This blog is a precursor for the long lecture I will do on this topic at the 2021 Pankey Symposium.

Over the last decade, there have been major changes in how we do things in our laboratory (Niche Dental Studio), but from small cases to full mouth and hybrid cases, traditional Prosthodontic protocols still guide everything we do. These foundational processes provide a structural/philosophical approach for all our cases.

It’s a philosophical approach to diagnosis and treatment that you have been learning in your Pankey Institute courses. It’s an approach that extends from your dental practice into our lab, so our lab becomes part of your practice.

What are the key principles of this philosophy or approach?

• We will use optimal diagnostic protocols, communication, technology and methods to deliver custom prostheses as efficiently as possible while not compromising on the quality of the products.
• We will do our best to deliver products that meet or exceed your expectations for optimal function, comfort, and natural esthetics.

Here are some of the things that we do the same and some we do differently than we did ten years ago.

Feldspathic ceramics still produce the most natural appearance.

In the past everything we made was made by hand, and it was the prosthodontic protocols of this handwork that enabled us to have success using CADCAM technology today. And while today’s CADCAM dentistry is great, it does not replicate the results of restorations made by hand. A machine can’t mill “infinity margins.” Monolithic materials used in milling do not contain multiple levels of opacity.

To blend perfectly with Nature, restorations must still be made by hand, and in our laboratory, feldspathic veneers are still our “go to” type of restoration for central incisors. Layered feldspathic ceramics not only look the best but also are the best for marginal integrity. The restoration on number 8 below is an example.

For fit and finish, these types of anterior restorations are still the prosthodontic foundation of our Niche Dental Studio.

We still aim to replicate natural teeth.

Another foundational attribute of prosthodontic protocols is to replicate nature. Part of our success has been how much time and effort we have put into studying natural teeth and helping Pankey Institute trained dentists distinguish themselves by using restorations that are exquisitely made to appear natural and blend in the patient’s smile.

Today’s patients desire natural esthetics once they understand the elements of what makes teeth appear natural. If a patient seems stuck on a cosmetic dentistry meme of the past and requests whiter, brighter, straight teeth that will not blend in their smile, a conversation with your patient that illustrates tooth, smile, and facial esthetics will be appreciated by your patient and distinguish you as a caring, exacting dentist.

To create restorations that appear natural and don’t “jump out,” we do the following things:

• Increase the “value” of the color but not enough to create harsh contrast.
• Play with the levels of the incisal embrasures and the translucency.

These prosthodontic protocols can be implemented by you, too, while doing composite build-ups.

We use new technology to optimize communication.

From the ceramist’s perspective, I don’t want to see just close-up images of teeth. I want to see the patient. For many of our cases, we see the patient in our lab. Local patients come in for a consultation. We consult with other patients via Skype or Facetime. Seeing the entire smile, the entire face in natural interaction, aids us in doing our best.

 Modern 3D technology has changed how labs communicate visually with doctors and their patients. We’re constantly sending 3D screen shots back and forth with our doctors so they can check out the design and show them to a patient. An image like this one is confusing to patients. So, we’ve been able to integrate those screen shots into a photo of the patient to create a virtual image the patient grasps more easily.

CAD technology allows us to work more efficiently, but we still hand-finish restorations.

In our laboratory, we mill a lot of lithium disilicate crowns for clients. Prior to milling the lithium disilicate, we like to mill the restorations in wax. The milling quickly does 80% of the model creation and gives us the opportunity to hand finish the other 20% as we traditionally would. We can now put all our esthetic and creative efforts into finishing the case. We also mill temporary restorations from IOS data without hand modifying them.

Using IOS and CAD has made the lives of our clients much easier. For example, in the past, with full mouth cases, we did a lot of wax-ups when raising verticals. The doctors found working with matrixes too time consuming. They preferred working with eggshells and would reline them. Little problems would creep in when seating these eggshells. Perhaps, the cant was a little off or the vertical wasn’t raised accurately. With 3D imaging, it is far easier, because now we can do our full mouth wax-ups, scan them, and print the eggshells from scans with full palatal rest and retro-molar rest. There is now only one definitive way to seat the eggshells.

This is just a taste. There is so much to share.

To see how we do actual cases, in detail, go to the free Pankey Webinar: Prosthodontic Protocols for the Modern Dental Team. There you will see how our modernized approach, guided by traditional prosthodontic processes, becomes an extension of your treatment goals. I look forward to sharing more with you at the 2021 Pankey Symposium.

