Few people have worked as tirelessly to advance the thinking of L.D. Pankey and Bob Barkley as Rich Green DDS, MBA. Recently, I ran across some of Rich’s quotes that truly capture the nature of his experience in dentistry.

A behaviorist’s definition of learning is changed behavior demonstrated. As my personal growth allowed, I relaxed and thought more about creating an experience in which my patients had the opportunity to learn something, which would challenge them to change behaviors that had negative impact on their life and health. The more I looked at those “learning moments,” the more they appeared. The learning occurred as I helped patients clarify what was most important to them and what they wanted to learn. As I facilitated a learning process with my patients, they were able to discover for themselves those two things, and then they were able to take their own steps in personal growth…People tend to support what they help to create.

Below Rich is speaking of his long-term work with Don Clifton and The Gallop Organization.

As we studied the uniqueness of individual private practices, one finding was the tendency of a dentist and team to unwittingly create barriers to the patient’s progress when what they really wanted was to create pathways to greater health. The barriers were typically caused by an impatient or judgmental attitude and the “teach and tell” method of attempting to change behavior.

In this last passage, Rich speaks to the central theme Bob Barkley taught across the country following the publication of his book, Successful Preventive Dental Practices. In the mid 1960’s, Bob worked closely with Nate Kohn Jr, PhD to dramatically reorganize how he interacted with his patients. In so doing, he largely abandoned what Rich refers to here as “teach and tell,” in lieu of what Bob called “CoDiscovery.” Because Nate Kohn, Jr. had his PhD in Educational Psychology, he exposed Bob to the latest thinking in learning science – and much of it had been influenced by the work of Carl Rogers, PhD.

It fascinates me that we can now go back and understand how all of this evolved, as well as why Bob chose to do things in a very specific way. Perhaps most important is how it all evolved through the hearts and missions of both Bob and Rich. And this last point is key, because if the motivation behind a person’s use of CoDiscovery doesn’t emanate from their heart, from a deeply sincere desire to help others grow and realize greater health through that growth, it won’t work. Instead, it will be perceived as being manipulative and thwart the desired outcome.

The “unwittingly created barriers” will block the passage of the relationship to the next interpersonal level — the level necessary to establish enough trust to proceed to the needed care. CoDisovery is an intentional practice, born out of a personal philosophy toward life and practice. This heartfelt way of interacting with others sometimes feels slow, but it is the fastest way I know to truly help others.

How long does a dental crown last? The answer is, “It depends.” In this blog, I will review how I manage answering this question for my own peace of mind and to reduce disappointment for my patients.

All of us can think about crowns that are currently in our patients’ mouths that have been in four decades or more…crowns that are doing fine. Sometimes, we look at a bite wing of one of these restored teeth and see space enough “to drive a truck” between the margin and the natural tooth structure. Yet, the crowned tooth is fine with no caries.

We also can think about crowns in our patients’ mouths that needed to be or now need to be replaced within five years or under…perhaps, even within two years. Some of these crowns were carefully and beautifully done.

We have a habit of thinking: The better our skill is, the greater is the longevity of the crown. We need to get away from this generalization because there are numerous factors that impact longevity.

Yes, the dentist’s skill is a factor as are the amount of time and energy we put into making it exquisite, the quality of the laboratory, and the materials. But the other part of the equation is that we put dentistry into the mouths of human beings, and human beings come with risk factors. The most common reason we replace a crown or filling is recurring caries. We see some patients who have new carious lesions every time we see them in the dental chair. They are at high risk. At the other end of the spectrum, we have patients who have not had a carious lesion in multiple decades. The functional risk of the patient is the second primary risk factor. We have patients who can break any type of crown, and we have other patients who have no evidence of functional risk.

What do I say to my patients? I tell them dentistry does not last forever, and there are challenges in predicting the lifespan of their restorations. I do not say, “When your crown fails at some point in the future, it will need dental treatment again.” Instead, I say, “We’re going to treat this tooth with a crown. At some time in the future, it will need treatment again.” Then I say, “The most common reason why a crown needs to be replaced is dental decay around and under the crown, and what we know about you is that you tend to get cavities [or not get cavities]. The second most common reason we replace crowns is that they break. The materials cannot withstand the forces. And what we know about you is that you are tougher on your teeth [or not as tough on your teeth] compared to many other people. “

This type of conversation makes most dentists nervous. They fear the patient will not want to do the crown if the patient knows they will eventually need to retreat the tooth. That has not been my experience. The reality that cars do not run forever does not stop us from buying a new car. The knowledge that your roof will last 10 to 14 years does not stop us from replacing the roof. The reality that the tooth will need retreatment in the future does not stop us from having it treated now.

