Covid-19 is a true Black Swan event for everyone around the world. Suddenly all dentists are banned from practice, except for emergency care, for at least several weeks. We are all feeling the impact of this strange new virus. How we choose to respond will make a significant difference in the long term impact of this crisis on our lives and our practices. Here are some ideas and information that may be of some help. 

Stay Positive 

Yes, your office is closed, and your team members are not working. There is legislation in the works that will allow you to pay your team with funds from the government. Sit down with your team and reinforce that this situation will not go on forever. Life will return to a more normal scheme. You are not going out of business, and they will have a job.  

Tell the Truth

Most of your team are hourly workers and this is really scary for them. Be honest about what you can and cannot do for your staff. Communicate openly with your staff and patient base. Make sure patients have access to you or a designated team member 24/7 if they need urgent care. Prepare your office totally for the event of having to care for someone with proper protocols and all the needed PPE. Take time to discuss what is happening with your family. Since church will not be an option for the near future, this might be a good time for some family prayer time. This is an opportunity to grow together and support one another and to demonstrate and ask for accountability.  

Take Advantage of the Time Off

Are there projects that you have been putting off at home or the office? Could some of your team be doing a deep cleaning or re-organization at the office? Could you be setting up some additional team training that can be done within the parameters of safe spaces or by video? Doctor, how about taking advantage of some of the video and other CE at The Pankey Institute that is online? 

Collaborate with Your Peers

Pick up the phone and call your friends. Share the information from the IRS. It is a big deal for your bottom line. Discuss putting together some group events when you can gather again. If you know of someone who needs a helping hand or some cheering up, just do it. 

Look at the current situation as a learning experience in coping. Keep the big picture in mind. There may be lines in stores and some folks with a “me first” attitude about toilet paper. However, we have power, water and food. Let’s do what we need to do to get past this and move on. Stay safe, wash your hands and pay it forward. 

It may not be this week. It may be next before you have a practice continuation plan in place and have communicated fully with your team and patients. When you do find you have some time, I encourage you to sit back and think about everything you have experienced over the last month and what new learning you have discovered. Then reach out to colleagues and talk over your learning. Continue sharing with each other throughout this time of social distancing. 

I am mindful of a quote from Carl R. Rogers: “The true wonder of learning is discovering for yourself.”  

Starting out in my career, I felt well trained technically, yet I must have subtly believed I was a “hardware” salesperson. Or, maybe it had to do with my tendency to be introverted. Whatever the reason, I found it easier to talk “hardware and technique” than to listen well and then help patients clarify their health objectives and the benefits they were seeking in their dental health care experience.  

I went to a workshop led by Carl R. Rogers titled Client-Centered Therapy. This workshop was significantly different than any of my previous educational experiences. It was a participatory experience. It took some time for me to assimilate his educational concepts into my life and practice, and I noticed right off that I had retained more from a workshop experience and could apply my understanding of what I had learned. When I returned to my office, I attempted to create a participatory learning experience for my patients. I learned from these early attempts more about learning and witnessed behavioral changes in myself and my patients.  

I sought out many other workshops at this time in my life. One was Parent Effectiveness Training, facilitated by a local devotee of Dr. Thomas Gordon. Then, I became reacquainted with Dr. Karl Olson, the retired President of North Park University where I had done my undergraduate schooling prior to going to Northwestern University Dental School.  

Olson had joined forces with Bruce Larson and Heidi Frost of Faith-At-Work and created The Leadership Training Institute, which focused on discovering your leadership potential through three separate weeks of “experiential learning.” The first week was focused on Know Yourself, the second-week focus was Know Yourself in a Small Group, and the third-week experience was focused on Designing Small Group Experiences for Others. Each of these three weeks was separated by six months of intentional application and reflection, which created a powerful learning period of discovering myself.  

From my point of view, there is nothing more rewarding than a learning experience in which one can become aware of one’s own learning in “the moment” or upon reflection. So, now that you have been thrust into participating in Knowing Yourself, your practice, your team, and your patients on a new level where there is a concern for everyone’s safety and wellbeing on an elevated scale take time to reflect on what you learned in “special moments” of the past month.  

Are any of your discoveries blog-worthy to stay in communication with your patients? They will appreciate your personal “touch.” 