According to a recent survey released by the John Templeton Foundation, people are less likely to feel or express gratitude at work than any other place. And their feeling of appreciation toward their current jobs, ranked dead last on their list of things they are most grateful for.

Oddly, this outcome isn’t because people don’t crave receiving gratitude at work. Ninety-three percent of those surveyed agreed that their bosses are more likely to succeed if they expressed gratitude more often, and only 18 percent thought that expressing gratitude made their bosses “weak,” or hurt the organization. Additionally, the majority surveyed reported that hearing “thank you” from others at work made them feel better about themselves and more motivated.

So, What Gives?

Why is something which is so obviously appreciated and helpful so frequently withheld? Why do Americans actively suppress gratitude at work, even to the point of robbing themselves of happiness and all its benefits?

The answer lies within the nature of our “reptilian” brain which lies buried underneath or logical neocortex. Our brainstem, midbrain, and limbic system are constantly surveying the environment to determine if we are safe as well as where we are within our tribe social status-wise, as well as how our tribe ranks relative to other tribes.

As a result, we are slow to give support and appreciation to others because it might change the organization of our social structure in such a way that we might personally lose out. Another way of saying this is that we are all built on a neurobiological level to be inherently selfish.

Overcoming Our Silence

The role of gratitude in dental practice should be a positive, intentional one that makes every single care team member feel values. When they feel good about themselves and their contributions, performance will rise. To this end, we must consciously work at overcoming our tendency to remain silent and ignore other people’s contributions and exceptional performances. And how can we do this?

1. Make gratitude part of your practice culture from the top down. One of the biggest takeaways from research on workplace gratitude is that your care team needs to hear “thank you” from the doctor regularly. This is because it’s up to the people with the most social, political, and financial power to clearly, consistently, and authentically thank, in both public and private settings, those who have helped their status. In other words, we need to lift everyone else around us. Rising tides should lift all boats.
2. Gratitude should also be built into your performance reviews and staff meetings, where time can be allocated for each person to say “thanks” to others on the team for being thoughtful and pitching-in at critical moments.
3. Thank those who seem to never get thanked. Thanking those who do important, but easy-to-take-for-granted work is key. Your office cleaning crew, your UPS delivery person, the mailman, your accountant… You get the picture. These simple gestures improve morale and increase trust, and therefore increase performance.
4. Aim for quality thankfulness, not quantity. Forcing your team to be grateful to one another won’t work if they’re harboring resentment and other unresolved issues which remain untouched. Hence, forcing gratefulness as a strategy is not “cultural,” its superficial and doesn’t work. Instead, it can feed upon the power imbalances which undermine gratitude in the first place, and therefore make expressions of gratitude feel inauthentic.

The key is to create times and spaces that foster the voluntary, spontaneous expression of gratitude such as morning huddles and regular team development meetings.

Many of you are already doing these things, but are you doing them frequently enough and with the right intentions?

Before I come up with a treatment plan, I always do certain things in a certain order. That structure has allowed me to feel confident that I can treatment plan any case that walks into my office. That structure, or process, affects how I approach my exam, make my diagnosis, and ultimately make my treatment plan.

The process begins by looking at the following five areas during the patient exam. I gather information in each of these areas in the following order:

1. The patient parameters of the case
2. The aesthetic parameters of the case
3. The functional parameters of the case
4. The restorative parameters of the case
5. The biologic parameters of the case

The first area I look at is the patient. What is the patient interested in? What are the patient’s circumstances, temperament, and dental health objectives? What is the patient’s current understanding of their dental health? How does that compare to my perception of their dental health? After answering these questions, I then move on to the four technical areas.

The first technical area I look at is the aesthetics of the teeth, gingiva, skeletal structure, and face. I then look at function, including the jaw joints, muscles, occlusion, and airway. The third area I look at is the restorative parameters of tooth structure, missing teeth, and the restorative materials and restorative techniques previously used in the mouth. And finally, I look at the biologic parameters, including caries, periodontal, and endo.

When I do my examination, I want information gathered in all five of these areas. When I sit down to do my exam diagnosis and treatment planning, I have all of that information in front of me and I’m going to always consider the five areas in the same order as I proceed with diagnosis and begin treatment planning.

When I plan the stages of treatment that will occur, the treatment sequence is in the order that is most appropriate for the case. For example, if the patient has a biologic health condition, perhaps, the need for a root canal or significant perio inflammation, I’m going to treat that condition at the front end of the treatment sequence, and not in the order in which I gathered information and reviewed it. The most appropriate treatment sequence will be the order in which I need to do restorative procedures to most predictably achieve the total best outcome.

