I have been thinking a lot about this. I have come to a conclusion... it is not CERAC I have a problem with.

Okay let me tell you about this meeting. It was a presentation that was going to demonstrate CERAC.

Let me back track to about 3 years ago. I went to an all day meeting put on by Patterson to introduce the CERAC. The dude spent the whole day (8 hours) talking about how great the machine was and how much money you can make with this machine. He answered every one's questions about money. What perplexed me is there was almost NO clinical photos. An all day lecture about dentistry and no teeth pictures. There wasn't any talk about how this benefits his patients. There was a lot of talk about how it is only one appointment, (which, don't get me wrong, I think is a HUGE benefit) but time is not something that moves me to make any decision. But that paled in comparison to the money talk.
So I left there with a bit of a bad taste in my mouth.
Since then I have dabbled on Dentaltown. I was a voyeur in the CERAC threads and my opinion really changed. There are some guys that are masters of CERAC. My faith in my fellow man was restored.
I didn't care what they were charging, they were spending time and working to make a product better for their patients. Their was no talk about how much money they were raking in. Only talk about improving their care. There was a lot of pride in their work.
Am I babbling here? Am I making sense? I work hard everyday to improve my product and be fair to my patients. I feel like if I do this well, I will make money. And it really turns me off to hear people talk about my profession as JUST a means to an end. Not a career of treating people and helping them with their dental needs.
Now back to the meeting.
They talk about how doing CERAC was the best decision they ever made. Then they started to show some of the before and afters. I was not impressed.

I was sitting next to a guy that I know that has a CERAC machine (This guy is my friend, I openly talk to him about this). As the dentist is presenting I asked him how is the insurance accepting these. He says that the insurance is only paying on 3/4 crowns and crowns, so you have to charge out everything as one of those. Hmmm?
I asked him how much to do a restoration. He says that everything is the same price regardless of the procedure, $800. Hmmm?
He also says he doesn't do many fillings anymore? Hmmm?
The dentist was doing MOD fillings with CERAC. The dentist was doing OL fillings with CERAC.
I was thinking to myself, "What is wrong with just doing a filling?" and I had some visions of an $800 charge and a little insurance fraud to go with that.
I don't have any problem with doing fillings with CERAC. But are people charging filling prices for fillings?
A different friend was telling me he worked for a dentist that would do CERAC fillings and charge $300 for them. I think this is fair. You are doing a filling that is indirect. You have overhead. A price a bit more than my price for a filling, I have no problem with this.
My problem is everyone thinking this is standard of care. If you are removing a old small DO amalgam, a FILLING is the standard of care. Have we gone away from this and no one has told me?
Now I have showed you some of my work. I can count on two hands how many of my filling I have replaced. I have been doing fillings at this office for 13 years. I have done over 10,000 fillings and have replaced just a few (I understand other people might be replacing them, but...). That is a pretty good clinical study.
I can tell you from a bunch of conversations I have had with other dentists, and the anti CERAC world, the sediment is there is a lot of over treatment going on.
The dentist is told in order to pay for the machine they have to do 13-20 restorations a month. Now don't you think there is a lot of counting going on in some offices?
I may be different, in fact I know I am different, but I don't know how many crowns I do in a month. I have never counted. But I can tell you sometimes I do 15 in a day but I can also tell you I have done 1 in a week. I am a general family dentist so my schedule can look very different day to day. Somedays I will do 3 New Patient exams, a couple of fillings on a child. The next day I could do 3 root canals. The next day I could see an elderly lady that has all sorts of root caries and then see her daughter to do 4 fillings on. I do what comes in. Somedays my production will be $15000 (pretty rare) somedays it will be $1500. I don't really count.
I try to make it so my overhead is not so high so I don't look at the schedule and say, "Damn! only 2 crowns today." (Don't get me wrong, I have some days that the schedule gets me down but it usually isn't about money).
Now, some of the users of CERAC misuese it and ruin it for the good guys. And I know the guys that are doing it right are cringing when people have this opinion about something they love and are passionate about.
They also realize that some dentists are using it for financial gain first and then patient second.
Then at the end of the lecture some guys around me are talking to each other, "Are you going to get one?", "I don't know. Are you going to get one?"
What!!? Did you guys just see the same presentation I did?
I find myself doing a lot more all porcelain onlays and 3/4 crowns qutie frankly, I love doing them. So I start thinking to myself, if I am doing 15 crowns a month by myself or if me and my partner are is are doing 15 together then we would definitely be thinking about a CERAC machine.

