Helping patients move past denial over their dental health is no easy feat. In your dental practice, you have likely encountered this situation many times.

The truth is, patients who won’t or can’t accept the treatment they need for improved oral health can be put on a more positive path. The hard part is that they often require a significant amount of patience.

In a previous blog, I discussed the mechanism of denial and how it functions to constrain our patients despite our best intentions. There is no ‘forcing it’ because the psychological weight is too heavy. Facing a loss of a measure of health is extremely difficult, despite whether we ourselves believe the issue isn’t significant.

Characteristics That Support Change For Patients in Denial

One way to help our patients in these situations is to avoid frustration. Acceptance of other people’s emotional struggles can come from checking in with our own personal response to stress.

How do you create lasting change? Exploration of this question can give you a clearer perspective about similar answers for others. It can also reinforce the sense that our reactions to stimuli or upset can be quite different.

Once you (or a patient) have accepted change, you will still need to rely on your own resilience to parry the unexpected difficulties or days where your resolve is less strong. Some of the qualities that help in this situation include courage, commitment, awareness, curiosity, confidence, support, and skill.

The foundation of change is the first of these qualities: courage. Making changes in spite of fear is reliant on our willingness to see the potential risks and move ahead anyways. A big piece of this is recognition. If you can recognize what is holding you back from change, you can externalize the fear, make it more manageable, and talk about it rationally with others.

How do you help patients accept and appreciate change? 

The Carolina bridge is a novel all-porcelain bonded pontic. It requires no significant tooth preparation, making it an outstanding option as an interim prosthesis.

Numerous bonded bridge designs have been advocated over the years for the temporary or permanent replacement of missing teeth. Both metal and all-porcelain designs of bonded bridges are popular, each with varying degrees of success.

All of these designs involve some degree of tooth preparation, which makes them irreversible in nature. This is where the Carolina bridge comes in. The key to success with a Carolina bridge is the availability of adequate surface area interproximally to ensure optimally strong resin composite connectors.

Utilizing an ultraconservative all-porcelain bonded bridge for the interim replacement of single incisors relies on clear understanding of indications, contraindications, and clinical technique.

I Love the Carolina Bridge & Here’s Why

The Carolina type of bonded bridge provides benefits like ease of placement, esthetic vitality (no metal substructure), ease of connector repair, and a totally reversible nature.

Patients best suited for an all-porcelain bonded Carolina bridge are young adolescents with missing maxillary incisors. In these cases, an all-porcelain bonded pontic is an excellent interim prosthesis because of its totally reversible nature.

The abutment teeth can be returned to their original condition simply through removal of the bonded pontic and the resin composite connectors.

The Carolina bridge can also be used as a restorative alternative in cases where a more permanent fixed prosthesis is impractical or unaffordable. This might be a result of the patient’s age, medical condition, or economic status.

Additionally, patients with missing lateral incisors and in whom the remaining edentulous space is too small for an implant are often excellent candidates for an all-porcelain bonded pontic of this type. By slightly lapping the adjacent teeth, an esthetically acceptable prosthesis can be obtained.

In my next blog, I’ll talk about the design of the Carolina bridge and illustrate my technique for implementing it in appropriate cases. 

Dr. Heymann will be a featured lecturer at the Pankey 2018 Annual Meeting in Nashville, TN

Curious what dental materials the Pankey community is currently raving about? 

Sometimes, when you feel bored or uninspired at the practice, you could benefit from trying out new materials. This type of change can simultaneously up your clinical game and get you excited about work again.

Check out the suggestions from 5 Pankey dentists below for inspiration:

Materials Pankey Dentists Love

Dr. Mark Kleive

“My favorite new material is the air abrasion hand piece from Groman Dental – Etchmaster. It’s simple, no big equipment, still a bit of mess, but very precise.”

Dr. Mike Crete 

“My favorite new ‘tool’ in my toolbox is CBCT. In the last two years, I have had a major shift in my diagnostics and treatment planning by using 3D imaging. Although I do not have a scanner in my own office, the specialists that I have a great working relationship with do have them and it has become a great adjunct to our diagnostic and treatment planning process.