Although my “structured approach” may not be the same as yours, I thought sharing mine with you could be of benefit to you. By establishing a process in which you gather and consider information in all five areas (Patient, Aesthetics, Function, Restorative, and Biologic), you will have all the information you need to consistently do diagnosis and treatment planning with efficiency and confidence.

For more information on this topic, I encourage you to take Treatment Planning and Case Presentation with me on June 11th – June 12th. This is a phenomenal way to solidify your knowledge and spend two days in sunny Key Biscayne, FL.

Most people who seek help for a sleep breathing disorder like snoring or sleep apnea are diagnosed by a sleep doctor and given a pressure mask, or CPAP. Millions of these are sold every year. For World Sleep Day 2021, Phillips, one of the two biggest CPAP manufacturers, surveyed 13,000 people in 13 countries around the world. Of the people who were prescribed CPAP, only 18% of them were using it. Of the people who were at risk, 27% said they would not take a sleep test because they did not want a CPAP.

It gets worse. The US Agency for Healthcare Research and Quality released a draft report about the use of CPAP for obstructive sleep apnea that concludes there is low evidence that CPAP has any long-term positive health effects. Any such report is debatable, but it is clear that CPAP is not the universal therapy that cures everyone some physicians believe it is.

The reasons people won’t use the simple device that helps them feel better during the day and, as far as they’ve been told, helps them live longer, healthier lives are as varied as any group of people can be. Common reasons they tell me include:

• I can’t stand anything on my face.
• The mask moves around and blows air into my eyes.
• I swallow air.
• It leaves marks on my face. (More of a problem when people actually went to work!)
• My spouse hates it.
• I want to travel, camp, RV, boat, etc., and it’s too inconvenient.

It is a wonderful time to be a dentist involved in airway therapy – providing good solutions to manage and resolve your patient’s sleep breathing problems. Oral appliances are better accepted by patients in every head-to-head study that has ever been done. While many people go to bed with their CPAP on, by morning, it’s off. Oral appliances are still in their mouths. Research points out that many hours of therapy is better than fewer hours of it, so the health effects are the same.

How do you talk with your patients about their therapy? It isn’t productive to bash CPAP – believe me, they’ll do that themselves. I tell people I love CPAP – when it is used, it’s great. CPAP is the treatment of choice for my father and brother. As you scan through your patient population with questions about sleep and breathing (you are using a screener, right?) you will find plenty of folks who want a CPAP alternative.

If you want to be a provider of oral appliance therapy, there is much to learn. The device portion is straightforward, but there are medical concerns, TMJ joint issues, finance, and office systems to sort out. The challenge is well worth the effort, of course. Dr. Pankey always puts rewards at the center of the philosophy. Nothing I’ve done in dentistry is more rewarding than helping people breathe.

Not every dentist will foray into providing dental sleep medicine but becoming well informed and adding airway conversations to your consultations will impact the lives of many. If you would like to dive deeper and develop your knowledge about dental sleep medicine and learn about the realities of introducing it into your practice, I recommend the Pankey Institute’s 5-day immersive Dental Sleep Medicine course.

When I speak with dentists who have dipped their toe in the waters of treating obstructive sleep apnea (OSA) in their practice, the number one reason they say they quit doing it or are not doing more is …

“I couldn’t get paid!”

You may be committed to helping patients achieve better health through treatment of OSA, but it’s challenging to make it financially possible. Here are three tips that will make dental billing for obstructive sleep apnea more consistent and predictable:

Use Practice Management Software to Simplify Dental Insurance

Understanding how to succeed in the complicated system of medical billing is a game-changer.

We have all figured out how to streamline our approach to making sense of dental insurance, but the rules are different for Dental Sleep Medicine (DSM). You should use a segment-specific software platform (DS3, NiermanDentalWriter, or other) for your SOAP notes and communication with physicians and payers.

These platforms ensure that you include the right notes, tests, patient status, and history to get paid. DSM and medical reimbursement are under the jurisdiction of rigid documentation of processes, protocols, and standard practices. Choosing the most effective DSM practice management software is the first step to payment because it will not let you forget to harness critical information.

Make It Easy for Patients to Say Yes to Treatment

My second piece of advice is the most difficult to implement because it requires a change in behavior. Talk less about co-payments, deductibles, and the patient’s responsibility than you may be used to in dentistry when dealing with obstructive sleep apnea.

