We’re There for You!

June 27, 2019 Michael J. Scherb, DMD

How many of us have had a patient call who was really upset with us or our office?

The other day, my office manager came to me and said, “Mrs. Jones called and is super upset.” We had just completed an upper and lower reconstruction. Due to the complexity of the case, I opted to place the lowers in permanently, but I placed the upper in with temporary cement, in case there were any modifications that she wanted made prior to finalizing the case with permanent cement.

My office manager continued, “her new bridge is loose, and she said she is going to get an attorney because she paid a lot of money for this and it is already failing.” I told my office manager it was in with temporary cement, and the patient must have forgotten that I told her this, which in fact was the case.

I asked my office manager to bring her in immediately, and I would take care of it. Mrs. Jones presented, and I greeted her with a smile. I said, “I will take care of you immediately.” I proceeded to remind her that the upper arch was in with temporary cement, and she said, “Oh yeah! I forgot about that.”

After allaying her concerns and asking her if she had any difficulties over the last month, to which she said no, I opted to place the restoration on with permanent cement.

I reminded her that there was one other section, which still needed to be put in permanently, but I would do this in the future, since I was unable to tap it off at the time. (Sometimes, when the seal is really excellent, even temporary cement will hold very well.) I reassured her that all should be well and to always remember that “We’re here for you!”

This can be one of the greatest statements you can make to a patient. So often they feel “discarded” once their work is completed, and you “have their money.” Or they feel like they are being bothersome if they contact you to make any adjustments. They feel that any issues they are having will work themselves out, or they will just get used to it.

I remind them that we are always there for them and want to make any needed adjustments or corrections to the work we’ve done before any other problems arise. We want to be proactive in taking care of their issues and not be reactive. Often it is a very simple correction.

Letting a patient know “We’re there for you” can go a long way to creating a patient missionary and can be one of your greatest practice builders. “We’re there for you” is one of my favorite messages to convey to my patients, and I repeat it often.

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Michael J. Scherb, DMD

Dr. Michael J. Scherb is on the Visiting Faculty of The Pankey Institute and a Pankey Scholar, an honor which has been conferred on less than 50 dentists in the world. He has been awarded Fellowship in the Academy of General Dentistry. A graduate of the University of Alabama School of Dentistry, he has practiced dentistry in Jupiter, FL since 1989. He is a certified member of the American Dental Association, Florida Dental Association, and former president of the North Palm Beach County Dental Association.

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Are You Communicating Brand Preferences to Your Team?

June 24, 2019 Lee Ann Brady DMD
There may be times when you see an unfamiliar brand of material on the tray before you. If you do notice, it’s likely because the brand of this particular material has come to matter to you.

You know the brand you prefer is predictably reliable, and you have worked with it a lot.

A while back, I went to take a Centric Relation bite record for a patient so we could fabricate an occlusal appliance. After I dried the upper teeth and reached for the bite registration silicone, I realized it was an unfamiliar material in the gun. While trying to complete the procedure, I rotated the gun to read the label. Sure enough, it was bite registration silicone, but not a brand I had used before.

After the procedure was completed and the patient dismissed, I found a few minutes to talk to my assistant that handles ordering. She has been very effective in managing supplies and an incredible team member. I started with a simple question that I hoped would not sound accusatory. “That was a new bite registration material I haven’t used before.” She was pleased to say the brand was less expensive and they were having a special, so it was even less expensive than usual.

Now many of you might think all bite registration silicone is created equally, and I learned my assistant thought so as well. Her cost-saving thought process works well for many for the things we use in the office where I don’t have a brand preference, such as 2 x 2 gauze. However, I do have a strong brand preference for bite registration silicone. They are not all the same hardness, and they do not all have the same set time or moisture tolerance. This was not the staff member’s fault because I had never communicated this to her.

This has prompted me to take a moment, sit with my staff and go through the materials we order and identify any other places where my preferences are very brand specific. While doing this, I explain why I have each preference.

From time to time, I try new materials and brands of materials, adopt some and reject others. My preferences change. Therefore, I offer this little story to remind myself and to suggest to others that we periodically review with our teams the brands we like, the ones we don’t like, and the ones we would like to try.

