When dentists are asked to use their imaginations to create a vision of the future, they usually see themselves as achieving their dreams, becoming successful and living the happy American dream. Using our imagination gives us a sense of control over our lives. I myself used the term “master of my own destiny” as my battle cry to create my practice philosophy. Was I accurate? Well, not to the degree I thought I would be. The old saying, “Man plans, and God laughs,” applies.

At the start of my career, I didn’t realize the effect that technology, the economy, advertising, and insurance would have on my plans. My definition of success at the start included words like accomplishment and achievement of a worthy goal. I learned the sense of well-being was to become an integral part of this.

Over four decades of practice, I learned that in order to live a life well-lived, certain components would be required. I could not have survived forty years if I had to go to work every day without the ingredients of a happy life.

The Ingredients of a Happy Life

The positive psychologists tell us that our well-being is dependent on five components. Dr. Martin Seligman, from the University of Pennsylvania, uses the acronym PERMA to describe these five.

P – Positive Emotion. For us to experience well-being, we need positive emotion in our lives. Any positive emotion such as peace, gratitude, satisfaction, pleasure, inspiration, hope, curiosity, or love falls into this category – and the message is that it’s really important to enjoy yourself in the here and now as long as the other elements of PERMA are in place.

E – Engagement. When we’re truly engaged in a situation, task, or project, we experience a state of flow. Time seems to stop, we lose our sense of self, and we concentrate intensely on the present. This feels really good! The more we experience this type of engagement, the more likely we are to experience well-being.

R – Positive Relations. As humans, we are “social beings,” and good relationships are core to our well-being. Time and again, we see that people who have meaningful, positive relationships with others are happier than those who do not. Relationships really do matter!

M – Meaning. Meaning comes from serving a cause bigger than ourselves. We all need meaning in our lives to have a sense of well-being. We need to create our own meaning with a sense of intent and purposefully design our own lives and practices accordingly.

A – Accomplishment/Achievement. Many of us strive to better ourselves in some way, whether we’re seeking to master a skill, achieve a valuable goal, or win in some competitive event. Flourishing in this way adds to the sense of wellness.

Happiness Is Subjective

All of the components together can be measured and hold the key to our well-being. Happiness, however, is about semantics. It’s about a subjective feeling.

Aristotle said it is “an expression of the soul in considered actions.” He called those actions virtues and said one could only measure the degree of happiness in a person’s life at the end of one’s life.

Freud said happiness can be found in lieben und arbiten—to love and to work.

And, Charles Schulz, the creator of the Peanuts cartoon said, “Happiness is a warm puppy.” In truth, we cannot completely describe happiness, but we all know when we are happy.

Because the state of happiness is a present tense phenomenon, I have chosen what will make us happy in the future by what makes us happy now. That is why I have chosen Martin Seligman’s definition of well-being as defined by PERMA as a guide to a sustainable career and a life well lived. All of the PERMA components of well-being — positive emotions, engaging work, positive relationships, meaningful work and achievement, can be built into our practices.

Why Is Happiness Like a Warm Puppy?

Having an experience or two a day of true connection with patients can make all the difference in being satisfied at work. This simple definition of happiness is a good way to measure how you are feeling about your chosen career and practice life, because, if in the present of your everyday practice life, you feel moments of warmth (like holding a warm puppy), you will hold up well against the difficult moments, and you will have a rewarding career in dentistry.

Capturing an exquisite final impression is our goal every time. Getting this result can be one of the most challenging things we do in dentistry. In addition to being masterful in taking an impression and handling the materials, we also must manage the oral environment properly.

Improving the Gingival Tissue Prior to the Impression Appointment

For crown and bridge impressions this process has to begin with optimal tissue management, and tissue management always begins before tooth preparation. Old restorations with poor margins often compromise hygiene with resultant irritated and inflamed gingival tissues. If the tissue is inflamed at the time, we recommend the tooth be crowned, we apply chlorhexidine varnish (Cervitec Plus – Ivoclar Vivadent). When the patient returns for impressions, tissue health is vastly improved.

Managing the Gingival Tissue for Tooth Preparation

Tooth preparation itself can result in difficulty managing the tissue. My preference is always to leave margins supragingival if that is clinically appropriate. My second choice is equigingival, where the margins are right at the crest of the tissue. If the margins are to be placed subgingival, I want to avoid cutting the tissue and then having to manage bleeding. If my initial margin placement is equigingival, I place a primary cord to move the tissue out of the way. This allows me to now drop the margin subgingival with minimal trauma to the tissue.

