Slip 'n Slide

Greetings,

Happy Tuesday everyone. I was reluctant to share this story with you, but I have had so many requests for it lately, I didn't want to leave anyone out. Plus, retelling the story is part of my "therapy." It's amazing to me how the things that happen to a person early in life can shape who they become.

I was 9 years old and the very first kid on my block to get a Slip 'n Slide. For those of you who do not know what that is, it's a long piece of yellow plastic that you hook up to a hose. The hose creates a water stream that sprays on the entire length of the plastic, making it slippery. The idea (without breaking your neck), is to take a running leap, land on your stomach, and slide down the plastic, rendering yourself helpless to the fun and excitement of it all.



This day was going to be all about me. I had invited my friends, 13 in all, including Donna (a fictitious name to protect her real identity). Now, since I was the first one who had one on the block, I was going to be the first one to take the fun-filled journey down the slide. After all, it was only fair. It was MY yard and MY Slip 'n Slide.

I strategically placed my friends down the entire length of the slide to ensure everyone had a chance to see me having fun. Don't get me wrong - they were all going to get a chance, I just wanted the jealousy to soak in for a little bit. I figured they would appreciate their turn even more. To this day I am still trying to figure out exactly what went wrong.

I had a good running start, a good take off, and a great initial contact with the slide. But somehow, the string on my bathing suit and my flabby gut created friction with the slide itself. As I took my dream ride down the slide, my bathing suit took a nightmare ride down my legs in the opposite direction. Now mind you, my bathing suit didnt just simply fall off, but intricately rolled into a tight, wet, ball that ended up bound to my ankles by the time I reached the end. It all happened so fast.

I know you are laughing, and so was everyone else, including Donna. Recovering from this was almost impossible. There was no way to quickly pull my bathing suit up before anyone could see. My shorts were wound so tightly around my ankles that I could barely get them off (which was the only answer). I had to stand up, take them off, unroll them, and then try to put them back on. I have never heard 13 kids laugh so hard in my life. I sent everyone home. Thirty-seven years later, I can hardly look Donna in the face. I know she still thinks about it. haha

To this day, I am never the first person to get something. To this day, I always try something out first before "exposing" it to anyone. I hope the story starts out your week with a smile or a laugh, and even though I am not completely over it, I am that much closer to letting it go. :)

Have a great week.

Scott

Immediate Load

Friday, and I can just taste the beer waiting for me when I get home. My son Luke finished school today. Well, he really finished on Monday, but they party for 4 days just to fill the days. My hard-earned money, well-spent.

Anyway, we were talking about implants. I was telling you about this case that was putting implants at the forefront of my mind. A prosthodontist showed us a case where he removed this patient's lower teeth and put implants in on the same day, and then put on a screw-retained denture. While he was showing up pictures of this I was thinking to myself, "My surgeon would never do something like this."

So I gave him a call. Which reminds me, I think you guys (guys means male and female dentists) need to have a very good relationship with your specialists. If you don't, and they are not easy to talk, to then maybe you need to get another one. I think you need to be able to call your specialist up and ask him questions. Now, my periodontist and I don't like to talk much during work because we talk too long and we both get behind, but that is a good problem to have.

This prosthodontist and I talked for about 10-15 minutes on philosophy. He doesn't mind doing immediate placement that much (but I can tell you he doesn't do it very often). It is the immediate load he has a real problem with.

Let's talk about this a second. This prosthodontist made everyone in the room believe that this was the only way. Whether he meant to do that or not, he still did it. If there was another way and he thought about doing it that way, he didn't mention it.

I was talking to my periodontist and he told me that failure is something that will drive him crazy. And immediate load raises the failure rate 5-7%. To him, that means 5-7% more of his patients are going to be ticked. That means 5-7% more of his work is going to have to be redone.

Like me, he is a perfectionist. He doesn't sleep at night when something doesn't go right. That means 5-7% more sleepless nights. And the cases that fail? They just don't fail; they fail epically. To him, it isn't worth it. He wouldn't have done it that way.

I asked him why he thought this guy would do it this way. He said his surgeon probably told him it was fine. You know who is telling the surgeon it is going to be okay? The implant rep. "Sure doc, we do this all the time. It is no problem."

It also cuts down on chair time. Think about it. In this case it is one surgery and one follow up appointment. If you don't do immediate stuff, you are looking at a lot of surgeries and a lot of time. Extractions and bone grafting. Then 6 months later, you place the implants. Then 4 months later, you might be ready. Then add in all the checks and "this hurts" and "I have a question appointments."