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Lee Ann Brady DMD

Dr. Lee Ann Brady is passionate about dentistry, her family and making a difference. She is a general dentist and owns a practice in Glendale, AZ limited to restorative dentistry. Lee’s passion for dental education began as a CE junkie herself, pursuing lots of advanced continuing education focused on Restorative and Occlusion. In 2005, she became a full time resident faculty member for The Pankey Institute, and was promoted to Clinical Director in 2006. Lee joined Spear Education as Executive VP of Education in the fall of 2008 to teach and coordinate the educational curriculum. In June of 2011, she left Spear Education, founded leeannbrady.com and joined the dental practice she now owns as an associate. Today, she teaches at dental meetings and study clubs both nationally and internationally, continues to write for dental journals and her website, sits on the editorial board of the Journal of Cosmetic Dentistry, Inside Dentistry and DentalTown Magazines and is the Director of Education for The Pankey Institute.

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Back on Track with “The Three Vs”

June 20, 2019 Robert Maguire, DDS, MASCL

Dentists in private practice face a myriad of uncomfortable problems that force us to find solutions or… S L O W L Y burn out. Do any of these resonate with you?

  • Ineffective marketing for attracting the type of new patients you need and want
  • Interpersonal problems among some team members
  • Difficulty budgeting for and incorporating new technology you want to embrace
  • Lack of energy to monitor your practice systems and staff
  • Insufficient time for yourself and your family
  • Overall fatigue

Hark, the Mind!

Often times, the problems we face in our practices are the result of our own “stinking thinking.”

I recently retired at age 60 after practicing for 28 years as a solo practitioner in Wolfeboro, NH. Over the years, I went through my fair share of issues but found a way to thrive with the influence of programs like The Pankey Institute and Dawson Academy. I focused on developing deep relationships with my patients and team. So, when I say your life and your practice will be more productive and fun when you live your life in alignment with your Values, your Vision, and your Voice, I speak from experience.

To makeover your “thinking,” you’ll need to engage you mind and consider these three Vs.

Values – Exercises 1-3

Values are the non-negotiables in our lives. These are the things that are most meaningful to us, things we would “go to the mat for.” They are personal and unique for each of us, for example, honesty, integrity, transparency, spending time with family, etc. Some practice values might include technical excellence, timeliness, cleanliness, appreciation, efficiency, scheduling sufficient time for conversations with patients, and fiscal responsibility.

So why are values so important? When violated, our personal and practice lives will be “out of whack.” Frustration, anger, helplessness, and despair are some emotions we might feel. So, start with Exercise 1.

  • Exercise 1. Take an inventory of your values. Make a list of what’s most important to you, as many as come to mind. Then choose your top ten and prioritize them. Once you know what’s most important to you, figure out the steps you need to take to make them a reality.
  • Exercise 2. Do Exercise 1 with your team. Have them each identify and prioritize their own personal values.
  • Exercise 3. Combine your findings and do the same exercise with your team to identify your shared practice values. This exercise alone will propel you and your team forward towards a more fun and productive workplace.

Vision – Exercise 4

Once you and your team know what you value the most, write out the vision for your dental practice. As you write out your practice vision statement, think about how you want to practice and what the ideal team member looks like. Think about your practice setting and how you want to relate to your patients. Get a clear picture in your mind, write it down, and then communicate it. You should be able to articulate it clearly and succinctly if someone asks you, “What is the vision for your practice?” Stating your practice vision should be as automatic as breathing.

Voice – Exercise 5

When you know who you are (your values) and how you want to live (your vision), your thinking changes­­–and with it your voice. Your words and actions will become authentic, intentional, and magnetic. Patients will be attracted to you and your staff because you are “the real deal.”

A “Magic” Process

The five steps to establishing your three Vs compose a highly effective process that bonds team members and clarifies a common direction for your team, as well as your office systems. Many times, we are tempted to evaluate and make changes in office systems when we are faced with problems. What I learned is that, as you strive for more happiness, more joy, and more financial success, looking at “The Three Vs” first, before looking at the office systems, is optimal. In my practice life, we took a fresh look at our three Vs frequently.

