I was at the Ontario Dental Society meeting giving a presentation on occlusion, and I was asked one of the most common questions I receive when discussing anterior-only appliances: “What about tooth movement, either eruption or intrusion? Isn’t that a risk with these devices?” The answer is, yes there are risks, as with everything we do. Let’s consider the risks and how we can minimize and avoid them.

There are many types of anterior-only appliances, temporary and long term. Popular temporary anterior bite splint appliances are QuickSplint® and the Best-Bite™ Discluder from WhipMix®. NTI-tss Plus™ from NDX® National Dentex Labs is designed as a permanent anterior only and then there are the Kois Deprogrammer, Spear style deprogrammer, Lucia jigs, regular deprogrammers, Dawson B-Splints and so on. They are designed so that when the patient bites in MIP, they only touch on the front. When the patient goes into any excursive position (right, left, forward or back), they can only touch in the anterior—plastic to plastic or teeth to plastic.

We love anterior-only appliances because of their efficiency and effectiveness in eliminating posterior contact and allowing TMJ muscles to optimally relax. But we do worry about tooth movement, so how do we evaluate the risk and how do we minimize it?

There are a couple of pieces to this puzzle. We know that super eruption of the back teeth may occur if the appliance is worn more than ten hours a day, consistently over many days, even weeks, in a row. This means the risk is minimal with nighttime wear only for eight hours a night. Since we do not want patients to wear these types of appliances 24 hours a day, a patient in acute pain might be best helped with an anterior-only appliance for nighttime and a different type of appliance for daytime.

There is also a risk of lower tooth intrusion. There are two ways to deal with that. One is to make sure they have contact from canine to canine to distribute forces. Another is to make the upper anterior discluder against an appliance on the bottom that is called “a slider.” This is essentially a thicker version of an Essix retainer on the bottom to distribute the forces. I have made these appliances for many years and have not observed a problem in my own practice. I had one patient with significant deprogramming who could only touch on her first point of contact, but that was not due to tooth movement. It was because of total elimination of her masticatory muscle memory.

If you are concerned about tooth movement, I recommend making the upper discluder on a full arch Essix and then put the patient in a full arch lower Essix (lower slider) that will distribute the forces. That will prevent the problem of super eruption and should significantly minimize potential for intrusion, even though you only have midpoint contact. This is a great way to moderate the risks of tooth movement for patients who are going to wear an anterior-only appliance long term.

I would like to add, that any time you put a patient on appliance therapy, you need to see them for post-op appointments. You need to verify the appliance is working—that their signs and symptoms are going away or minimizing. And, you need to check their occlusion and mandibular position. So, I always plan multiple follow up appointments and include those in the appliance therapy fee. Even when the patient and I think everything is going great and they are wearing their appliance only at night long term, I ask them to bring their appliance to every Hygiene appointment for professional cleaning. This reminds us to ask how things are going with their appliance and gives me the opportunity to check their occlusion and make sure there are no negative consequences of the therapy. I also tell my patients to call if they notice any change in their bite. “We need to have you come in and check that right away.”

One of the greatest challenges of dentistry is developing a conceptual framework for how to approach complex cases. We leave dental school bright-eyed but unfamiliar with the personal and professional tools that help us get to know patient needs and provide optimal care over a lifetime.

Phased therapy is a skill that takes time to develop but creates the mental space to build relationships and techniques simultaneously. How do you follow through on a treatment plan over the course of many years, phasing out the process to improve the patient’s experience, your experience, and their ability to afford it?

Single tooth dentistry may seem simpler than a full mouth reconstruction, but it still poses its own set of challenges. You’ll be able to gain skills without requiring patients to commit to a heavy financial burden, but you’ll still need to manage esthetics and deal with unforeseen issues with occlusion.
A dental career is one marked by introspection that necessarily leads to improved patient care as you gain greater self-knowledge alongside technical skills. Here are 2 tips you can use to develop your love of both simple and complex cases, your long-term relationships with patients, and your passion for dentistry:

1. Approach Learning as a Layered Process

It’s easy to get hung up on technical prowess and let your communication skills or personal development suffer. The mountain of knowledge that exists in dentistry is formidable, especially the way it is presented early on in our dental educations.

But you don’t have to build Rome in a day. Start with single tooth dentistry so that you have time to learn the technical and behavior skills along the way that will build your confidence to tackle bigger cases.
Longevity in a career as physically and emotionally demanding as dentistry requires that we approach learning as a layered process. Each case deepens our understanding of how to evaluate and succeed at the next one. Along the way, we can find joy in each incremental improvement.