Do you realize how much money the surgeon is saving by doing one visit? Listen, I am not bashing surgeons; I am just making an observation. I have tried to put pressure on my surgeon to do immediate stuff and he just won't do it.

A 5-7% failure increase is too risky for him. Do you know what failure means? You have to bring a patient back in who is just starting to realize things are failing. You have to tell them that you have to redo the whole thing. The patient gets angry. You try to soften the blow by telling them you will do it at no charge, so now the surgeon is angry. And you're angry because you're doing this a no cost, too. The surgeon loses the patient and maybe even a referral source.

By the time you're done removing the implant, doing a bone graft, waiting (this time), placing the implant, waiting (this time,) and then putting the crown on, you have a ticked off a patient and you have lost tons of money. So, he is saying it isn't worth it? As I write this, I am leaning toward agreeing with him. Is all that worth 6 months of waiting?

I think it is definitely worth discussing. Do you give the patient the option? If they want to go with the immediate, do you tell them they are going to be responsible to pay for the whole thing again?

I would like to know what you think. Are you and your surgeon doing any immediate stuff? Have you had any implant failures, immediate or not?

Have a great Memorial Day weekend. Do me a favor and do a little remembering what this weekend is about: people putting their lives on the line for their country and what it stands for. I am humbled when I think about that. I hope you are too.

Man, it is noon. I can smell the beer now!
john

Saving Teeth vs Placing Implants

Hey all,

I don't have much time today because I have to go to a funeral. One of my patients died in his sleep on Sunday. His wife, a nurse practitioner, was sleeping right next to him. 67 years old. You never know guys. You never know.

Anyway, we were talking on Friday about me going to the Seattle Study Club for the first time. A local prosthodontist presented a case; we were supposed to get together in groups and try to figure out the best way to treat this patient. The patient was 63 and money was not going to be a problem. He was a full-mouth rehab and everyone knew that. But how would you rehab him?

He had some compromised teeth on the bottom, but they were savable. There was some erosion that had happened, but he claims he has no gastric reflux. He was going to need some root canals and some perio surgery, and then crowns on each tooth. Well, to make a long story short, everyone had a different opinion. And of course they were all different than the way that this dentist did it.

I will cut to the chase. The dentist had all his lower teeth out. He did five implants and an immediate screw-retained denture. After 4 months, he began the fabrication of his lower fixed perio-prosthesis. That is basically a porcelain denture that is "screw-mented" is what he said. Two of the implants got cemented with temporary cement and the other three are screw-retained (with no reason to take them off). The lower bridge is concave, so the patient just flosses (with yarn, of all things) and water picks under there. Easy.

Needless to say, I was blown away. I have learned (and am now thoroughly brainwashed) to save teeth at all costs. From school to the L.D Pankey Institute, it has always been save, save, save.

And that was being conservative! This guy is telling me that taking all the teeth out and dropping implants in is conservative. I had heard of this before this study club and scoffed at it. "Come on," I said. Now seeing this in slides, talking to other "conservative" dentists, I am blown away. My mind has been spinning since the meeting.

I think I am a changed man. BUT not totally changed. My eyes have been opened up to another mode of conservative treatment.

Let's talk about this a second. After the study club on Wednesday, I came back to work and on Thursday I had two tough patients. Guys in their late 60s. Guys that are medically compromised whose teeth are failing faster than I can fix them. You know the type: they have less saliva and more plaque, AND they don't have the dexterity or the motivation to brush and floss as well.

I have done more than $4000 worth of work for both of these guys that is now failing, less than 2 years later. (Yes, they both are on a three month recall, they both have fluoride trays and SOMA.)

So I told them both that taking out the teeth was an option. Meaning an implant-supported denture is now one of my options. Why spend $10,000 before you make the decision to take them out? And it is better to try to get them to do this now when they are in their 60s than when they are in their late 70s.

So taking all the teeth out (say, 12 teeth) and then doing 4 implants, then putting a screw-retained denture is going to run, off the top of my head, about $11 to $12k.
Damn, that is expensive. But then they can enjoy them. They will never have decay again. Most likely, they will never have a failure. All those other things are not going to haunt them (and YOU) for the rest of their lives.

I want to save teeth. I am sure of that. But I can tell you that I have had sleepless nights not knowing what to do with some people in my practice. Now I know.

Hope you are having a great Wednesday,
john

P.S. I talked to my implant surgeon, and he reassured me that he still does NOT do immediate load. You all know the success rate decreases, right? What would the number have to be for you to not do immediate load?