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Robert Maguire, DDS, MASCL

Dr. Maguire is a Navy Veteran who got his D.D.S. degree from Georgetown University School of Dentistry in 1984. He completed Bachelor of Arts at the University of New Hampshire in 1980 and Master of Arts Degree in Strategic Communication and Leadership at Seton Hall University in 2009. He was a former president of the New Hampshire Dental Society from 2014 to 2015. Dr. Maguire is a fellow in the International College of Dentists and the American College of Dentists. He is also a member of the American Dental Association and the New Hampshire Dental Society. Early in his career, Dr. Maguire became an avid student of both the Dawson Center and the Pankey Institute, completing all of their week-long continuums. It was the "Pankey Philosophy" that inspired him to continually develop his technical and communication skills. In addition to these credentials, he is also a certified trainer for the DISC Personality Assessment Tool. Dr. Maguire specializes in teaching others to be effective communicators (www.dynamicdentalcomm.com). Dr. Maguire recently retired at age 60 after practicing for 28 years as a solo practitioner in Wolfeboro, NH. He attributes his success to the deep relationships he made with his patients and team. His practice thrived without the influence of PPOs or Premiere programs with set fees.

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Creating Dental Anatomy in Composite with Disposable Tips

June 17, 2019 Lee Ann Brady DMD

One of my goals with composite restorations is to do as much of the forming and shaping prior to picking up a curing light as I can.

The material is easy to sculpt before it is cured, and access to the surface of the tooth is easier with hand instruments. Once I have placed all the composite and have a dense fill, I remove as much of the excess sitting above the final occlusal surface as I can. With this step accomplished, I turn my attention to creating the occlusal anatomy.

My OptraSculpt handle and disposable tips from Ivoclar Vivadent are perfect for this. The various tip shapes allow me to create incline planes, occlusal grooves and the curve of the marginal ridges into the occlusal embrasures. This process often removes and shapes the composite. My assistant holds a two by two that has been moistened with rubbing alcohol to remove the excess off the end of the instrument. I can place a different shape on each end of the instrument, or I can interchange them as I need them.

Using a series of disposable tips enables me to work without the composite sticking. This has reduced the necessity for meticulous management of expensive instruments which frequently need replacement. And, I resist the desire to use dentin adhesive or an unfilled resin on the instrument to reduce sticking.

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Lee Ann Brady DMD

Dr. Lee Ann Brady is passionate about dentistry, her family and making a difference. She is a general dentist and owns a practice in Glendale, AZ limited to restorative dentistry. Lee’s passion for dental education began as a CE junkie herself, pursuing lots of advanced continuing education focused on Restorative and Occlusion. In 2005, she became a full time resident faculty member for The Pankey Institute, and was promoted to Clinical Director in 2006. Lee joined Spear Education as Executive VP of Education in the fall of 2008 to teach and coordinate the educational curriculum. In June of 2011, she left Spear Education, founded leeannbrady.com and joined the dental practice she now owns as an associate. Today, she teaches at dental meetings and study clubs both nationally and internationally, continues to write for dental journals and her website, sits on the editorial board of the Journal of Cosmetic Dentistry, Inside Dentistry and DentalTown Magazines and is the Director of Education for The Pankey Institute.

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Quid Pro Quo

June 12, 2019 Paul Henny DDS

Like many aspiring students on a track toward dental school, I studied Latin with the hope that someday my understanding of Latin root word forms would translate into a greater value to me as a dentist.

That day never really came as an obvious epiphany, but rather as thousands of subtle moments later while reading, listening, or learning.

Not Your Standard Definition…

And it also came the day when that I started to attend The Pankey Institute and saw the tag line was “quid pro quo,” and it confused me. It confused me because all standard definitions of quid pro quo sound transactional – something is given or taken in return for something else, so it did not line up with the Institute’s preferred definition: “Give before receiving,” which has a much different tone…a much different intention.

Even today, due to my Latin training when I see “quid pro quo,” I have to stop myself and insert the Pankey definition when thinking about my profession. And I would argue that it is deeply important that we all do so, because viewing dentistry primarily as a transactional business is to devalue it down to a highly skilled trade. And this totally neglects the spiritual and more holistic aspects of our work which are the true source of joy, fulfillment, and meaning over long careers – a lesson Dr. Pankey routinely taught.

The Pankey Institute’s definition of quid pro quo is more aligned with words like Scott Peck’s “love” (selflessly giving to another with the sole agenda of helping them to grow and to become healthier and more fully functioning). The Institute’s definition is more aligned with trust and investing…investing in the sense that we believe that if we selflessly facilitate in others’ greater self-knowledge, self-understanding, and personal empowerment, they will reciprocate by gifting us an opportunity to help them achieve their goals.