Dr. Lee Ann Brady

“My recent favorite is Cervitec Plus, Chlorhexidine varnish. It is an incredible antimicrobial adjunct for high caries risk patients. It reduces the bacterial count for 3-5 months and is applied at their hygiene visits. It is also great for around temporaries to create fabulous tissue health when seating restorations.”

Dr. Jennifer Davis

“My top two favorite materials lately:

(1) Not a new thing, but it still amazes me. Use of MicroPrime, a Gluma product,  after etching my composite preps. The amount of post-operative sensitivities and/or root canal procedures that come from my office now is amazingly low. Wish I had the foundation for a research study.

(2) I am loving using products to stain provisionals to custom match a tooth to the dentition. I use Protemp as my provisional material most times. They make such limited shades, though. Therefore, I stain with either Cosmodent tints, Creative Color, or Kerr-Kolor in white.”

Dr. Michelle M. Lee

“Not a material, but my mind has been blown with microscopes in the last month from the training I’ve been getting at Penn. It’s just been such a great experience and taken dentistry to the next level in terms of detail, finish, and marginal integrity. I have been loving learning more about this, as well as the integration of microscopes and dentistry with digital workflow! Fun stuff!”

What new or old favorite material are you excited about? We’d love to hear from you in the comments! 

Why is it sooo difficult to manage people? Probably because we spend time trying to “manage” people.

I’ve come to the conclusion that people aren’t meant to be managed. Scary words from a CEO, right? The truth is, I’m not very good at managing people, so instead I strive for creating clear expectations, responsibility, and accountability.

I believe that everyone has unique gifts and we should position people to utilize their strengths. When someone isn’t performing up to my expectations, communication is the key to affecting change. I have learned that the ultimate outcome is completely in the hands of the team member.

So how do we hold people accountable and what happens when they repeatedly fail to live up to their responsibility? The key is effectively communicating the expectation for their performance and developing ownership around the outcome. I find it most effective to do this during face-to-face meetings with a system called the 3 Fs: Fair, Firm, Frank.

3 F’s of Effective Communication

Fair

When a team member underperforms, I schedule a short meeting with them to discuss the situation. During the discussion, I begin with questions about their behavior or performance to determine what led to it and how to correct it.

The objective: To make certain the team member understands the expectation of the level of performance, acknowledges where they fell short, and creates a commitment and a plan of action which results in achieving the expected level of performance.

In this meeting, you want to be FAIR – listen to the team member while creating clarity around what happened and what the preferred action would be to avoid repeating the situation in the future.

Firm

Sometimes the “fair” conversation doesn’t have the desired results or the team member improves for a period of time but then slides back into old habits. In the event that this happens, you will have to schedule another meeting. During this second meeting you have to be FIRM.

The objective: To have the team member, immediately, bring their performance up to the expected level.

Briefly review the area of underperformance and remind the team member of the commitment and plan of action they made during the first meeting. Be clear that if the team member chooses not to immediately bring their performance up to the expected level, that will indicate to you that they are not a willing, contributing member of the team.

Frank

Despite having the “Fair” and “Firm” conversations in an attempt to correct performance, there are times when a team member simply does not upgrade their performance to a consistent and acceptable level. If that occurs then it is time to be FRANK.

The objective: To clearly explain that the consequence of a failure to immediately perform at the acceptable level will be termination.

As with all leadership, you should find your own style, language, and habits. I tend to try to be encouraging and remind the team member of why I believe in them, while emphasizing the need for the team member to perform up to expectations.

I also like to email a team member after the meetings recapping what they committed to. This confirms I heard what they intended and that we are working off of the same expectations.

Regardless of your leadership style, the 3 F’s provide a solid guide for how to address underperformance in the unfortunate instance when it is progressive.

Note of thanks: Dr. Rachel Pullsen shared “the 3 F’s” with me and the other women who came together this past July for the first annual Pankey Women’s Retreat. Thanks so much, Rachel, and give a big thanks to your sister-in-law who I believe is the originator of the 3 F’s. We all grew as a result of your sharing!

Ever since I started my AEGD residency following dental school, I have loved continuing education. I’ve always sought new courses, new educators, new techniques. But for me, the most impactful educational experience was taking The Essentials courses at The Pankey Institute.