If the success rate was 10% less, would you do it? What if it was 7%? That is, implants are 97% successful. Would you do it if that was lowered to 90%, know one out of ten is going to fail?

I wouldn't and neither would he. That is why I say my mind hasn't been changed totally. We will talk about that on Friday.

Blog Exposure!

Our office likes to track where we are getting new patient referrals from. When I meet a new patient, I always greet the patient and ask them how they heard about the office. Usually, it is family or a friend. The econd most common is internet and third is probably insurance carrier referrals.

I had an interesting encounter with a patient a few weeks ago. Let’s call her Mrs. Wrench. I asked her the same series of questions and got a response I was not expecting. She told me that she was looking for an "honest" dentist that was not a "shyster." She was searching the internet and found the Daily Grind blog. She started to read the posts and liked what she was reading. She said she felt like she got to know me a little and said it made her want to come on in. She also told me her mother told her to be careful coming in to see me because I might write about her and use her name in the blog. I told her not to worry, there are a few laws that will protect her from that issue. I told her I was going to write this blog about our meeting and I hope she gets a kick out of reading this post.

I was really surprised by this encounter and her finding the blog. When I write blog posts, I forget that this gets sent out into the cyber world wilderness. I have kind of incorrectly assumed only dental professionals read this stuff. I figure any other person would have no interest in reading about our trials and tribulations or joys of the profession. Well, she had read them and seemed to really like reading them.

She has been a great patient, very understanding and serious about improving her oral health. She does not have insurance, but doesn’t hesitate to have the necessary treatment completed. I have enjoyed helping her and need more patients like her.

I know that patients want to feel like they know the doctor and staff. If they can make some level of connection with the office on a personal level, everyone is happier. We really strive to make patients feel welcome and cared for. I know all kinds of little details about many of our patients that I try to file away in my limited data bank so I can have real conversations with them. I feel this is what separates many of the small private offices form the big corporate clinics. I know they are not all this way, but from my experience, people are willing to pay a little more and drive a little farther to receive this sort of care. This sounds like some old-fashioned business model, but I believe in it.

Have a great week.

jj

Seattle Study Club

Hey all,

I have a friend that has never seen "Good Will Hunting." WHAT?!!! It is a phenomenal movie. I looked it up on my phone on Amazon, and there it was and there was a button that said, "Buy it now, with the push of one button, for $3.95." I was down. I pushed the button. 3 days later I got a package and it was "Good Will Hunting." One small problem - it was a VHS tape.

I haven't had a VHS player for about 5 years. So now I have almost $9 in a movie that I will never watch. I wrote to Amazon and told them what happened. They responded in about 5 minutes telling me that I will have a full refund. Wow. I wasn't expecting that. I guess that is why they are a gujillion dollar company.

I went to a new study club this week, new to me that is. It was the local chapter of the Seattle Study Club. I have always wanted to get in on this but just never did. I have heard good things about it, and I heard there were some real heavy hitters there. I wanted to be a part of this. You know, it is a little intimidating to go to a group that you really don't know. There were about 25 people there and I only knew about six of them. I went with someone but we didn't sit together because I wanted to see the screen better and I wanted to meet new people.

Here is how this meeting actually worked. There was a prosthodontist that told us about a patient that he saw. He showed us some x-rays and pre-op pictures and asked us to get in groups of 4-6 and figure out what we would do. The case was a full mouth rehabilitation and everyone knew that but the question was how to rehabilitate this patient.

We broke up into groups. I knew one of the six guys only by name. I would also say that the group I was in was fairly young; I was the oldest. But I am not one to think that I know everything. I do not like to tell people that what I think is the best way (maybe I am a little different as a blogger, it is easier to act like you know everything when you are just typing). But I did say that I thought this guy was in for a lot of dental work. Perio surgery, root canals, the whole bit. Being that most of these guys were young, they basically said that they hadn't done anything like this. I really respect people that are humble. I respect people that are listeners. I respect people that are there to just be sponges.

Let me tell you about this patient. This guy had every tooth on the bottom except 18 and 19. He had what I call a reverse smile line. His lower centrals were supererupted. He had some erosion of some sort going on but claimed he didn't have a reflux problem. The ling of the upper incisors were pretty abraded. All his lower premolars had root canals in them but were never restored (his brother is an endodontist in Ohio or something like that). The uppers just needed to be restored but the lowers were going to take a lot of work.