What is the quid? What is the quo?

In other words, we offer our true and sincere caring as the “quid,” and if done in the right way, at the right time, with the right person we get the “quo” in return, as a reward experienced as a new trusting and deeply helpful relationship which yields respect, admiration, and appreciation in an ongoing fashion.

We get emotional confirmation in return. As dentists serving patients in our professional capacity, we get proper financial compensation in return as a SYMBOL of how much the person values the relationship and what it has brought into their life.

“Because I care.”

In a recent sermon, our minister said: “The summons for us as people of God…those who are called to be full of compassion, mercy, and love, is to live in such a way that people ask ‘Why’? Why do you feed me? Why do you clothe me? Why do you visit me when I am sick? Why do you do these things for me? And our response will be, simply, because I care…because I love you.”

Quid pro quo…THAT is what it means to me.

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Paul Henny DDS

Dr. Paul Henny maintains an esthetically-focused restorative practice in Roanoke, Virginia. Additionally, he has been a national speaker in dentistry, a visiting faculty member of the Pankey Institute, and visiting lecturer at the Jefferson College or Health Sciences. Dr. Henny has been a member of the Roanoke Valley Dental Society, The Academy of General Dentistry, The American College of Oral Implantology, The American Academy of Cosmetic Dentistry, and is a Fellow of the International Congress of Oral Implantology. He is Past President and co-founder of the Robert F. Barkley Dental Study Club.

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Your Patients Want to Know…Invisalign & Oral Health

June 10, 2019 Deborah Bush, MA
In the Pankey Institute’s Invisalign focus course, course leaders invite you to consider the ways in which Invisalign can be used to enhance what you do for patients on a daily basis.

One of the most significant benefits to be gained from Invisalign is achieving a more optimal environment for eliminating gum disease and maintaining periodontal health. Another is the preservation of natural tooth structure.

In my position as Director of Content for Patient Prism Academy (at www.patientprism.com), I work daily in helping dental teams communicate with their patients and prospective patients, and sometimes even among themselves. Knowledge translation is my strength. I’ve made it my business to know what patients want to know. The following information is provided in a form you can easily include in your treatment presentation when discussing dental alignment with your patients.

You know this, but I remind you here. The ideal candidate for aligner treatment is not limited to esthetic cases. Your patients who are battling gum inflammation and inflammatory diseases such as diabetes and CVD, or your patients whose teeth are worn, chipped, crazed, or perhaps even mobile, will be receptive to this particular discussion.

They Just Don’t Know

The ADA has told us that, although 75% of adults (80% of adults over age 65) have some form of gum disease, only 60% have any significant knowledge about it. It’s not surprising, then, that even fewer have an understanding of the association between their dental alignment and the health of their teeth, their dental alignment and the health of their supporting bone and gum tissue, and their dental alignment and their systemic health.

Your Patients Want to Know What Studies Have Shown

  • Gum disease has surpassed tooth decay as the leading cause of tooth loss.
  • Plaque accumulates more where teeth are crowded.
  • Where teeth are crowded, more types of harmful oral bacteria are present in the plaque below the gum line.
  • When teeth are crowded, there is increased risk for development of periodontal disease and tooth loss.
  • When teeth are crowded, there is increased risk for chronic gum inflammation.
  • Even low grade chronic inflammation harms periodontal tissues and systemic health.
  • Crowded teeth, in combination with any of the following, increases the patient’s risk of gum inflammation, periodontal disease, and systemic diseases:
    • Tobacco use
    • Diabetes
    • Heart disease

This is to say that, if more than one of these factors is present, the risk to health is even more.

  • Gum disease, chronic or acute, exacerbates (makes worse) cardiovascular disease and diabetes.
  • Poorly aligned upper and lower teeth put abnormal force on each other. Over time or suddenly, this abnormal stress wears down, chips, or creates cracks in precious dental enamel. The stress can also weaken root support, inflame periodontal ligaments and nerves, and result in loose teeth (teeth that wiggle).

Your Patients Also Want to Know

  • Battling gum inflammation, periodontal disease, and systemic disease can all become problematic due to crowded teeth. Until teeth are aligned properly, the personal cost can (will) grow in terms of the extent of treatment needed and the time and expense required for treatment to restore health and quality of life.
  • Additional benefits of Invisalign treatment will be a more esthetic smile and proper tooth spacing for restoration of damaged teeth (and replacement of missing teeth if one or more teeth are missing).