2. Build Trust Through Patience and Demonstrable Success

Nothing works without the patient’s trust and acceptance. They will be more likely to say yes to a simpler restorative case. What you’ll find is that as they get to know you and you get to know them, their willingness to engage in future dentistry will improve.

With patience, you’ll put in the work to improve their health and esthetics. The fruits of your labor will naturally result in greater trust.

Later this year, I’ll be hosting my course “Think Global, Work Local,” at Pankey Online. During this course, I’ll dive deeper into the concepts I’ve brought up here.

I’ll be covering three cases that stood out in my career, including the details on preparations, impressions, fee presentation, treatment planning, restorative care, and case results.

I can’t wait to see you there for this opportunity to dive into a Pankey-infused approach to learning over a lifetime!

When I think of the small things my practice does on an everyday basis that have a big impact on patient relationships, patient satisfaction, and case acceptance, the first thing that comes to mind is what we call check-in and debrief.

Early in my practice years, way back when I was practicing corporate dentistry, when I walked into the operatory, the patient already had topical in place and my job was to get them numb. There wasn’t much of an opportunity to have a conversation. Over time, I learned the concept of check-in and debrief, which is really about how you can use the time at the beginning and end of the appointment to influence the relationship you have with the patient.

These are ideal times to build value for what the patient has agreed to do at that appointment and to tie the goals of the patient to the value of the treatment the patient is receiving, or you hope the patient will accept.

Usually, the check-in and debrief each take about two minutes. My assistants participate in this process with me, so they have increased understanding as well.

Previous Conversations Inform Me

I can be mindful and successful with my conversations if previous conversations with the patient were documented. My assistants take notes for me during my conversations with patients. I need to know:

• What is important to them,
• What they are hoping for, and
• What could get in the way of accomplishing what they believe is best for themselves?

My Check-in Conversation

During the check-in, I aim to converse about what we have planned to do and how this fits the overall goals of the patient. Usually, I enter the room and there is a little chit-chat. Then I ask, “What is your understanding of what we are going to do today?” The response helps me gauge the patient’s awareness. Following this conversation, I may ask, “What is your understanding of how this is part of your long-term health plan?” Or, if the patient has a stated a good understanding of what we are going to do, I say, “Yes, and this is how it fits into your long-term goals for your teeth.” They should now have a good sense of why the appointment time is of benefit to them.

My Debrief Conversation

During the end-of-the-appointment conversation, I aim to thank the patient for being cooperative, talk about what they can expect as a result of today’s appointment, and what they can expect as we move towards their preferred future. No matter what happened during the appointment, I want my patients to hear how much we appreciate them being our patients and being there today. When we talk about what to expect from today’s appointment, we can go over any post-op instructions, which are also presented in written form. Lastly, I want to give them hope that we are accomplishing steps on the road to their preferred future and that we can get there with their continued cooperation. I want to see the rays of hope register on their faces.

I believe all of this is of high value to the patient personally and in building value for the practice. It is well worth the time, and for me, it is a standard part of every patient visit.

In 1999, I participated in the writing of a 500-word bio of Dr. Lindsey Dewey Pankey, Sr. for his posthumous induction in the Pierre Fauchard Academy International Hall of Fame. Although he was born over a century ago, his legacy has impacted many thousands of dentists and millions of patients.

Sharing this abridged bio with you 20 years later means that the asterisked number of dental professionals instructed by The Pankey Institute has greatly grown. Nevertheless, I offer this to you in its original words to make his abridged biography more widely known.

From the Pierre Fauchard Academy International Hall of Fame of Dentistry, 1999

Dr. L.D. Pankey, Sr. Was born on July 31, 1901. He received his Doctorate in Dental Surgery degree from the College of Dentistry at the University of Louisville, practiced in New Castle, Kentucky for one year, then relocated to Coral Gables, Florida, where he practiced dentistry until 1969. In 1932, he became a member of the Florida State Board of Dental Examiners and served 12 years, including his term as secretary and chairman. Concurrently, he was a member of the American Association of Dental Examiners, serving as Vice President in 1942 and President in 1943.

Throughout his professional career, Dr. Pankey was an essayist, lecturer, and student.

Having made presentations before countless local, state, national and international dental groups, he was best known for his seminars on “A Philosophy of the Practice of Dentistry.” In 1956, his Philosophy lectures were organized into three-day seminars. Subsequently, a curriculum was developed whereby practicing dentists would attend a series of once-a-year classes over a three-year period. In these classes, Dr. Pankey helped dentists find fulfillment through building relationships with patients about the benefits of optimal dental care. He helped his colleagues seek a balanced life. And he inspired them to do their personal best for every patient.