Our group talked about what it would take to restore his lower teeth. Would we tell him to go to Ohio for the day and do root canals on all his teeth? Then do crown lengthening on the lower anteriors and then crown them all? Hmm...

We didn't know. We waited for them to tell us. One group was going to keep this tooth and this tooth and do an implant here and an implant here. Everyone had a different opinion. The prosthodontist, who does some incredible work, put up the final pictures.

He took out all the lower teeth. Let me repeat myself slower. He took out all the lower teeth.

So this guy went for oral surgery. He had 12 teeth out, ridge augmentation (to flatten it out), 5 implants all in one day. Then he went to the prosthodontist's office ON THE SAME DAY, where he had a transitional denture already made that he put on the implants, meaning he cut a whole in the denture where the implants were and screwed the denture onto the implants. He did an immediate load screw-retained denture. Wow. I was blown away.

You see, the most conservative thing to do is take them all out. This 63 year old patient will never have decay issues again (on the lower). This patient will never a broken root from a post and core, or have to deal with a failing root canal. And you know what? I totally agree with this guy's treatment. Taking the teeth out was the most conservative treatment. It is blowing my mind just writing it.

I am going to follow this up on Wednesday. Let's talk about this some more. Everything I have learned in school, everything I have done for the last 15 years was to save teeth. Save teeth, save teeth, save teeth, save teeth. I have brain washed myself. Now I am learning that this is starting to become OVER TREATMENT. No perio surgery, no root canals, no post and cores, no prepping, no cord. All trying to save teeth. My head is spinning. I am going to try to get my thoughts together and we will talk about it on Wednesday.

Have a great weekend.
john

Collections

For the record, I appreciated all the comments on the last two blogs. I want to address them. First, my recalls. We have been in communication with TeleVox, our voice appointment confirmation system. It turns out they do recalls too. It is integrated into your system and if the person is due this month they will call them and remind them to call the office. We are working out the kinks, so I will let you know.

About the comparing. I know it is wrong in so many ways to compare. I know that you never know what is going on with other people when you compare. It doesn't matter to me that the people building the 8000 sq. ft. mansion on the lake are two physicians. It doesn't matter to me that the dentist down the road can't afford the Mercedes payments. It is not about them (and a couple of you alluded to that). It is about me. It is me not loving the situation I am in right now.

I know I should "count it all as joy," as the book James says. I know this, but I think it is human nature to compare. I mean, God devoted a commandment to coveting others things. Comparing is not a new problem (it is at least a 2500-year-old problem). But it is a problem, at least for me. I will try to keep myself in check. And most of the time I do consider it all joy. I just think it would be more joyous with other people's stuff.

I haven't talked about TV in awhile. Modern Family is still my favorite show. We are still big fans of both NCIS shows. We started watching Hawaii Five-O and Blue Blood.
I have heard The Middle is very funny, but I forget to put it on the Queue. Anyone seen this? Is it worth it?

Today I want to talk to you about collecting money. Before I go on, I have to tell you that I know that collecting all the money at the time of the service is always the best and that is what we try to do at our office, BUT sometimes it doesn't work that seamlessly.

My accounts receivables have always - and I mean always - been about $75,000. That means when I first started they were $75,000 and today they are about $75,000. They spike to $90,000 and dip to $65,000 but 99% of the time they hover around $75k. I get a report once a month and it is 4 pages long and it has everyone that owes the practice money, from the $4 outstanding to the $1998. It reports how many days they are delinquent and also where they are. Are we waiting for insurance? Have arrangements been made? Have we sent them to collections?

Before I talk about this list, let's go back to the systems. Yes, it is our goal to make sure everyone pays on the day the service is rendered. They are instructed to say, "Your bill comes out to be $1,500 today Mr. Warbucks. How would you like to pay for that? We take cash, check, MasterCard, Visa, Discover, American Express. If none of that is acceptable to you, we can get you application for CareCredit." We give them every option.



But this is hard to do. For instance, if the patient has insurance and the insurance says it pays 80%, we all know they pay more like 50%. Unless you have gotten a pre-determination, you never know what the patient is responsible for. So we collect the 20% at the day the service is rendered and we tell them there is a good chance the insurance will pay about 30% less than you think and you will be responsible for it.
We found that if we ask them to pay 50% up front it kind of ticks them off (and we can't afford to tick off the patients that actually do come in). Then we have to collect the rest of the money.

Then there are people that have huge treatments done and they make arrangements with my front people. "Why don't you pay half up front, and half at the cementation?" But then at the cementation appointment, there is some issue and then that becomes a collection issue.