Feel free to copy any of this to an information sheet to utilize in your consultations. Because your patients view videos fed from YouTube via your social media, I encourage you to use these bullets to organize your thoughts to prepare a video presentation for patients.

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Deborah Bush, MA

Deb Bush is a freelance writer specializing in dentistry and a subject matter expert on the behavioral and technological changes occurring in dentistry. Before becoming a dental-focused freelance writer and analyst, she served as the Communications Manager for The Pankey Institute, the Communications Director and a grant writer for the national Preeclampsia Foundation, and the Content Manager for Patient Prism. She has co-authored and ghost-written books for dental authorities, and she currently writes for multiple dental brands which keeps her thumb on the pulse of trends in the industry.

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Which Type of Zirconia Do You Want?

June 5, 2019 Lee Ann Brady DMD

Most dentists think of zirconia as the highest strength, all-ceramic material that they can use to balance esthetics and durability.

It is the material we go to for patients with occlusal risk, for second molars at higher risk of fracture and for all-ceramic bridges.

You have likely heard of flexural strengths of 900-1,400 mPa being thrown around. While this is the flexural strength of a certain category of zirconia, you might not be aware there are different types.

Not all Zirconia has the same strength.

Because dentists have demanded manufacturers make versions that are more esthetic, some types are not as strong and durable as others. The general rule of thumb follows. The prettiest zirconia is the weakest. Conversely, the opaquest zirconia is the strongest. For example, the white opaque zirconia that visible as the substructure on the underside of a bridge is the highest strength and may have flexural strengths of 1,000-1,400 mPa. The other end of the spectrum is the highly esthetic materials we refer to as “translucent,” “crystal” or “esthetic” zirconia, and they may have flexural strength of 500-700 mPa. There is also a category of material with strengths in between.

Because there are many manufacturers and brands, you will want to be familiar with what your lab offers. Ask your lab what types of zirconia they can provide, and their specific strengths. Ask your lab how you should specify which zirconia to use for a given case. This, of course, will be determined by the esthetic and functional demands of the individual situation.

Some labs can note your preferences in their computer. For example, they can note that you always want the middle strength material for second molars, the highest strength for bridges and the prettiest material for premolars.

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Lee Ann Brady DMD

Dr. Lee Ann Brady is passionate about dentistry, her family and making a difference. She is a general dentist and owns a practice in Glendale, AZ limited to restorative dentistry. Lee’s passion for dental education began as a CE junkie herself, pursuing lots of advanced continuing education focused on Restorative and Occlusion. In 2005, she became a full time resident faculty member for The Pankey Institute, and was promoted to Clinical Director in 2006. Lee joined Spear Education as Executive VP of Education in the fall of 2008 to teach and coordinate the educational curriculum. In June of 2011, she left Spear Education, founded leeannbrady.com and joined the dental practice she now owns as an associate. Today, she teaches at dental meetings and study clubs both nationally and internationally, continues to write for dental journals and her website, sits on the editorial board of the Journal of Cosmetic Dentistry, Inside Dentistry and DentalTown Magazines and is the Director of Education for The Pankey Institute.

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The Economics of Great Communication — Part 2

June 3, 2019 Robert Maguire, DDS, MASCL

The steps I’m outlining here are not a list of transactional procedures. Rather, they are transformational life-changing concepts. My hope is that you will be as courageous and as excited to learn about how to be a better communicator as you are to learn about implants or smile design. If and when you do take the plunge, get ready to work hard and at the same time experience a more joyful and fulfilled life. Everyone in your life will benefit, and your practice will flourish. As I wrote in Part 1 of this blog, as a result of improved communication in my practice, an interesting thing happened regarding the practice income. Instead of “me chasing it, it chased me.”

Take a look at yourself with DISC Personality Assessment.

The first step to developing your communication skills is to take an up-front look at yourself. This can be a difficult step as you dive into investigating who you are and why you do the things that you do. One of the most beneficial things I did to help myself in this area was to take the DISC Personality Assessment. This detailed report helped me better understand myself, my personality style, and my motivation. Not only did it provide me with new information about myself, it gave me hope that yes, in fact, I could learn how to relate more effectively with others.