Setting realistic expectations results in less patient frustration, sadness, and disappointment. It also lessens conflict between the dentist and patients. I want my patients to understand the reality that dentistry does not last forever. It all has a lifespan, just like a car or washing machine. Any tooth we treat will need to be treated again. I also want them to know their risk factors for decay or breakage relative to other patients. Is it high? Is it low? Is it somewhere in between? We can then have a conversation about what they can do and what we can do together to minimize those risk factors.

For years now, I have followed this simple reflective process. I hope it proves to be helpful for you in your personal and professional growth. My reflection BAG contains Blessings, Accomplishments, and Goals. 

Blessings  

List all the blessings you are grateful for; family, friends, satisfying work, freedom to worship, health, warm home, living in America, etc. Give thanks for the blessings of life. Gratitude is essential to the journey, and too frequently in our “push” to “get ahead”, we forget our core blessings. Compared to these Blessings, getting ahead isn’t the most important thing. INVOLVE YOUR FAMILY THIS YEAR…even your two-year-old will feel the gratitude. 

Accomplishments 

Summarize all things you accomplished throughout the year. This is such an important step to write down because it never ceases to amaze me, when I reflect, just how much I have accomplished. I always need my calendar for this one because I find I forget all the little things I did do throughout the year. The journey can be so (apparently) slow and frustrating, that seeing how far you progress each year is very important. 

Goals 

Now that you are grateful for the mess you have gotten yourself into, write down your goals for the coming year. Come up with 20-30-50 ideas. Many times, the “best” ones are the last few that pop into your head. Remember the Pankey Cross and plan in all areas, Work, Love, Play, and Worship. Know Yourself, Know Your Patient, Know Your Work, and Apply Your Knowledge (this is a part of that). Spend as much (or more) time and money on the behavioral - communication aspects of care as you do the technical aspects of dental care. Plan to integrate Joy, Wonder and Relationships into your work. 

Set Aside Quiet Time to Reflect

Please set aside quiet time to do this. The first time it may take several struggling hours. I reflect several times a year and still set aside a few hours, but it has become almost like meditation for me and is one of the most important things I do for myself. I do this to continually refocus my efforts and to enhance gratitude. This has become part of my personal Peace process.

Thinking Beats Regurgitation

Throughout our education process we dentists are taught to memorize and regurgitate…not to reflect nor to think (I believe, at times, thinking is beaten out of us). We look to others to provide us the “answers” we might be missing that will guarantee our passing the tests (success). Sometimes we glance at someone else’s success and, thus, we let others define success for us — and we all are obsessive enough to bust our butts for an “A” to please someone else. If we just miss being perfect, we feel like such a failure. And for those of you paralyzed by needing to be perfect…Perfection is a disease. The goal is excellence, not perfection. John Wooden said it best:

“Success is the self-satisfaction in knowing you did your best.”

I bet many of us feel like we are living in a movie these days.  I’m sure you have compared this pandemic to any number of movies. The first movie that comes to mind is  Jaws. In that movie, everyone wanted to know when it will be safe to go back into the water. And now, forty-five years later, people are asking a similar question: Is it safe to go back to the dentist?

Let’s explore the parallels.

The year Jaws came out, 1975, I was serving as a Captain in the Dental Corps at Ft. Dix N.J. During my time there I came down with Hepatitis B. I became infected from working on a patient…without gloves. Remember kiddies, this was 1975…there were no rules. It was The Wild Wild West in health care. As we all know, hepatitis is caused by a blood-borne pathogen. I became quite jaundiced and severely ill. I spent two weeks in the hospital. I started feeling better after one month.

I felt good enough to go back to work, but the U.S. Army had other plans. I couldn’t go back into the clinic until my liver enzymes were back to normal. I was tested frequently not only by the military, but also by the county Board of Health. I remember how diligent they were about the testing. They were serious…I couldn’t go back to work until I was cleared. That was mostly to protect anyone I would come into contact with. I was a known carrier, unlike the infamous Typhoid Mary who carried her disease covertly. I’m sure the public was grateful that the government was acting so responsibly. Like today, the public health department’s job is to protect the public. That trust must exist for us to function as a society.

Fast forward to 1981. I was practicing full-time in my own private practice when the AIDs epidemic arrived in the U.S. By then I had learned my lesson and I was one of a small number of dentists who wore gloves on a routine basis. But I was in the minority. AIDs changed our entire profession. By the time it was over (if it ever truly was over) the life of every dentist changed forever. This time around I learned how serious government could be in enforcing public health regulations. They meant what they said. (For those who are interested look up the case of Kimberly Bergalis). This was a classic example of the combination of bloodborne pathogens and dentistry.

One thing I noticed during that period was the public awareness of dental practices and sterilization techniques. AIDS changed everything. It wasn’t the isolated patient who wanted to see how instruments were being sterilized. Many people stayed away during the height of the crisis. In time the fear eased up but not before more stringent rules and regulations were enforced. And once again the public was grateful.