I am excited about maybe having a CERAC machine someday. But I can assure you it will not change the way I see teeth. They will still be white not green.

Have a great weekend,
Rest on Sunday,
john

No this is not the CERAC blog

Okay before tomorrows blog, which is still up in the air, I wanted to lay some ground work.
Just so you all know, I have done my research on the CERAC machine and every scientist says the product is great.
They all say the material that comes out of the machine is top notch.
To let you know I have been pleasantly suprised at the data. Superior product from a superior machine, made from a superior company (I have a bunch of their machines in my office).
I am not trying to backtrack.
I was just a little hot after that study club.

I however do not want to write a blog that is that is offensive. I have tried that and it has not worked out for me.
I am still thinking about it...
Talk to you tomorrow, Maybe.
john

I hate being ripped off.

Okay I went to a CERAC study club last night and I am not happy. Fridays blog is going to be on my opinion of CERAC.

It is going to take me a couple of days to calm down and I don't want to say things I might regret (that is growth, baby). I also want to write about this, today's topic, because I was hot about it on Monday and I have sinced calmed down enough to write about it.

Today's topic is about getting ripped off.

You know if you go to a place of business, it can be anything, like a mechanic, a specialty store, Disney? Have you ever left a store and really felt a pit in your stomach because you just think you have been ripped off in the highest degree.

Like, (not the same but I am setting the stage for my story) if you went to the mechanic. This is kind of different for me because I don't know anything about cars. They would say you need a new sphitzer valve (Fletch reference) and I look and he says see here you need to replace that. Then he looks up the part in the book and it says $50 and then he looks up how long the book says it will take, 1 hour, that is $150. So your bill is $200 to change the sphitzer valve. Now this doesn't tick me off that much because I don't know what the heck they are doing. I don't know a thing about cars. So I trust my guy and pay his bill. Even though I wish it wasn't so much.
Or (again, not the same but I am getting there) if you go to Disney with the family. It is 110 degrees and you can't wait any longer (you put it off as long as you can because you know what is coming) because you are starting to get dizzy. You go to the counter and your worst fears have come true...5 drink, $35 dollars. Ouch. I again don't blame Disney. It is not really price gauging. You get this awesome Dumbo cup that can sit in your cabinet for 5 years. But Disney has other stuff mixed in with the drink. They have the cart, they have cups, they have characters walking around while you are drinking your drink, it is part of the whole drinking experience.
I understand I am going to get it...I take it like a man and move on.

Now the thing that gets me is my local pool store. I have an automatic pool sweeper. (One thing that gets me is that the material the pool sweep is made of breaks down in pool water, figure that. I pay almost $600 for this thing and he tells me I will probably get three years out of it. What!!?!). This things drives around the pool and cleans up all the leaves at the bottom of the pool. Now every 4 minutes or so the thing automatically backs up. The reason for this is that if it gets stuck on a step it is not stuck there until the end of the day. So it has a valve on it that kicks it back. Pretty cool huh?
The valve I have has a hole in it. It needs to be replaced, no problem. Let me just run up to the Pool store and buy a replacement valve. My wife was out so I called her to go and get it.
She came home with it and said, "you know this thing was $65 don't you?" I said, "WHAT?!"
So I went on eBay and looked it up. $32 dollars BUY NOW and $5 dollars shipping. That is $65 compared to $37.

Now this makes my blood boil.
Now I am not talking about buying something that has service attached to it.
I am not talking trusting this guy more than I trust someone else. I am buying a product, not a service.
Now I am also not talking about, I could get it online for $25 and he sells it for $29. Of course I understand what it cost to own a shop, I understand what it cost to run a business. I don't understand sticking it to your loyal customers.
That is 100% more. That is highway robbery. Now if I didn't go to eBay and find this out, I would of never known he was ripping me off.
Am I being a baby? Do you say, "this is a capitalist society, and he can do what he wants"?

