is not what you expected? Keep in mind that you have a disappointed patient in your chair, eager to toss those temporary veneers in the garbage in favor of new shiny permanent ones. It is easy to blame the lab, but you also have to look at yourself and what you could have done. Where your impressions and instructions perfect? Did you miss something? One of the best dentists I know that I really admire said not to cement something in unless it is perfect. I know perfection is not a reality, but I mostly try to follow this guideline instead of desperately trying to adjust a case to make it fit when it seems off at first glance (or try-in).

When you and your lab finally come together and create that perfect smile for your patient, your feelings of hate and frustration instantly vanish, replaced by those of love and admiration. Your patient is happy, and you are ecstatic not to have to make another provisional as well as take yet another impression. However, the memories remain. When that next patient comes in asking about veneers, you start second guessing if you should use that lab again or try another one that will deliver that perfect set of veneers for you on the first try with no adjustments. The color will be amazing, the margins will be indistinguishable. I am starting to realize that this dream of mine is some sort of juvenile myth that I will be chasing for a number of years until I realize that it likely does not exist.

I was watching one of Dr. Frank Spear’s lectures online, and he was discussing permanently cementing a case. He showed photos of his temporaries, and compared them to the final crowns that he received from his lab. Guess what. They were not identical. He mentioned that he always makes adjustments to his final veneers or crowns because, as a lab tech, it is impossible to perfectly duplicate the final shape and contours of your temporaries. You will always have to adjust the occlusion slightly. That is when the light bulb finally went off. If Frank Spear cannot get his lab, which I am sure is amazing, to prevent him from touching those final crowns with a bur, then I really need to calm down.

On the flip side, I am starting to understand all these composite gurus that do so much of it and do it well. They have total control, and although it may seem like a ridiculous undertaking to do an 8-unit case of direct resin when your lab can do the job for you, I am starting to wonder if they are on to something here. Yes, you are dealing with color, contouring and shaping. You will spend hours setting up the case with a wax-up, then polishing and making any occlusal adjustments, but you expect this. When I am spending those same hours adjusting porcelain, I just keep questioning why I decided to go down this road in the first place. I may not have found the perfect lab yet, but I have found the perfect composite, which works better and better every day, the more I use it. Have any of you guys found the perfect lab yet? Do you use several different ones depending on the case or are you loyal to just one?

Have a great week!

Lilya Horowitz, DDS

I Love CE!

#LOVECE #CEJUNKIE #DENTALNERD

Spring has always been a time to look forward. I enjoy planning out my summer, setting goals, and reviewing my expectations.

Professionally, it is the excitement of planning to attend bigger CE events. They are perfectly timed, approximately every other month. This year, I attended the Chicago Dental Society’s Midwinter Meeting. HOW HAVE I WAITED THIS LONG TO GO??? What a great meeting! I added some great participation courses to my transcript for my future MAGD, and I am kicking myself that I didn’t enroll in more. Lesson learned! Calendar blocked for next year!

Following the #CDS14 meeting will be the Michigan Dental Association’s Annual Session. I have and will always continue to support my local component and fellow colleagues.

The commencement of my annual meetings is the Grand Marshal of the series, the 2014 AGD Annual Meeting & Exhibits. If you haven’t attended, you should reconsider. It is here in Michigan this year and a great time to “Rethink. Refresh. Renew.” Before you start throwing out the jokes (Will there be power? Will it be safe? What exactly is there TO DO in Detroit?), it is going to be a great time! Admittedly, we don’t have the honky tonks of Nashville, but there will plenty to see, do, and learn at the #AGD14!

I am not a part of the committee that created it, but I LOVE the title theme this year! Think about the words! Michigan, as a community, has been working on that theme for many years. We are still treading water and sometimes making waves. Outside of the city limits, which of course has had its fair share of poor publicity, we have been making it. According to Webster’s:

Rethink: to think again about (something such as a policy or course of action), esp. in order to make changes to it. (n): a reassessment of something, esp. one that results in changes being. made

Refresh: to give new strength or energy to or to revise or update (skills or knowledge)

Renew: to give fresh life or strength to.