Dr. Pankey also developed a procedure for occlusal rehabilitation. In collaboration with Drs. Arvin W. Mann of Ft. Lauderdale, Florida, and Clyde H. Schuyler of New York city, he developed a teaching manual. In 1959, they began giving seminars, attracting dentists from throughout the United States and many other nations. Their occlusal rehabilitation procedures became known as the Pankey-Mann-Schuyler Technique (PMS). He was acknowledged by the dental profession for this work by being elected President of the American Prosthodontic Society.

Over 7,000 dentists attended the occlusal rehabilitation and philosophy classes taught by Dr. Pankey. The dentists who attended these classes formed the nucleus of support for establishing The L. D. Pankey Foundation, Inc., and creating “The L. D. Pankey Institute.” The Pankey Institute was the first advanced dental education organization of its kind in the world. It opened the doors to its first class in Miami, Florida in 1972. The curriculum was organized into what has become known as “The Continuum,” a series of one-week classes taken at a pace that is convenient and pertinent to the growth of the participant.

Well beyond simply honoring its namesake and continuing his teaching, The L. D. Pankey Dental Foundation, established a higher mission for dentistry “to bridge the gap between what is known and what is practiced.” Since 1972, The Pankey Institute has instructed over 17,000* dental professionals from many nations of the world, affecting the dental outcomes and well-being of millions of patients. Dr. L.D. Pankey, Sr. was deeply committed to the Institute’s success, participated in its development, and lectured at the Institute up until the time of his death in March of 1989.

Dentistry, our beloved profession, is better because of the man we recommend for induction. The Academy is privileged and honored to induct Dr. Lindsey Dewey Pankey, Sr., into the PFA International Hall of Fame of Dentistry.

Financial literacy is the foundation of our relationship with money, and it is a life-long journey of learning. The earlier we start, the better off we will be, because education is the key to success when it comes to money, and our financial life is likely to become more complicated as we get older.

Becoming financially literate involves learning and practicing a variety of skills related to budgeting, managing, and paying off debts, and understanding credit and investment choices. Personally, we have more energy around creating an effective spending plan, than a budget! Basic steps to improve our personal finances include creating a spending plan, keeping track of expenses, being diligent about timely payments, being prudent about saving money, periodically checking our credit report, and investing for our future. Financial literacy is the ability to understand and effectively use various financial skills, tools, and processes; including personal and business financial management, spending plan creation, and investing, while learning to live on less than we make!

We believe financial literacy is one of the most important things we can learn and help others learn, and the learning never ends. We believe the subject qualifies as a mandatory part of primary education. Yet presently, it is only a required course in public schools in just 17 states in the USA.

Given that college students graduate with an average of $32,000 in debt due to student loans and credit card debt, and on average, a graduating dentist in 2020 reported close to $300,000, in dental school debt (ADA).

Therefore, we believe, it is imperative that young people learn the basics of credit, debt, spending plans, saving, and investing before they face that burden. It is never too late to become financially literate, and the earlier we start, the better.

We are adding some basic financial literacy lessons into the intentional design of our coursework. Come join us and devote appropriate time and energy to really getting on top of personal and practice finances.

2021 Pankey Financial Course Offerings:

• Mastering Business Essentials (MBE) – April 29th – May 1st

• Creating More Financial Freedom – August 20th – 21st

In Seth Godin’s blog, he writes:

“In all markets, the market leader gets an unfair advantage. That’s because casual and unsophisticated customers choose the leader because it feels easier and safer. The strategy then, is not to wish and dream of becoming a big fish. The strategy is to pick a small enough pond. By engaging with the smallest viable audience, you gain the reputation and trust you need to move to ever bigger audiences.”

As dentists in private practice, attempting to be everything to everyone dilutes our value while it simultaneously puts us in direct competition with large DSOs and every other iteration of a business model that has deep pockets, the ability to survive big mistakes, and time on its side.

Instead, we need to know our strengths, make certain they match up well with our target audience, and then relentlessly become better and better at serving our target audience well. That is what L.D. Pankey, Bob Barkley, Peter Dawson, Frank Spear, John Kois, and many other dental leaders did.

None of these people pursued a business model which aspired towards a practice full of undiscriminating patients. Instead, they targeted a small market segment. That segment is composed of those who value improved health, appearance, and function. Avrom King called those folks the “values elite. They helped their market segment on a very high level, and by doing so, they created their future.

Many of us are successfully doing this still. That is how you compete against “the corporates”—you don’t.