Retraction of the Gingival Tissue for the Impression

Once tooth preparation is complete, retraction creates a space for the impression material to go past the margin apically so that we can create the proper emergence profile of the restoration. There are many ways to retract prior to an impression. I personally use a second or top cord with a larger diameter than the primary cord I placed to move the tissue for subgingival preparation. If the tissue is bleeding after the placement of the top cord, I place 3M’s “Retraction paste” as a hemostatic agent. This allows for optimal control of bleeding without worry of negatively impacting the set of my impression materials or staining the prep or gingival tissues.

Taking the Final Impression

The final impression is taken with Flexitime impression material (Kulzer). I have my assistant load the tray with heavy body material. I first wet the top cord, so I do not cause bleeding upon removal. The area is now thoroughly dried to allow for proper contact of the impression material to the tooth and tissue surfaces. I inject Flexitime CorrectFlow (Kulzer) and then seat the impression tray. I hold the tray for the full intra-oral set time and do not allow patients to close or bite on the tray, as movement can negatively impact the accuracy of the impression.

Is the impression perfect?

Once removed I inspect the impression using magnification to assess that I have adequate flash beyond the margins of the light body, no pulls, voids, drags or evidence that the impression moved. There is no way to correct an impression for errors. If errors occur, we repeat the process from the beginning to take a new impression.

Check out some of my short videos about impressions on Restorative Nation at https://restorativenation.com/?s=impression.

Viktor Frankl believed the key to the successful creation of a happy and successful life was to aim toward a deeply significant and meaningful life purpose. On this, he commonly referenced Friedrich Nietzsche’s quote, “He who has a Why to live for can tolerate with almost any How.” Suffering is no fun, but suffering for a deeply significant purpose becomes much more tolerable when you know that the end will justify the means.

Loving Others

On love, Frankl said, “Love is the only way to grasp another human being in the innermost core of their personality. No one can become fully aware of every essence of another person unless they truly love them, because by love we are enabled to see the essential traits and features in the other person; and even more importantly, see that which is potential in them—that which is not yet actualized, but ought to be actualized.” So, this begs yet another challenging question: Do we love our patients enough to suffer with them, as well as help them to become more of what they are capable of becoming through our collaborative work in dentistry?

Finding Courage in the Face of Adversity

The practice of true relationship-based / health-centered dentistry represents a counter-cultural decision with regard to mainstream thinking and behavior, as corporate dentistry is rapidly moving the profession in the exact opposite direction. Consequently, dedicating oneself to a truly patient-centered philosophy requires courage, commitment, and perseverance. Additionally, one is likely to experience tepid local support for it, as most peers will be following a very different philosophy – a philosophy focused on what they want or need to get out of dentistry, and not what life expects of them. Regardless, the striving for a cause greater than oneself, allows us to experience more meaning in a month than most corporate dentists find over their entire career.

Regarding Success

Regarding the achievement of material success, Frankl wrote, “Don’t aim for it, because the more you aim at it and make it a target, the more you are going to miss it. For success, like happiness, cannot be pursued; it must ensue, and it only does so as the unintended side-effect of one’s dedication to a cause greater than oneself, or as a by-product of one’s surrender to a person other than oneself.”

Personal Meaning

As you can see, meaning and personal relevance can’t be bought, copied, or transferred. Rather, it’s an inside-out process which must be discovered within ourselves and then refined over time. If this is the kind of challenging, growth-oriented journey which motivates and inspires you, then The Pankey Institute represents the very best place to both begin it, as well as nurture it all along the way.

Viktor Frankl wrote his famous memoir, Man’s Search for Meaning, over a period of nine days in 1946, and it has become an indispensable meditation on the wisdom Frankl gleaned from his gruesome experience at Auschwitz. The horrific circumstances he faced – circumstances which caused many others to surrender their very will to live, caused Frankl to focus his energy on a pursuit of meaning. He sought to find a deep sense of personal relevance in the face of incomprehensible evil, helplessness, and hopelessness. This, in turn, led him to discover personal relevance could be found through the cultivation of:

· Purposeful work

· Developing a clarified, values-driven Vision and Goals

· The intentional loving of others

· Courage when confronted by extreme challenges

· Choosing not pursue material success, and instead, focus on allowing it to ensue

As we advance toward and through our purposeful work, as well as through loving others, we will inevitably be confronted by circumstances which require tremendous courage and perseverance. Frankl felt these situations – these periods of courageous suffering were key to our ability to progressively discover the deeper meanings to life and to positively change as a result of new realizations and perspectives. On this, Frankl commented, “Without suffering and death, human life cannot be complete.”