I have a small business and recognize that I have the trust of my patients. Are things expensive? Yes. Are they fair? Yes. If my service and products are better than the average guy can't I be a little more expensive? If I choose to have more staff than the next person in order to have a better experience for my patient isn't it okay if I charge more? If I choose to have better equipment more technology to serve the patient better, isn't it okay to be a little bit more expensive than the next?

But when it comes to someone buying a product here, it is different. (We don't make it a habit of selling products here, like Sonicares or whitening products, it is not a huge part of our practice)
When we do sell them products, we sell it to them for LESS than they can buy it at the store. We buy a Sonicare toothbrush for lets say $75 (because I don't really know) and the store sells it for $140, I sell it to my patients for about $99. I mean we pay the tax and may make $5 on the deal, which is enough for our troubles. This is not a money making thing. We sell the bleaching material at cost. I mean we have already made the money off of them for the bleaching.

I hate getting ripped off. I don't know why it rubs me so much but it does. Sometimes when you are buying a product you are not comparing two of the same things. This time I am comparing an apple to an apple. One apple was $65 and one apple was $37.
It wrong, just wrong.

Calgon, take me away.

We have quarterly meetings with our financial consultant. We go over everything that happended in the last quarter.

Let me preface this by saying my father and I don't know crap about money. We are pretty good at making it and really good at spending it but all the stuff in between we have always relied on other people to do it.
The first 10 years I have worked here we had an office manager that did everything.
So I became less and less interested in that part of the practice. We sat down once a week and she told us all the line items. In the same weekly meeting she told us what was in the bank. We asked her questions about the pulse of the front desk, i.e. accounts receivables, is hygeine schedule staying busy...things like this.
Our office manager retired and this all went away. Now we were in trouble because neither my father or I knew how to write a check.
So we had two choices... hire someone else or we had to learn the system (learn the system, I laugh out loud just thinking about it).
So we hired someone. He has an accounting mind and he runs a couple of small business like ours. I think in a week he goes to three offices. He has a box in an office and one day a week he pays the bills, payroll, takes care of our complicated health insurance plan, 401k plan and other financial issues that might come up.
So now we are back to the present.
We are having a sit down with our financial consultant. In the meeting is our accountant dude, me and my father and two people from our advisors.
Before the meeting our guy sends over all the things that are pertanant information
to the meeting. Where has our money has gone. How much we have, account receivables, new purchases, things we have thrown away (for depriating assest), anything you can think off.
Now between the 5 of us we hash out or business for about 2 hours.
Mostly I listen. But lately I have been getting more and more of the questions. Now it has become apparent that this might be a passing of the torch kind of thing. At the office the torch has definitely been passed. I make the bulk of the decisions and my father will step in when he sees me flouder like a fish out the water. Or when I have a breakdown in our office (usually involving a lot of F-Bombs) I plead with him to help me. And he does.
Now back to the financial decisions....Let me say one more thing...
Decisions... is it me or do we dentists have to make 10000 decisions a day.
Can I buy new instruments? The sterilizer is not working should I call the tech? Distilled water is so expensive should be buy a distiller? Yes, then what distiller should we buy the $399 one or the $599 one? Do you want the green microbrushes or the red? Do you like these cotton rolls or these? Ms. Jones just lost her job do you still want to charge her full price? The curing light in room three is losing power what do you want to do? Do you like the Colgate toothbrushes because the Crest rep was in today?
Should I try to save #31 with a crown lengthing and post and core and crown or should he just get an implant? And so on and so.