Not only did I learn about the complex temporomandibular and masticatory system, perhaps more importantly, I gained the skill and confidence I needed to tackle complex esthetic cases and truly found my sweet spot in dentistry.

Finding My Way in Dentistry

I am a bread and butter general dentist. However, my favorite cases are the ones that have the capacity to change someone’s smile, to make them not only healthier and more beautiful, but most importantly, improve their confidence. Once I gained these skills I wanted to implement them into my practice as soon as possible, but unfortunately I tripped over a few stumbling blocks before I found the right way to do that.

I remember one particular patient I had who really could have benefitted from some esthetic dentistry. I spent hours mounting the case, cropping and organizing photos, even waxing up anterior teeth on a model to show him the dramatic esthetic improvement I could make to his smile. That patient was engaged and listened to everything I had to say.

He came back for his second consult, asked questions, but at the end of the day never pursued treatment. I learned a valuable lesson in that case and numerous others. When I stopped presenting the treatment I thought patients needed and instead let them tell me what they wanted, I started closing cases.

As a part of my comprehensive exam, after the radiographs, the periodontal probings, the hard and soft tissue exam, and often clinical photography, I simply ask the patient, “Is there anything about the way your teeth look that you would like to change?”

To be continued…

The truth can be hard to face: Something is wrong with the design of these provisionals … We may be working on a broken provisional and feel the deep frustration that comes with knowing something went awry.

I challenge you, in these moments, to reframe the ‘problem’ as a mystery to be solved. You are the clinical detective who needs to work backwards a la Sherlock Holmes to figure out ‘whodunit.’

Mystery of the Broken Anterior Provisional

Remaking and adjusting an anterior provisional from the upper right to the upper left canine (for the second time) is a horror story in the making. Before you allow that narrative to take over and call the lab to have them rush the case back, remember to rely on your intuition and technical expertise.

You may not be able to call the lab because you haven’t taken final impressions. Either way, let the provisionals tell you what the flaw in the design is, rather than believe you can run the solution show.

A good first place to look and listen for answers is the occlusion. For example, if the patient reports that they wake up with headaches after you’ve placed the provisionals, you would want to look closely at envelope of fucntion. Is the patient heavy on the centrals and laterals? If so, you can begin the process of adjusting.

Methods of the Dental Detective

As you examine the issue, you may find other clues, such as that the patient is catching on the incisal edge in their return stroke from protrusive. You continue to adjust, beveling edges for a smoother transition. You leave the guidance shared between the canines and centrals, keep it smooth, but even this doesn’t stop the patient from breaking the provisional.

If you’ve ever seen or read a good detective story, you know this isn’t the time to quit. When things seem most opaque, the detective is usually at a breaking point where the parts might finally start to fit together. Once they do this, the flood gates open and they rush toward the explanation.

You will reach this point while adjusting again. In response to what you’ve learned, you begin to shallow the patient’s guidance and share protrusive with the premolars. You decide to shorten lower anteriors and increase overjet by proclining the restoration. Here, you’ve come to the solution. You need to work it out on an articulator perhaps and then go back to the mouth.

The main lesson is that we have the most to learn from cases that don’t go perfectly. Plus, it would get pretty boring if there were no dental mysteries left to solve …

Have you ever recommended treatment to a patient and then gotten the “deer in the headlights” stare with the sound of silence in the room?

This is usually an indication the patient was listening to what you had to say … they just were not ready to HEAR what you said!

Knowing Your Patient and Learning When They Are Ready

One of the aspects of the Philosophy of Dentistry as taught by Dr. LD Pankey is the concept of “knowing” your patient. Do you really know what your patient’s circumstances, objectives, and temperament are?

When you really understand your patient, you are able to meet them where they are. You will then know when they might be ready to hear the recommendations you have to improve their dental health.

Knowing your patient starts with asking the right questions and using active listening skills while getting to know the patient. What are their values, fears, expectations, perceived needs? Do they have an appreciation of dentistry and value what it has to offer? A.K.A., what is their dental IQ?

Do they need more education about their current condition? Does their budget now include dental care? Are they ready to make an informed choice about their treatment options?