Making a comment in response to this blog is one way you can encourage a “continuing conversation” of Pankey participants’ “new awarenesses.” 

It used to be a challenge for me to help patients who came in with recurrent aphthous ulcers, lichen planus or erosive lichen planus, burning mouth, burning tongue, or geographic tongue that was uncomfortable. I’d worry about the pharmaceutical reactions of prescription options such as prednisone, steroid mouth rinses, and lidocaine rinses. Now, that challenge is greatly reduced due to the success we have had treating these problems with nonprescription topical antioxidants. 

There is a group of nonprescription topical antioxidant products that I rely on weekly from PerioSciences. These products not only promote healing but also provide significant relief from soft tissue pain, xerostomia, and burning sensations in the mouth. This is PerioSciences’ AO ProVantage line of mouthwashes, gel, and toothpaste. They are without a doubt the best products I have come across in my career for oral medicine applications. They were developed by dental scientists and other researchers and contain two antioxidants from the skin of apples. The products are marketed to help with a number of things in addition to oral wound healing, for example, to treat superficial gingivitis and to maintain patients who are at advanced risk of perio inflammation.  

In my practice, I have two patients who have chronic erosive lichen planus. We discovered that the application of the AO ProVantage gel to a lesion, four or more times a day, allows the body to heal the lesion. Within three to four weeks, the lesion is gone completely. After lesions are gone, my patients stop using the gel and start using AO ProRinse three to four times a day to prevent the outbreak of another erosive lesion. If they get another lesion, they go back to using the gel. The mouth rinse has reduced the number of outbreaks for these patients, and having these products on hand, has allowed my patients to successfully manage outbreaks on their own. 

I have lots of older patients who suffer with burning mouth or burning tongue. AO ProRinse mouth rinses have worked well for them. Some of my patients have severe dry mouth in association with the burning—some with Sjogren’s syndrome, some with Lupus disease. We start them on the hydrating formula of AO ProRinse, and they rinse their mouths four to six times a day with remarkable results. It’s also been of great value to my patients going through chemotherapy to keep their mouths hydrated and comfortable.  

The PerioSciences products are nonprescription and now readily available via Amazon. Once introduced to the products and given guidance, my patients have found it easy to determine when to start using the products and how often to use them. Topical antioxidants are just one more example of industry breakthroughs I am grateful to have in my clinical toolkit and widely available to patients.  

Emotions can flare up rather unexpectedly. When it comes to our patients, we need to have our antenna up and help them step out of their fight-or-flight mode and dial into a better perspective. 

True Story… 

Recently, I was in Lowe’s and in the “returns” line ahead of me was a man who was attempting to exchange a Sears socket head for his Craftsman socket wrench he had purchased years ago. (Lowe’s has an agreement with the makers of Craftsman tools now that the Sears empire has collapsed, and you can buy Craftsman tools at Lowe’s featuring the same lifetime warranty.) 

The man wanted to exchange his worn-out socket for a new one, in the way he had done in the past at Sears. The socket head likely costs less than $5.00. The dutiful Lowe’s staff started up their standard exchange routine, wherein they attempt to gather personal information so they can track inventory and justify the exchange. The man refused to cooperate and give any personal information. He just wanted an exchange with no questions asked and no receipt required.  

The pitch in his voice rose, as he said, “I’ve got tools older than I am, and I’ve never had to do this before. Are you trying to accuse me of stealing this socket head?” Those of us in the line looked at each other and started to wonder how this happened so fast over such a small item. 

The cashier wasn’t particularly masterful at managing the awkward event. He responded by coldly reciting the store policy. The man then grabbed his socket off the counter and said, “Just forget it. I won’t be buying all that lumber over there on that cart or shopping here ever again.” And then he stormed out.

Everyone working that morning just shrugged and acted as if it never happened, apparently quite adapted to this type of customer behavior. I went on and returned my item and then purchased a few other things, but I couldn’t help but think about what had just happened…why and how it might have been managed better. 

Where Did the Breakdown Occur? 

Oftentimes what we see isn’t what is driving the situation. I think the socket might have been a symbol to this man of the breakdown of his great relationship with Sears. In other words, his anger at Sears for abandoning him was displaced onto these Lowe’s employees.  