Now with the advent of me taking on the financial decisions it becomes, "Should we change to Bank of America because you can earn a half of a percentage point more in interest? Do you want to go with a high deductible medical insurance plan (a health saving plan) because it will save you on premiums? Yes, well then what plan do you want to go with, the $1100, $1700, the $2100, or the $2500? Yes, then do you want to fund your employees accounts? Yes, then how much.
Do you want the employees to be paid every week or every other week? Yes then do you....
Are you fricking kidding me?
What do I pay all you people for? Someone else make a decision.
We are at a meeting with 3 financial people and two dentists and all the financial people keep asking the dentist what they want to do with their money.
If I wanted to make all the financial decisions I would be paying you three.
Did I tell you I don't know CRAP about money?
So after the meeting the head financial dude and I are left in the room. He starts getting on me (he really does care about me and my office and I really love him and he likes me, I think) about being a poor manager. I told him I am not a micro manager. (I am not a detail person and I understand my limitations. I put people in charge of something I trust it is going to be done.)
He says, "I am not asking you to mirco manage, I am asking you to manage". Ouch.
He looks at the office and sees the money part. I look at it and I see about 15 parts that I am in charge of.
Now I can see how easy it is for dentist to sell their offices to a mangement company. Look I will pay you a million dollars and all you have to do is the dentistry. SOLD.
I will never do this but I am understanding how difficult it is to running all aspects of this machine.
But he says, "just manage".
I took this to heart. I am trying to see up things here that are not micromanaging but checking the systems.
I am having monthly meeting with the front desk people. I am having monthly staff meetings. I am asking for more details in the sheet of account receivables.
But then we go to the financial meetings and he says, "How is it going? Did you find out about X?" I have had 6 meetings since our last meeting and I forgot to ask about X.
It is a process, I am growing. I might be growing intolerant but I am growing none the less.

See you Wednesday,
john

Just when you thought it was slowing down.

What a day, yesterday.

(I tried hard to make this blog visual, and have lots of pictures but my camera and computer are driving my bonkers. You know when you are doing something and it is working and then you try to do it again and it doesn't work. You want to pick up something very valuable and throw it down to the ground and stomp on it. I was able to get two in...I will continue to work on it. Wish me luck. I might be in the market for a new camera and montior soon. Don't forget to double click on the pictures and you will be able to see the detail)

I have had a couple of patients walk in this week that I think I have to tell you about.

First, an 81 year old woman comes into my office for a New Patient Exam. Now when someone is later in life I usually alter my treatment plan so to be as fair as possible. Meaning, I usually will not treatment plan a full mouth reconstruction on someone this late in life. I know all you neigh sayers will disagree, but I treat all mature people like I would want my mother to be treated. I want them to be as comfortable as possible with as little work as possible.
You might say, “Well, you never know she might live to be 100.” There are very healthy 81, you know the ones that still do aerobics and play tennis and then there is the smoking, watch TV with a couple of glasses of wine, 81 (not that I have a problem with smoking and wine). This woman happens to be the latter.
But she had some needs that couldn’t be ignored.
On the top she has 2 and 5-12. #5 and 6 are broken down to the gum line. #10 has a 12mm pocket on the mesial, due to a root fracture. #’s 11 and 12 are abutments to a 3 unit cantilever bridge.
So she has #2, 7, 8, 9, 11 and 12.
I thought about regular partials but she didn’t want any wires showing. Iwill come back to the bottom in a minute.

On lower she has 21-29. 23, 24, 25 and 26 all had deep (apically) caries . Good occlusion, good perio, no TMD.
Money is not an issue.
So I am able to do any type of treatment but remember my philosophy about my mother or in this case my grandmother (well, maybe your grandmother, my grandmother was mean as a snake).

I am NOT going to suggest implants so don’t even think about it. In the discussion appointment her and her husband were saying stuff like, “remember Bob down the street, who had all that work and the next year was in that nursing home?”
So this is what I decided to do.
Remember, this is MY blog. I am up for constructive criticism but not mean spirited jabs.
On the top I decided to remove 5, 6 and 10 then just do a traditional partial. I can get retention on #3 and #13 (which is a cantilever). Now I am going to have an issue with retention on #7. I will put a lingual clasp and hope for the best. I could do some sort of precision attachment but that would involve prepping for a couple of crowns and adding $2600 to the treatment plan.
Now on the lower, I have decided to extract her incisors. Then do crowns on the remaining teeth (21, 22, 27, 28, and 29) connecting them with a hadar bar and then adding ERA attachments on the distals of #21 and #28. So the lower will be real solid. A lot of work but I didn’t think I had much of a choice. If I have to do work I want it to be excellent.
All this to tell you that this little mature lady is going to have $13,000 worth of work.
$13,000, now that is a lot of coin. I keep going over it in my mind. Should I do the ERA's on top. Is that too much work on the lower? I guess that is what conscientious dentist should do. This is how I make myself feel better.
She is starting in a couple of weeks. I will let you know how it goes. I will take lots of pictures. As you can see I am still having trouble figuring out how to put pictures on the blog. Today I got two in and it won't let me do anymore.