Gain insight into the personality styles of your team members.

Once I understood my personality style, I was then able to better connect with my team. I had each member of the team take the assessment to help them discover for themselves who they were and how they communicated with each other. This exercise proved to be an eye-opener for all of us.

This new personal insight was like an eyeglass prescription change. Instead of seeing each other’s faults, we were now able to more clearly see each other’s strengths and work together more harmoniously. Honesty, authenticity, and accountability became part of our daily lives. When conflict arose among us, instead of “burying it,” we resolved it.

As a team, we were able to see each other’s “uniqueness” rather than our “strangeness.” At this point, dentistry became more fun and productive; the practice income or “numbers” rose dramatically. Keep in mind that all this growth occurred before tackling the “transactional” details like appointment scheduling or collections.

Get to know and “connect” with your patients at a deeper level.

Next, we set out to better understand our patients: their needs, their wants, their fears, and their desires. We embraced the thoughts of Theodore Roosevelt who said, “People don’t care how much you know until they know how much you care.”

A few things we did to better connect with our patients included: being aware of our posture, our tone of voice, and the words we shared. We had training and developed our listening skills, asking more questions and talking less. Other changes we made included doing a thorough new patient exam and always keep the conversations focused on the patient. As Dale Carnegie would say, we became “interested” instead of being “interesting.”

Collectively, we agreed that we would not talk about ourselves unless the patient asked us. Additionally, we embraced the use of positive language. The phrase “no problem” was banned from the office.

Continually develop your “co-discovery” skills.

As a team, we committed ourselves to continuing education, seeking excellence in both our technical and communication skills. Our desire was to better understand the individual needs of each of our patients with the goal of helping them achieve optimal dental health.

We valued “helping our patients see what we were seeing.” We embraced the idea of “co-discovery” by asking thoughtful questions and involving them more in their dental examinations and treatment discussions. For example, we used the phrase “gum health measurements” instead of gum disease or gum pocket probing.”

We took intentional steps to make sure that our patients felt well cared for and well informed. We worked within our shared values that included timeliness, cleanliness, politeness, and technical excellence. “Inform before perform” and “quality is not a variable” became an important part of our practice culture. And when situations didn’t go as well as we had planned, we talked about it using AARs or “After Action Reviews,” a system developed by the U.S. Army.

Fine-tune systems after learning how best to work together.

Once we figured out who we were as individuals and how we could best work together as a team to serve our patients, we then started to delve into and fine-tune our systems. A sampling of some of the areas we developed included–patient greeting and check-out, telephone skills, collections, scheduling, morning huddles, staff meetings, job descriptions, and a personnel policy manual, to name a few. As we became better communicators, our office became a fun and more productive workplace. And as a side benefit, at the end of our work day, we had energy left to share with our families.

Let everyone know how much you care.

I’m asking you to be contrarian in your thinking. Instead of looking solely at the transactions of your practice, focus first on how you communicate with yourself and with others. And when you do, your life will never be the same. When you become a great communicator, everyone wins–you, your staff, your patients, your family, and your friends. And remember the quote from Theodore Roosevelt, “People don’t care how much you know until they know how much you care.”

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Robert Maguire, DDS, MASCL

Dr. Maguire is a Navy Veteran who got his D.D.S. degree from Georgetown University School of Dentistry in 1984. He completed Bachelor of Arts at the University of New Hampshire in 1980 and Master of Arts Degree in Strategic Communication and Leadership at Seton Hall University in 2009. He was a former president of the New Hampshire Dental Society from 2014 to 2015. Dr. Maguire is a fellow in the International College of Dentists and the American College of Dentists. He is also a member of the American Dental Association and the New Hampshire Dental Society. Early in his career, Dr. Maguire became an avid student of both the Dawson Center and the Pankey Institute, completing all of their week-long continuums. It was the "Pankey Philosophy" that inspired him to continually develop his technical and communication skills. In addition to these credentials, he is also a certified trainer for the DISC Personality Assessment Tool. Dr. Maguire specializes in teaching others to be effective communicators (www.dynamicdentalcomm.com). Dr. Maguire recently retired at age 60 after practicing for 28 years as a solo practitioner in Wolfeboro, NH. He attributes his success to the deep relationships he made with his patients and team. His practice thrived without the influence of PPOs or Premiere programs with set fees.

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