Our culture has become coldly transactional, and this was a clear symptom of it. We’ve all seen patients figuratively fly off the handle for small and insignificant things. Back in my insurance involvement days, people wanted to argue with us over having to pay a $5.00 copay. 

Most people who come into our offices are somewhat overwhelmed and over-stimulated, and it is easy for them to conflate and draw the wrong conclusions about what is happening around them. When this happens, we need to quickly help them relax enough to get what they came for.  

What Would You Say? 

I keep thinking about what the Lowe’s cashier could have said to make a difference. Perhaps, “Aren’t those Craftsman tools amazing? How long have you had this socket? Wow! And I’ll bet you use it all the time! We’re so fortunate to carry these amazing tools now that Sears has gone out of business! Can you help me out? My boss needs me to track the store inventory, even when we do exchanges like this. I know this is an inconvenience, but can you share with me your name in case you ever have a problem with this new one?”  

…Thinking on our feet while chairside can be difficult when caught by surprise. I’m grateful that in my relationship based mode of practice, I can amend my policies on the fly, so people come first.   

LuxaCrown is a new material that was released by DMG America last year. LuxaCrown is a dual cure composite material that comes in a convenient chair-side cartridge. Because it has the physical properties of composite, it is much stronger and longer lasting than bisacryl provisional material. The manufacturer says it can last in the oral environment up to five years, maybe longer. It is stain–resistant and color stable, so you can leave it in the mouth for long periods without concern that the color will change. I though it would be helpful to share the situations in which I now use LuxaCrown instead of a bisacryl material for provisionals. 

Multi-Unit Restorations 

In my own practice, I don’t use LuxaCrown for single crown preps where the provisional will be in the mouth for a couple of weeks, perhaps a month, or a little more. But, the strength of LuxaCrown and the color stability of this new composite material make it what I consider to be an incredible new clinical tool in my practice to provisionalize multiple units where there is pontic space. With LuxaCrown, I no longer need to reinforce the pontic with Ribbond or orthodontic wire. I don’t have to do anything to make sure we don’t get fracture at the connectors, because the material is strong enough and durable enough it to hold up, even long term.  

Anterior Veneers 

The other situation in which I use LuxaCrown routinely is with my shrink wrapped provisionals for anterior veneers. The strength of the material makes it more durable in a partial coverage anterior setting. And the color stability is appealing because the veneer may be in provisional for two months or three months, depending on how long it takes us to get patient approved provisionals for shape and contour that the patient really loves. Not having to worry about the color changing over time has been a huge bonus.  

Anterior Onlays 

Another situation in which I am using LuxaCrown is for partial coverage onlays in the posterior. So often we experience bisacryl onlay provisionals popping off the teeth, but LuxaCrown provisionals stay where you put them.    

Phased Dentistry 

And, I use LuxaCrown whenever I am phasing dentistry…when I am doing what I call “interim restorations” and the provisional restorations will be in the mouth multiple months before the patient receives ceramic restorations. Perhaps, the patient will be in provisionals six to 24 months while they go through orthodontics and we do final restorations in quadrants or even sextants of the mouth. Patients don’t mind having LuxaCrown in their mouths for long periods, because in addition to its stability, it polishes pristinely smooth and is glossy.   

We are bombarded weekly with ads for this or that course in “airway management” or “how to make money treating sleep apnea.” And, we are dealing with airway management every day whether we like it or not.  

Who has not had a patient come in with a worn dentition who claims, “Doc, I can’t ever remember grinding my teeth.” How about the patient who keeps fracturing restorations and says the same thing? You might want to question these folks or their partners about sleep habits. It is very likely you will find they are members of the population with some form of sleep-disordered breathing.  

Do you remember why we learned to fabricate and adjust bite splints?  

Have you had parents ask you about what it means when they can hear their young child grinding his or her teeth at night? Childhood bruxing is almost always a symptom of some sort of airway issue. What is happening in a child who presents with proclined incisors and an anterior tongue position? Do you think putting the child in headgear is going to solve the underlying reason the tongue has to be forward so they can breathe? 