Patient #2 is a 66 year old retired physician from Puerto Rico. His family was poor, so as a child he had no dental care. His college roommate became a dentist. So in the middle of his life he had a reconsturction done.
All his teeth are crowns. He has a bride from #2 to #10. Abutments on #2, 4, 6, 8, and 10. #11 is broken off below the gum line.
#4 has through and through decay .
The lower has a bridge from 19-31. Abutments on #20, 22, 23,24,25,26,27, 30 and 31. Get this, the abutments on #30 and 31 are on a huge blade implant .
On the lower he has through and through decay on #27 . He recently had two root canal done on #23 and 24 and they accessed the canals through the INCISAL. So he has these two giant holes on the incisal part of these teeth.
His bite stinks. So because he doesn’t have upper left teeth and he doesn’t occlude on the right he postures end to end.
Wow, let’s marinate on this for a second. Basically he needs another reconstruction Gammichia style.
He is going to need either a new bridge from 2-10 and then he needs implants on 11-14(maybe an implant bridge, so at least 2 implants).
Then he needs to have the lower redone. That is crowns on 20-27. Then implants for teeth #19 and I don’t know what we are going to do with those blade implants. I guess I can use them. Cutting this thing out would be a huge undertaking.
So that is 20 G’s (no not gagillion) without even doing the implants, which he will need at least 3, which is about 10 G’s more.
The problem with this guy is I don’t think he knows it is coming. You know the patients that come in just wanting a cleaning.
Like me at the mechanic. Yesterday, my battery light goes on in my truck. I tell him I have a dead battery. He says do you want the electric systems test for $39. I say, "No, I have a dead battery." So he puts a ridiculously expensive battery in my truck and off I go. It takes a bit but about 2 miles down the road the light comes back on. I am just like my patients.
So this guys comes in and recognizes he has a need but I don’t know if he knows he has a $30,000 need.
I can fix this guy but what is he going to say when I tell him it is going to cost him a Escalade to do it.
He comes in all smiles and leaves in a pool of sweat.
I know he must know that this kind of work takes a long time, because he had it done in the past. But like I said he had it done by his friend, so I am pretty sure it was done at a reduced rate if anything at all.
He is coming back for a discussion appointment in a couple of weeks. I will let you know how it goes.

This was all yesterday. Just when you thought it was slowing down

What, no Wednesday blog?

Sorry, Sorry, Sorry.
Yesterday was my birthday (39)and I have been busier than a one armed paper hanger.
From work my wife and I went straight to the Gator basketball game, which they squeeked out.
I have no excuse but I promise I am already working on Fridays blog (that is a bold face lie).
Talk to you tomorrow.
john

Call my therapist

I had a pretty good day yesterday.
So good that I am changing topics for the day.