Then there are the people that come in expecting to get a tooth out at $175 and I tell them it is best to save their tooth. They want really bad to save their tooth but they only brought $175, so I tell them they can bring the rest of the money in next pay day (nI have to tell you, these people are better at paying than the people who get the huge treatment, make payment arrangements, and then can't pay at the cementation).

There are people that expected their insurance to pay 100% (and so did we), butthe procedure was denied for some reason or another. Or the case that I just plain got over-zealous about and finished the work before they could afford to pay. There's also the patient that has been a patient here for 10 years and never can get their head above water and can never get ahead of their dental issues. They come in with a problem and I tell them to pay when they can.

How about the college kid who tells you his dad is going to pay? You send a bill to the father and they go absolutely apes#@$%t. How about the physician patient that has been a patient for 18 years? He gets his treatment and never stops at the desk, just walks right out. You know he is good for it. He has never been a problem, but he gets on the list because we have to collect from him. But you get enough of the above and what you are left with is a 4 page audit report (about 250 people).

Now, about the list. Over 50% have a line through them, meaning it is taken care of. For 10 or so, their treatment is not finished, so they are a non-issue. Another 10 or so have financial arrangements and are currently sticking to the arrangements. So that leaves about 80 or so people that are delinquent in some form or another. In a practice this big, I don't think that is that bad. Twenty or so are 30 days past due. And a couple of them are like $5 or $7, and these people are probably thinking they will pay the next time they come in.

Which reminds me of a question I wanted to ask you, Are you sending people a bill for outstanding balances of $20 or less? I have told my staff not to send a statement for $5 or less. But they say that if we have 100 people that owe $5, that is $500 out there that is our money. 14 people are 60 days over due. 7 people are 90 days over due, and 7 people have been sent to collections.

And the funny thing is, usually it is the SAME people. They will finally pay their bill and then come and get their teeth cleaned or break a tooth and there they are again, on the list. I just shake my head. I can go up there and micro-manage, but I like just sitting back here and shaking my head.

I don't know how to do this. I am not saying that we do it the best because I don't know what everyone else is doing. How do these numbers sound to you? How are your collections? Are you really strict with patients? Are you more loosey-goosey and are you getting burned? I am looking forward to hearing from you.

Have a great Wednesday,
john

Odds & Ends

Greetings,

Boy, I have been in a slump lately. Just one of those periods of time where things don't always turn out exactly the way you would want them to. The one thing I do love about being a dentist though is taking time off. It always does my mind good to get away for a few days and just recharge.

Recently, we went to Boston. Wow, what a great city. Right across the street from our hotel was a small cemetery. John Hancock, Paul Revere, Samuel Adams, and many more famous names from history are buried there. I was just amazed. I had to go by the place "Cheers" was based on, not to mention all of the other historical sites. We were told that we HAD to go to Regina's Pizza, which is supposedly the best pizza on the planet. It has been open since 1926. The line was wrapped around the building to get in, but I must admit, it was the best pizza I ever had. I cannot wait to go back and see all the things I missed the first time around.

Usually in September, me and "the boys" take a motorcycle trip out to the Carolinas. I have been through 4 motorcycles in the last 10 years because I just can't seem to find that perfect fit for my size. I am 5 foot 6 (5 foot 6 and a half, if I blow dry my hair), and finding a short bike can be difficult for me. This is my Yamaha FZ6r that I am riding right now.

I forgot to mention that when we go on the motorcycle trips, we do not go by our normal names. I am Scooter! (Sometimes I go by Mad Dog, depending on the weather.)

The Carolina mountains are just beautiful, especially on the Blue Ridge Parkway. There is nothing quite like being out in open, smelling the mountain air, and being just on this side of very dangerous. Here are the guys from the last trip.

back row:left to right: Turbo, Scooter (that day), Dragon Slayer, Nitro, and Afterburner (kneeling). I could tell you their real names, but that would go against the code. I am going to be at an implant course this September, so I am not sure if I'm going on the trip this year or not.

Last night, we took my parents to a place called Cinebistro. Basically, it's a movie theater where they serve you dinner in your seat while you watch the movie. We ended up seeing Thor in 3D, which was actually really good. If you are ever on I-75 near Wesley Chapel, check this place out. It's a very unique way to enjoy a movie. Well, not much more with odds and ends today. I hope everyone has a great week. I am hoping mine turns around because I haven't even been able to get a matrix band to fit on a tooth lately!

Talk to you all soon.
Scooter... umm I mean... Scott