We don’t have to treat all these issues, but we certainly should be able to communicate with our specialists and medical community for appropriate diagnosis and treatment of underlying issues that have a direct impact on the success or failure of our restorative care. 

The American Sleep Apnea Association estimates that 22 million Americans suffer from sleep apnea. Since we see our patient base, on average, two times a year, it makes sense that we should be doing at least a basic screening for sleep-disordered breathing. This can be anything from mild snoring to serious sleep apnea.  

Basic diagnostics would include paying attention to a person’s body mass index, neck size, asking whether they snore, and providing the Epworth sleepiness scale as part of your standard health history. Be aware that some folks with the worst sleep apnea or narcolepsy are not overweight. These are often the very fit appearing folks who are serious bruxers. 

If you really want to get involved in treating these people, you need to get more education.

Either at The Pankey Institute or somewhere that has a multi–day course. You need to commit to going into the process deeply, as there is much to learn and treatment is not simple. You will quickly learn that unless you develop great systems and team members, it is not an easy way to make money. However, you will be truly saving lives. 

If that does not sound right for you, commit to being a good diagnostician and develop an excellent referral network with some ENT doctors in your area. Most of these doctors are looking desperately for a dental colleague with whom they can discuss cases and develop treatments beyond just the use of CPAP. If you can refer just one child for early treatment each year and help prevent a heart attack or stroke for a person with undiagnosed sleep apnea, you will have done great service whether you get involved in active treatment or not. 

(more…)

After about ten years in practice, I had “one of those days” when I sat down at the end of the day and said to myself, “Is this what it’s going to be like for the next thirty years?” I was working hard, making money, and considered successful by my friends and peers. But, patients were not saying yes to the dentistry I was capable of delivering. 

I had a long talk one evening with Dr. Loren Miller while at The Pankey Institute. His parting comment stuck with me, “Son, it’s time for you to do some straight-line thinking.” I then realized that I needed to change if I wanted my patients to change. I needed to practice in a manner that allowed me to be happy and serve my patients well. In order to do that, I needed to define what I wanted out of my life – personally and professionally – and start living that life.

Starting Point 

Each of us will find our core philosophy in our own way, but you don’t have to reinvent the wheel to get there. There are many resources to help you get started. What follows is a list of ideas from Jim Rohn that I like as a starting point.

1. Set some key goals for life – personally and professionally. Then be like a sailor. No matter where the wind is blowing from, keep tacking toward the goals. 
2. Learn from both success and failure. Don’t take everything personally. Analyze when things go right and wrong, and learn from your mistakes. Success is a series of small steps toward your goals. 
3. Read. Reading requires concentration and focus. These are skills we need to find success. Reading allows you to learn from the experience of others. The brain functions differently when you are reading and writing than when you watch a YouTube video. 
4. Keep a journal or write a blog. Keep track of your path to clarifying your philosophy. You don’t really have a personal philosophy until you are able to explain it to your team and others. 
5. Practice the art of active listening. It is a learned skill that is valuable in your practice and your family. Surround yourself with people you admire. Observe and listen to them.  
6. Be disciplined. Every day is filled with a myriad of choices. We know the difference between good and bad options. It takes discipline to make good choices and stick to that path. 
7. Don’t neglect your personal and practice life. If you don’t take care of yourself, your relationships and your business no one else is going to do it for you.  

This all sounds similar to what L.D. Pankey wrote and said, doesn’t it? 

Moving to Fee for Service Care 

I had many mentors on my path to change: Avrom King, Sandy Roth and The Pankey Institute. It was neither quick nor easy, but these sources came together for me to help me have the courage to commit to change. That change was not driven by money. It was driven by the desire to help people willing to commit to seeking outcomes they desired that were within my capacity to facilitate. That may seem “fluffy,” but from a client perspective, it is a really big deal. We asked our clients to take ownership of their own health. If that was not within their capacity, we chose not to be involved in their care. Our philosophy evolved over several years and allowed me to move from insurance dependence to fee for service care. We called our practice an “outcomes-based” practice, thirty years later, and three years out from handing off my practice to my former partner, it is still a successful fee for service practice. 

Moving from insurance dependence or mixed dependence to a completely fee for service care takes commitment to a special kind of practice philosophy. The listed seven steps above can start you on the way to clarifying your own.