As an example, consider this: When you visit your doctor and they suggest an x-ray, draw blood, or order a specific test, do you usually say, “How much will that cost?” No, you don’t. We know that tests and medical treatment recommended by our physician are necessary and not usually optional to achieve optimal health.

Plus, we know that their treatments will be covered by our medical insurance (after the deductible and with certain co-payments). As dentists, we are expected to have significant upfront financial discussions about how much the patient will have to pay out of pocket because of the different nature of dental insurance.

Unfortunately, this same approach when applied to a sleep apnea appointment may backfire. Treatment of sleep disorders can be life-changing, so it’s beneficial to the patient if you focus less on dollars and more on care outcomes.

When we get detailed about the financial arrangement, upfront copayments, and deductible discussion, patients think we are still treating them as a dentist, not as a medical care provider. Make it easy for patients to say yes by leaving out the money talk. Many will have good coverage and can make the treatment a possibility.

Outsource the Details to a Competent Billing Company

Hire a billing company to do the dirty work. Third-party billing companies (Four Pillar, Nierman, Pristine, Dedicated Sleep, GoGo, Brady) typically charge a small per claim fee around $50 and 8-12% of the paid amount. This fee is worth every penny.

I have seen far too many revolutions from the administrative teams in dental practices when they were forced to try to figure out the weird, ever-changing rules of insurance reimbursement.

Billing companies are experts. Plus, the cost as a percentage of sales works for medical practices, so why shouldn’t it for dentistry?

Treating patients for OSA with Oral Appliance Therapy (OAT) is easier clinically and technically than making bite splints in centric relation. And yet the minefield is littered with the remains of dental teams who tried to do the billing themselves.

If you only did one case per month, subscribed to a cloud software solution, paid a billing company their fair share, and risked not talking so much about money, you would still help patients get healthier, feel very fulfilled, and make more money than you are now.

That success can breed more success. You just might add $100,000 to your annual revenue! Curious how you can start incorporating treatment of sleep apnea into your practice workflow?

I’ll be holding a live, three-hour virtual course, “Treating Sleep Apnea In Your Practice With Oral Appliance Therapy,” on Friday, May 21st, 2021. Registration for my course is easy at Pankey Online.

Join me from 2 pm to 5 pm EST to learn more about the medical background of sleep conditions, marketing sleep appliance therapy, and more in-depth techniques I implement to transform medical billing.

Can’t wait to see you there!

Sign up for free at Pankey Online to access complementary and paid CE-granting webinars spanning hot dental topics like sleep apnea treatment, equilibration, and indirect bonded anterior restorations. 50+ cutting-edge courses at your fingertips …

What would you like to build your relationships upon in your practice? With all the attention that is paid to dental insurance, it sometimes seems as though that becomes the foundation of our relationships with patients. When this is the basis of our relationship, the moment the plan changes, the patient may be looking for another dental office. Do we want to have our relationship based on such a fragile platform?

When I think about what we could have at the foundation and how we could make this happen, several things come to mind.

Compassion as the Basis

Basing a relationship on compassion can begin with the very first phone call. When a new patient calls, compassion can be expressed by something as simple as, “What prompted you to call us today? I hope you are not experiencing any discomfort.” Right out the gate, you are putting out there that you care about their comfort.

For a new or an existing patient, you might to say something like, “I’d like to make sure we schedule enough time to do this very thoroughly…very gently, and that we provide you with the best possible service so you are as comfortable as you can be.”

When you talk with patients about conditions you are seeing in their mouths, you can express concern as simply as saying, “I see a crack in this tooth, and I am concerned that, as it gets larger, you may experience some pain. Have you experienced any pain there?”

Mutual Trust as the Basis

On the very first call, you can begin to base your relationship on mutual trust and respect. You might do this by saying something like, “I’d like to schedule enough time for you to get to know us and for us to get to know you. When we learn what is important to you, we can help you make choices that are in your best interest. We’ll want to know what your previous experiences have been in dentistry because we want to provide you with the best possible experience in this practice.”

During Hygiene appointments, you might say something like this, “As I look in your mouth, it appears to me that over the years, you’ve gone to the dentist regularly and done everything you could to take care of yourself. You’ve chosen to have treatment when it was recommended. I believe that if you have the right information and you have some support in working through the process, we can help you make good choices for yourself in the future.”

If the patient is not in pain, you might say something like, “You’re in a really good position right now. We’ve got time to study the information we’ve gathered and to learn about your preferences. The doctor will want to go over all the information we’ve gathered today and spend time thinking about your oral health circumstances and options. If you decide later to have treatment, you will be fully informed about your options so you can make the decision that is right for you.”