What Does Life Expect of Us?

During his time in Auschwitz, Frankl fundamentally changed his perspective toward living, as he observed that what he wanted from life didn’t matter in the grand scheme of things. Rather, what truly mattered was: What did life expect of him, and could he live up to it all, in spite of the horrible circumstances which surrounded him each and every day?

Purposeful Work

Trying to apply Viktor Frankl’s other-centric philosophy today requires us to turn the current egocentric culture on its head, as implementation begs even more potentially life-changing questions such as:

· Why am I here?

· What have I been called to do?

· How can I make sure I will be able to achieve it?

By sincerely answering these questions, it’s my hope you will discover, like Frankl, that your work in dentistry isn’t just about what you want from life; rather it’s about much more. It’s about a “calling” driven by your desire to significantly help others.

I believe that some wear is normal. I base this on the fact that I have very few if any patients who are in their seventies or eighties and still have mamelons on their incisors. Wear is a concern when the amount of tooth structure being lost is out pacing the patient’s age.

In Part 1 of this series, I wrote about determining when wear leaves the physiologic category and becomes something we need to discuss with patients. Both attrition and erosion can cause severe tooth wear, but they pose different long-term risks. Once we have a sense of the cause of tooth wear, we can partner with the patient to treat the damage and manage the progression.

These are the guidelines for discerning attrition from erosion.

Attrition is the loss of tooth structure caused when the patient rubs two tooth surfaces together. You will observe:

· Matching facets on upper and lower teeth

· Facets on tooth surfaces that occlude

· Enamel and dentin worn evenly

Erosion is caused by the presence of acid from issues like GERD and eating disorders. You will observe:

· Facets that may or may not match on upper and lower teeth

· Facets on tooth surfaces that are not in occlusion

· Dentin cupped out and wearing faster than enamel

· Tooth structure wearing around restorations that remain unchanged

Note that attrition can be seen in addition to erosion, often giving us a false sense of how much the patient truly parafunctions, as the etched tooth structure wears away more easily.

I ask the question “Is wear normal?” at almost every lecture I do on occlusion. Usually the response is a small number of mumbled replies. A good follow up question is “How many eighty-five-year-old patients have you seen with mamelons?” I hope you are thinking not many, if any at all. So, yes, tooth wear of some amount is normal. A combination of attrition, erosion and abrasion cause all of us to lose enamel over a lifetime.

Is the wear advancing at a pathological rate?

The more important question is when is the wear age-appropriate and when is it advancing at a pathologic rate? We don’t have the data to know how many millimeters of enamel loss is appropriate at every decade of life. In order to help with this answer in my office, I play a mental game. With the picture of the patient’s current wear in mind and a knowledge of their age, I imagine if the wear continues at the same rate at what age their teeth will be in jeopardy or need restorative dentistry to be saved. I then reveal this estimate to the patient.

You can document wear over time in three ways.

I believe it is important that I help my patients understand the process and the options for protecting their teeth. To quantify the amount of wear that is happening, we take a measurement from the CEJ to the incisal edge of several teeth with wear. We take the measurement on the mid-facial and record it on the patient’s perio chart. At subsequent appointments we can now repeat these measurements and have clear data that the process is continuing. Another great way to document tooth wear is with photography. With repeat photographs, we and the patient can see the change over time. Today with digital impressions and software we can scan the arch, and then compare scans months or years later and get a precise measurement of the change.

The Ancient Greek aphorism “Know Thyself” is one of the Delphic Maxims inscribed on the ancient Temple of Apollo. Dr. Pankey referenced this aphorism because self-awareness is key to our ability to stand apart from our patients and form healthy and effective interpersonal boundaries. This ability to “stand apart” greatly influences how we see our patients and the world that surrounds THEM. It not only affects our attitudes. It also affects our behaviors.

Lack of Self-Awareness Leads to Misinterpretation of Patient Behavior

Until we take into account how we see ourselves, we will be unable to understand how our patients see and feel about themselves and what the dental issues they are experiencing mean to them. This is because a lack of self-awareness causes us to function more on assumption than reality, and this in turn causes us to project our prospective onto our patient’s behavior and then fool ourselves into thinking that we are being objective. These assumption-laden relationships significantly limit our potential to positively influence and relate effectively with our patients. And this limited ability to relate to our patients on a deeper level easily leads to misunderstandings, the devaluing of recommendations, deferral to insurance companies, and even to open conflict.