Now… almost 40 years after AIDS we have a new pathogen – the coronavirus– Covid-19. The biggest difference is that this one is an airborne pathogen. And that makes all the difference in the world. Fear is ubiquitous. There is a new shark in the water. Like Typhoid Mary, it does not show its fin.

Safety is a big concern for most humans.

Behavioral psychologist Abraham Maslow formulated the Hierarchy of Needs. At the very base of the Hierarchy are physiologic needs like food and sleep followed by safety and security needs. His theory stated that people would not seek satisfaction of higher needs (love, belonging, self-actualization), until the basic needs were met.

Forty-five years after Jaws roamed the ocean it is generally safe to go back into the water, but rest assured, we do know one thing… there will always be new and more dangerous sharks to worry about, and when it comes to humans, safety is a basic need after food and sleep.

Patients have been deciding on the essential nature of dentistry forever.

As long as fear remains and people do not have the absolute certainty of safety, they will not return to dental offices except for services they perceive as essential. If your client base is full of people who are truly health-centered and trust you, your routine dental services will thrive in the pandemic. Your patients won’t wait until they are in pain to book an appointment.

But that’s the test of what you are all about, isn’t it?

If your routine services are not thriving, then your practice has had a history of attracting a broader market of people. How is that working out for you now? Beyond COVID-19, if you are in private practice, pay extra attention to targeting individuals who want the finest health and give them ample reason to trust their safety with you… no matter what.

Ferrule is a critical factor in being able to plan the prosthodontic phase of treatment for an anterior tooth that has had endodontic therapy. It is also an ingredient in predicting the longevity of the tooth and restoration. Yet, given this level of importance, it is often misunderstood and overlooked.

What is tooth ferrule?

Ferrule is the amount of natural tooth structure we have left on an anterior tooth on which we are going to do a post-core and crown. Knowing the amount is integral to knowing how we are going to seat the crown and it gives us ballpark information about the longevity of that restoration. We look at the natural tooth structure of the tooth on the buccal and the lingual.

The amounts of the natural tooth that are left on the mesial and distal don’t matter. We don’t measure them. They don’t help us at all with retention and longevity.

On the buccal and lingual, we look at the height of the natural tooth structure, measuring from the margin of the crown prep up to where the core starts. We also look at the thickness of that natural tooth structure, measuring from the outside surface of the crown prep to the inner surface where the post space begins. We measure the height and thickness, both buccal and lingual. We then use the smallest number. If we have less tooth structure on the lingual, then the ferrule is determined on the lingual. If we have less thickness than we have height, then the ferrule is determined by the thickness.

Wherever the place is where we have the least natural tooth structure, that now becomes the ferrule we use when we start to think about how we are going to treat this natural anterior tooth.

How does ferrule impact restorative decisions?

The amount of ferrule impacts restorative decisions such as:

• Bonding versus cementing the post
• Bonding versus cementing the crown
• Doing a post at all
• Predicting longevity after restoration

Guidance for these decisions has been formed from substantial research published by the University of Washington School of Dentistry in Seattle that looks at the longevity of the post-core based on the amount of ferrule and whether we bond or cement.

If we have minimum ferrule (1.0 to 2.0 mm) and we want to get the maximum longevity for the anterior restoration, we should bond the post-core and then bond the crown with a dual-cure resin bond system that adds strength to the restorative material, like NX3 Nexus™ Dual Cure from Kerr, Multilink® Automix from Ivoclar Vivadent, or G-CEM LinkForce® from GC America. There are lots of choices of systems you can use, but we need to etch, prime, and bond for high bond strength. We need to keep in mind that even though we are increasing the longevity of the restoration by bonding, the restoration on minimal ferrule will not last as long as a restoration on a greater amount of ferrule.

If we have 2.0 to 3.0 mm of ferrule, we can choose whether to bond the post-core and cement the crown or to cement the post-core and bond the crown to get the same longevity as the tooth with 1.0 to 2.0 mm of ferrule treated by bonding both the post-core and crown. When we have 2.0 to 3.0 mm of ferrule, we can increase the longevity of the restoration even more if we bond both the post-core and crown.

If we have greater than 3.0 mm ferrule, we can cement both pieces without affecting longevity.

If we have 4.0 mm or greater of ferrule, the question becomes whether we need to do a post-core on this tooth or do a fully bonded restoration.

Key Points to Remember

• The amount of ferrule we have has a strong impact on the longevity of the restoration.
• We can increase the longevity when we have less ferrule by bonding both pieces, the post-core, and the crown.
• When we have very little ferrule, we need to understand that we have a reduced longevity for the post-core restoration, even in the face of bonding.
• The amount of ferrule is one of the strongest indicators of how long an anterior crown will last, as well as whether we have bonded or cemented. How long a crown will last involves additional factors I will discuss in another blog, How Long Do Crowns Last?