Shared Values as the Basis

When we discover shared values in conversation, there is a powerful connection between us and the patient. If a patient mentions a filling has lasted for decades, you might say something like, “It seems to me that you like to have your dentistry last as long as possible?” And if the patient says yes, you might say, “Excellent, we’ll take that into consideration when we think about options for you.” Give them opportunities for discovering together with you what is most important to them.

The foundation you intentionally build on compassion, mutual trust, and shared values will enable you to expand conversations you have with patients about insurance and the cost of care. You will be able to assure them you will do whatever you can to make the dentistry they value affordable for them.

Around the world, people use AI-powered technology every single day. AI algorithms generate everything from Google search results to predictive text when writing emails to speech-to-text messages on smartphones. Every time you’re shopping and see “Recommended for you,” that’s based on AI data analysis, comparing your shopping habits to those of thousands of other people.

When I spoke at the annual Pankey meeting in New Orleans in 2015, my artificial intelligence software was just in its embryotic stage. Fast forward five years, and it is on the forefront of a technological revolution that improves the operations, ROI, and patient experience in dental practices of all sizes.

Data is hindsight. Intelligence is foresight.

Artificial intelligence programs are trained by using millions of data points that were categorized by humans already. AI software is taught to recognize the meaning of what it is seeing and/or hearing. Then, AI software programs extrapolate results and apply the information to predict behavior, coach behavior, command machines, and more.

9 Ways to Leverage AI in Dental Practice

Hygiene at home: Smart toothbrushes can record how patients are brushing their teeth and share that data with dentists, typically via an app. That allows dentists to identify bad habits and teach patients how to improve their at-home hygiene routine. Some apps even remind patients when it’s time to schedule their next dental appointment.

Voice-activated commands: In healthcare, medical and dental providers are already using voice-activated technology to dictate their notes into patient electronic medical records (EMR) and to access radiographs and other images hands-free. They are also using voice commands to research symptoms, diagnostics, and treatment options. This year will see an explosion of voice-activated commands in the workplace. Gartner, Inc, a world-renowned research and advisory company, predicts 25% of digital workers will use virtual employee assistants (VEAs) daily by the end of 2021. It also predicts that by 2023, 25% of employee interactions with applications will be via voice, up from just 3% in 2019.

Pathology identification: Computer vision AI analyzes radiographs in real time to detect pathologies and standardize quality of care. It provides confidence in the dentists’ diagnostics, and ensures problems are not missed. Companies like Pearl, Videa, and Overjet are successfully implementing computer vision AI in thousands of dental practices and improving diagnosis, case acceptance and ultimately patient outcomes.

Treatment planning: AI computing models are based on the treatment plans and outcomes of hundreds of thousands of patient records. Dentists can leverage AI to analyze different treatment possibilities and determine the potential for success, the length of the case, the materials that would be used, costs, and other considerations.

Treatment acceptance: Augmented reality isn’t just for kids’ games. Dentists use AI-powered augmented reality to generate smile designs in real time. When patients can see how the dental work will improve their appearance and restore function, they are more likely to start treatment.

Data analytics: At its most basic functionality, AI is big data computation. Its advanced algorithms predict future outcomes based on data patterns. Some dental support organizations around the country are already using AI to crunch numbers for predictive analysis designed to increase case acceptance, improve show rates, and optimize schedules.

Insurance reimbursement: For decades, insurance claims have been manually reviewed by dental professionals employed by the insurance carrier. AI can review claims, radiographs, and supporting documentation in seconds, generating approvals or identifying fraudulent claims much more quickly.

Elevated patient care: Technology has already revolutionized electronic health records. In this decade, AI will make it possible to closely tie oral health conditions to overall systemic health which will lead to better communication between providers and breakthroughs in both disease prevention and treatment.

Patient phone calls: Companies like Patient Prism leverage AI’s natural language processing algorithms and machine learning to quickly identify why patients called, the services they requested, the associated revenue, and whether the call ended in a booked appointment. Dentists use the data for everything from front office training to winning back unscheduled callers to determining whether their marketing efforts are driving the right kinds of calls.

Groups like the Artificial Intelligence Dental Council, a non-profit organization established by Pearl, are leading the way on the research and future applications. From helping patients at home to making it easier to book appointments to ensuring accuracy in diagnosis and treatment planning, AI is already revolutionizing dentistry. The future has arrived.