Knowing Yourself Leads to Knowing Your Patient

Bob Barkley’s co-discovery method is the pathway to “knowing our patients” as well as allowing our patients, over time, to know us on a philosophical level. And it is the practice philosophy which moves people toward health or keeps them stalemated in dependency. Knowing yourself leads to knowing your patient which allows you to optimally apply your knowledge. And isn’t that your mission?

I’ll admit that for a portion of my professional career I didn’t think twice about occlusion.

Today occlusion is as well integrated into my thought process as caries, perio or restorative considerations. What role does occlusion play in your practice? Is it part of your routine diagnostics? Is it fully integrated with your esthetic and restorative treatment planning? Or do you only wonder about it when a patient breaks something or you are concerned about moving forward with a severe wear case?

Early in my career occlusion would show up as a frustration.

One example is when I would prepare a second molar being very careful about creating adequate occlusal clearance, using both depth-cutting burs and checking the result with bite registration, just to have my assistant come and tell me she didn’t have enough clearance to make the provisional. It was a relief years later in my first CE course with a focus on occlusion to learn this was not rapid super-eruption or a mistake on my part, but muscle release due to removal of a key occlusal contact, and I could predict this before I prepped the tooth.

How about the patient who would come into my office for a hygiene visit or a buccal pit restoration with no joint sounds and call the next day concerned that their jaw had been clicking ever since they left the office the day before? What a relief when I learned these patients had an underlying risk for disc displacement called ligament laxity, and I could diagnose it quickly at an exam appointment.

An everyday occlusal issue I run into is the patient with a limited opening who needs posterior dentistry.

Perhaps, they can open at the beginning but rapidly fatigue and their jaw begins to shake and close as we work. What a gift it is today that I can identify this as a symptom of overuse of the elevator muscles, treat it easily and quickly at a restorative appointment with a deprogrammer, and offer the patient options for relaxing their muscles and allowing them to stay healthy.

The process of demystifying occlusion and having it become an everyday reality for me required committing to a series of hands-on CE programs, being willing to manage my learning, and then taking it back to my patients and beginning to use what I was learning in small steady steps. The benefit has been less frustration, increased confidence with my patients, and an ability to help patients in new and profound ways I didn’t have before.

My appreciation for occlusion didn’t stop with my practice.

It became a passion and is a huge piece of the continuing education I teach with The Pankey Institute to demystify occlusion for others.

The original owner of our practice recently retired.

Although he had been planning on retiring and a new associate had been identified by both of us months in advance, this transition was very profound and stressful for the entire team. So, with a long term game plan in place, we began the transition between associates. It became evident that each individual within the practice was struggling with this change in their own unique way. Supporting others through change became my part-time passion.

While some team members were engaged in the process, no one was fully comfortable with the transition to this unknown “new practice.”

We had 1.5 years of an office atmosphere that was taking us to this destination with new team members that we did not fully know. We were wondering if it was going to be an office environment with which each person would want to identify. Thankfully, one of the values that binds us—education, came into play in a positive fashion.

In recent years, our team has attended continuing education together, locally.

However, it has been a long-time goal of mine to travel greater distances with the team. Coincidentally, The Pankey Institute unveiled the first Pankey Learning Group for hygienists. The effect that this had on my practice has been amazing thus far.

Although I offered the opportunity to the entire hygiene department, only one hygienist chose to attend.

She attends this learning group, and it has been meaningful to her personally and professionally. She has become highly engaged with her patients, and while leadership and gratitude had not been her most prominent attributes in the past, they certainly are now.

Upon her return, she begins to pull the rest of the team enthusiastically through this transition that embraces a new associate and has us enthusiastically embracing our new unknown. This one hygienist has been embedded in my leadership for twelve years, and now it turns out she has always been absorbing my vision and philosophy. She just needed a little bit of investment from me to become a leader within the team.

The value of having a team member learn, from the colleagues who have helped frame my personal and professional growth, has been priceless.

With more education planned for each of my team members at The Pankey Institute, I am thinking this will be the foundation for a cohesive group of similarly minded professionals working together to provide the best comprehensive dental care for our community.