I particularly like “refresh.” Who wouldn’t want to refresh? This triad of words is exactly how I feel as I approach an upcoming CE weekend or event, and even more so after I leave. Something that is said causes me to rethink how I may have approached a task or situation previously. I learn a new skill that renews my interest in a technique I was fearful to take on. And I absolutely have refreshed my drive to learn more, see more, and do more.

Colleen DeLacy, DDS, FAGD
Michigan

Hard to Swallow

“Doc, I think I just ruined your afternoon.” Although my patient is a joker, I knew he was not joking when he uttered those words.

This illustrates how a routine day can quickly become a memorable one. Let’s talk about those times when something completely unexpected happens during a dental visit.

I always try in my crowns before final cementation. For twenty-odd years, patients have asked if anyone has ever swallowed a crown. Fortunately, for all those years, I’ve been able to answer say no. Until now.

We were trying in the lower left second molar. The crown needed to be inserted several times as I needed to adjust the occlusion quite a bit. We were just about there with the occlusion when… Gulp! Just like that. I turned my back and it was gone!

It was not a great feeling when I realized what had just happened. How does one handle this situation? I first made sure he had indeed swallowed the crown. In other words, he was not choking or struggling to cough. Fortunately, there were no signs that. Quite simply, the crown was there one second and gone the next. Plus the patient was absolutely sure he had swallowed the crown. That made it unnecessary to subject the patient to a chest x-ray in order to confirm that he had not aspirated the crown.

The take-home lesson for my staff and I was to be prepared and remain calm. Although this was my first such encounter, my staff had been through it before with previous dentists they’d worked with. It felt good to have my staff compliment me on how I handled the situation. Remember, it is best to remain calm and reassure everyone in the room.

Understandably, the patient wanted to know what would happen next. In my usual honest way, I informed him that it would “come out the other side.” I gave him a minute to, uh, digest that thought. Then I told him he could either look for the crown or we could make him a new one. He scheduled for a new impression. Since this visit had already caused enough excitement for everyone involved, we opted to recement the temporary crown and call it a day.

I felt I needed a new impression since the original crown needed so much adjustment. At this point we might as well start over. When he came in for his next appointment, he was joking about what had happened and promised not to swallow anything. He also kept apologizing for stressing me out by swallowing that crown.

Now, when patients ask me if anyone has ever swallowed a crown, I have a different answer.

Andy Alas, DDS

Why Are We Not Thorough?

When I was in dental school, it took three hours to do a new patient exam. It involved reviewing the medical history, the extraoral soft tissue exam, the TMJ exam, the intraoral soft tissue exam, forensic charting of the teeth (fillings, recession, furcations, mobility) and the 6-point perio charting (including bleeding on probing and suppuration), as well as review of the appropriate radiographic series (full mouth and/or pan plus bitewings plus selected PAs). We were taught to be thorough.

Then we got out of dental school and entered the “real world” of general practice dentistry. Suddenly, most of our colleagues were not charting the extraoral findings, not doing a TMJ examination, or not charting the periodontal status on every tooth (they may have looked but did not record anything, or they did the lesser PSR recordings, which look at a selected subgroup of teeth). For many, a new patient exam is a 5- to 10-minute greeting by the dentist. How does the patient benefit from this?

I recently had a new patient in my office. I always book a one-hour examination with me, not including dental hygiene services. We still do complete forensic charting as taught in dental school and add an intraoral series of photographs, as well. In this particular case, there was a deep pocket on the buccal of the upper right second premolar when all the other teeth were within normal healthy periodontal parameters. This tooth had been treated endodontically and had a post and core and crown. It all looked normal and was asymptomatic, but the deep pocket in one location (of 6) on that tooth was a strong suggestion of a vertical crack on the root.

We had two choices. We could wait until the tooth was symptomatic and act, or react. Or, we could assume the vertical crack was there, extract and preserve the bone for placement of a single tooth implant. We elected to do the latter. Upon examination after extraction, the tooth really did have that vertical crack. If we had not done a thorough 6-point probing on every tooth, we would have missed this finding. My patient was grateful we were thorough, and told us that no dentist had ever examined him this comprehensively in his past. We had earned his trust.