I think most dentists are cut out of the same mold. I remember in my first year of dental school we had this professor who wasn’t a dentist but either a sociologist or a psychologist, but part of his class was to profile me and my classmates and anyone else that came through our school. And as it turns out, we were pretty much all wired the same. We are all perfectionists, people pleases, yes men, and all pretty much approval sucks.
Basically, we all want to be liked.
I think I try create all these systems in my life for people to like me and I put up all these walls just so people won’t dislike me. I treat people a certain way; I drive a certain way, practice dentistry a certain way, write a certain way… so people will like me.
(In a way, I can identify with Stuart Smalley).
Now it is easy in the office to hide this because I can say I want to have a successful business. I can say to my front office, “Did Ms. Williams come back for her second appointment?” (The first appointment at our office is always a New Patient Exam; basically it is an appointment that is just about me and them. They don’t get a cleaning; it is just an hour and a half with just me.) So the second appointment is a pretty good measurement. I would think to myself, if they come back for the second appointment, they LIKE ME!!
Now, in the back of my head I know this is crazy. There are a hundred things they may have stopped them from coming back. Too far to drive, the coffee was cold, the administrative staff was not friendly, it hurt to take the x-rays, they didn’t like the color schemes, it turns out we didn’t take their insurance…to name a few. But to me it is a direct hit to the ego.
OH! And yes, most dentists have egos.
So, when they don’t come back, I create diversions, “Oh, I didn’t like her anyway”, or “It must have been something the front desk did” or “She probably couldn’t afford me anyway”.
You see...It is crazy.
At the beginning of my career, it was really bad. I was a mess most of the time. (Well, I am still a mess most of the time, but I hide it better). I was new to this thing called dentistry and when something went wrong, or when someone called to have their x-rays transferred…call my therapist.
Can you imagine having a practice where when you went in the morning thinking, “If I don’t get a 100% today, it will be deemed a failure”? I know I am not the only one (remember we are all basically the same). And when I was a younger dentist this is the way I felt. Now, I can’t imagine why our suicide rate is so high. Dentistry is a hard profession to master. It is very hard to get 100% during the day, so to people that are wired to want 100%, this is a deadly (no pun intended) combination.
(A painful memory is when I was out of school for about 4 years and was having one of those months. I asked my wife if she could handle me going back to school because I don’t think I am cut out for general dentistry.)

I started to look at the big picture; I have a wife that loves me. I have children that think I walk on water (they are still young, what can I say), I have a great staff that believes in what we are doing, I have great friends, I have thousands of patients that call me their dentist, people at church think I am walking the walk, and my neighbors think that I am a good neighbor.
The overwhelming majority of people that I am around like me. So you see I still want people to like me, but I don’t NEED everyone to like me. I still am an approval suck but it is under control.
Do I piss people off? Sure. Do people leave my practice because they don’t like me? Yes. Do I hurt my patients (of course, I try hard not to)? Yes. Do I occasionally leave a filling too high? Yes. Do I obdurate the MB canal .5mm too short sometimes? Yes.
I am a flawed individual. I am not perfect (my therapist says I should keep saying this) I can’t do it. So I try my best and that is going to have to be good enough.
I can’t be everything to everyone. So I try to live by the motto…I can strive for perfection and settle for excellence. I know this sounds corny but it is true.

Back to yesterday.
We got up and got ready for church. It is always a good day when I don’t cuss before church. When we got to church everyone was smiling. Last week I had a church member that came to the office for a New Patient Exam. In the same week he came back for a cleaning (a prophylactic experience). I forgot to tell you, when someone come to my office for the first time, they always get a hand written letter by me welcoming them to the practice and telling them thank you for choosing our place. He came up to me at church and said, “Thank you, for the letter, it was a great touch.” That made me feel great.
Then after church we went to Five Guys burgers, by the way if you have never eaten there you are missing out, it is awesome. The place was filled with people we know.
A woman came to me that we know (not a patient) and said, “I know someone that just started coming to your office and she LOVES IT. She told me about an experience she had at your office and told me how great it is.” Aw man, twice in one day.
Then there was a family in there eating that had just switch dentists, to me, after a long relationship with another dentist. They just love the poop out of me. From the eight year old to the mother (seven kids) it’s a big lovefest. Then the father says to me, “Everyone in the family loves you so much that I made an appointment for myself next week.” At this point I am flying high. My head is so big; I could hardly fit it in the restaurant.
Then I saw him. He looked familiar. I stared and tried to light the candle of thought that lit his name (Pearl Jam rules). And it hit me. He WAS a patient. I haven’t seen him in about 4 years. Then the thoughts came, “I wonder why he doesn’t come to our office anymore? What did we do to upset him? What doesn’t he like about me?”
But then I caught myself and let it go.
This is a big step for me. Letting it go. Then my 4 year old slapped me back to right now when he needed me. “I gotta go pooppy. Will you wipe me?”
"Honey, where are you?"

See you Wednesday.
john

Aly...I have those burs you were looking for. Can you email me so I can send you the #s and the pictures. I am a Jgammichia@aol.com