I oftentimes find myself initially putting out the “fire” for a patient (ie. repairing a broken cusp or chipped front tooth, getting the patient out of pain) and then easing the patient into care in our office in a way that makes them feel taken care of.

I may take several years to build trust with the patient, educate them about optimum oral health, and help them understand the root causes of their condition. Over time, the patient usually starts to ask more questions and dental health becomes a high value for them. They eventually say something like, “Hey doc, I’m READY … when can we get started?”

Developing your clinical skills is very important to providing excellent dental care. But I find it’s equally important to develop your communication skills such that you can really get to know your patient and know when they are READY to own their condition and get started with the necessary treatment.

A bedrock value of Dr. Pankey and those who have chosen to follow his visionary teachings is that the welfare of patients is first and foremost. 

Putting the patient’s needs first is the lens through which all other professional decisions we make as caregivers must pass. If something doesn’t pass the test of being in the patient’s best interest, as ethical dentists we must give it a serious review.

Why Technical Skills Alone Are Not Enough

The response to this commitment by many dentists is to dedicate themselves to perfecting their technical skills, whether that be during their dental school days or in frequent post-graduate studies. Dr. Pankey encouraged this, harkening back to the days of his parents’ dry goods store, saying it is necessary to “have it on the shelf.” 

While a necessity, simply being a good technical dentist is not enough. We live in a world of marketing sensory overload and patients experience a tsunami of messages when trying to make healthy choices. How can a good dentist stand out from the crowd and benefit more patients?

Empathetic Understanding Is Key

Dr. Pankey’s mantra was “Know Your Patient, Know Your Patient, Know Your Patient,” but limiting that knowledge to the patient’s clinical condition short-circuits the concept’s power.  Knowing the patient’s circumstances is priceless and allows you to understand some potential barriers they may have to moving forward with treatment, as well as when now is the right time to pursue optimal dental health.

Combining excellent clinical knowledge, an empathetic understanding of a patient’s circumstances, and earning the patient’s trust can open a powerful pathway to optimal health for our patients. Knowledge, understanding, and trust, coupled with our dedication to what is best for the patient, allows for the possibility of true partnership.

Treasured learning from Dr. Pankey and the Pankey Institute are the tools to partner with our patients – to walk with them, hand-in-hand, on the path to optimal health. The marketer sees the patient as a prospect – someone who will bring business and profits. The technician sees the patient as a collection of defects that need expert fixing. It is the master dentist who brings skills, both technical and behavioral, to partner with patients as they guide and support them toward their vision of health.

We have a remarkable heritage at Pankey. Around the 1950’s and 1960’s, four innovations converged to permanently change the dental profession worldwide. Pankey dentists were part of the creation of all of them.

In my last post, I talked about the invention of the sit-down chair. Now, I’ll dive into time and motion studies, high speed air-driven rotary handpieces, and the “washed-field’ evacuation technique. These innovations had a significant impact on the future of dentistry.

Pankey Innovators of Modern Dentistry

Time and Motion Studies

These studies evaluated and changed how dentistry was delivered, e.g. four-handed dentistry, ergonomics, efficiency, etc. My father, Dr. John Anderson was a large part of that along with men from the east coast. Don Coburn from Canada was also a major time and motion researcher and later became a strong supporter of the Institute. My dad wrote several articles in the Dental Clinics of North America about office design related to time/motion principles.

High Speed Air-Driven Rotary Handpieces

Before the 1960’s, belt driven handpieces were the norm. Dr. Henry Tanner was at Bethesda at that time working with engineers designing this new high-speed technology. This too was reluctantly received by the profession at first but now one can’t imagine doing dentistry without it. Dr. Tanner was on the faculty at the Institute and you can find his portrait in Master’s Hall.

“Washed-field” Evacuation Technique

This is the type of high volume vacuum system we use each and every day today. It replaced the workhorse cuspidors used by everyone in the 50’s and early 60’s. The new water-cooled high-speeds needed this innovation for pulpal health and prepping efficiency. To my surprise, there are still cuspidors being used in operatories to this day. Elbert Thompson of Salt Lake City, Utah was the dentist that created a consumer friendly system of high volume evacuation. He was a friend of Dr. Pankey and an integral associate of these other innovators.

What Pankey history do you admire? We’d love to hear from you in the comments!