I do a lot of consulting for insurance companies, lawyers and disability management companies for orofacial and TMJ injuries from trauma, mostly motor vehicle accidents (MVAs). In these cases, I am asked to determine which injuries are due to the MVA and which are pre-existing problems. It’s a detective process for me and I enjoy sifting through records from my colleagues to attempt to figure out the source of the pain and dysfunction. Unfortunately, so many of the dental records I review have areas on the forensic chart for the extraoral and TMJ findings to be recorded that are completely blank. These critical structures are either not examined at all, or nobody takes the time to record their findings. This leaves me, and the patients, in a difficult quandary. It is sometimes to the patient’s detriment when I cannot demonstrate definitively that a problem is directly due to trauma and not a pre-existing problem.

I presume that we are taught to be thorough in dental school for a good reason. Why do we stop doing this? How do our patients benefit from us not being thorough? This is my plea to you to get back to basics and be more comprehensive. I think you will be surprised by how grateful, surprised and delighted your patients will be when you do this. I am now beginning to redo the complete examinations on patients who have been part of our practice for 10 years or more. So much has changed in that time that it is time to revisit their goals and their health.

And now for an update on my practice sale. I had it valuated in the Fall; within three weeks of listing it, I had two firm offers from two incredible dentists. I had the difficult decision of deciding between these two. I chose the dentist with 20 years of experience who possesses a skill set in general practice dentistry in treatment areas that I routinely refer out. This will likely lead to me reaching my goals of fewer hours and less stress faster. Did I make the right choice? Time will tell. I have such admiration and respect for the other dentist, and I hope I can find a way to work with her in the future.

I am now still in the final negotiation stage and hope to have the deal completed before the end of March. Onwards and upwards. And back to the grind…

Warm regards,

Larry Stanleigh, DDS

Success and Giving Back

To laugh often and much; To win the respect of intelligent people and the affection of children; To earn the appreciation of honest critics and endure the betrayal of false friends; To appreciate beauty, to find the best in others; To leave the world a bit better, whether by a healthy child, a garden patch, or a redeemed social condition; To know even one life has breathed easier because you have lived. This is to have succeeded.
—Ralph Waldo Emerson

I really enjoy this quote. Nowhere does it state that success is your mansion, yacht and sports car. It’s about the connections you make with people and the community.

In my residency, I am fortunate to be able to complete complex dental procedures and treatment plans for patients at a reduced rate. Most of these patients would not be able to afford this treatment at a private practice office. Unfortunately, even with a 50% discounted rate applied to procedures, a few of these patients still cannot afford to get treatment. For a few of these, treatment would literally change their lives.

As a 2013 dental graduate, I will struggle to be able to afford to give away much free dentistry out of the gate. I need to get my six-figure dental school debt that starts with a three under control before I’m in a comfortable enough position to extend free services out of my office. Of course, I want to be involved with events like Mission of Mercy and Give Kids a Smile as much as possible.

While I may not be able to give out free dentures right away, I am able to contribute to my community in other ways. For instance, I currently volunteer at the Idaho Humane Society, taking dogs out for walks and giving cats some much-appreciated petting. Families wander around checking out the animals for one to adopt, and I can assist them in this special event. I have to admit though: this volunteering is a little selfish because it’s free pet therapy after a stressful day!

Some other opportunities for giving back may be tutoring area school kids, helping out with reading day at the library, volunteering at the food bank, coaching a kids sports team, and more. The volunteer opportunities are endless and doing something outside of dentistry is a great change of pace. I hope for the new dentists like me that we do not become close-minded to giving back just because we are in debt. Think of it as an opportunity to step outside the dental world and find something enjoyable to do for others.

This pleasantly plump lil’ lady loved rolling in the grass and belly rubs.

I wanted to adopt this Border collie, an excellent fetch partner.

Free pet therapy after a long day!

Katie Divine, DDS