More dental leaders are blogging on the subject of leading dental patients to improved health by learning what is important to them. Often, the next words we read are “We need to meet patients where they are.” What exactly does that mean???

To me, this doesn’t mean we meet expectations of low cost, faster care, with immediate results. This doesn’t mean we make promises that all their dental needs are met for the next six to twelve months. It doesn’t me the therapy we provide will solve an incipient or chronic problem for life. It doesn’t mean their insurance coverage dictates the value of the care we deliver. It doesn’t mean we are going to open our office after hours or on the weekend because that’s what someone wants. It doesn’t mean we guarantee a crown or veneers will last and never need to be replaced.

To me, this means understanding the individual patient, not patients (plural) as a population with trending, new expectations in 2022. It means focusing on the things each person thinks are important and relevant to their lives…where their priorities lie. Then, we can attempt to strategically tie what they value to their dental health to help them make a connection to a preferred future self. Most people, it seems, are unable to make these connections on their own.

Two Big Questions We Ask Ourselves

What do our oral health findings–ideally uncovered during a co-discovery exam, mean to a particular person? If our findings don’t have meaning to the patient, how can we possibly motivate the patient to take action? All of us struggle with these types of questions because we can’t force our values, our philosophy of oral health on others.

We can, however, create opportunities to reveal a pre-existing, unrealized value of health the patient has. If we find the patient is not health-centered, we can triage that person appropriately so we spend most of our time with patients who are health-centered.

“Revealing” Unrecognized Value Takes Time

Early in my career, I thought I could educate my patients to see the value of oral health the way I saw it. I found I was often knocking my head against the wall. Some people just didn’t value it. They wanted help when they were in pain, but preventing dental deterioration wasn’t something they felt needed immediate action. Moving forward with treatment was not on their personal agenda.

Gradually, as I read Bob Barkley, L.D. Pankey, Nate Kohn, Jr., and others, I realized they had gone through a discovery process of their own. The first task was to get to know the patient and understand the patient’s value for health and the patient’s oral health objectives. It was also to try to discover if their oral health circumstances were important to them so I could help them envision their preferred health future. But that takes time—time with each patient.

If your practice is primarily insurance dependent, you are underpaid most of the time. How do you compensate for this problem? You find ways to work faster. You find ways to see more people in a day. You delegate more. You look for a way to cut your lab technician’s salary out of your life. You buy in bulk and wake up in the middle of the night wondering why you got into dentistry in the first place.

It doesn’t have to be that way!

Many years ago, when I began spending time with new patients to learn if they are health-centered, I was able to better manage my time with them. If they valued health…if I could connect them with their dental needs on a deeper level, then spending even more time with them was well worth it.

Those who value health are the patients we can easily help understand why we take our comprehensive approach to restoring and maintaining optimal oral health.

You can be more productive per hour than you can imagine, IF you take the time to connect with patients on a deeper level and you strategically find ways to spend most of your time with people who care about their health in the first place.

L.D. Pankey wisely said, “People change, but not very much.” And that’s a critically important life lesson, one that took me years to accept because I thought my philosophy would psychologically trump theirs, and I would therefore win the day. I was wrong – very wrong.

Many times, we need to increase the vertical dimension of occlusion (VDO) to put teeth where they should be esthetically and restore teeth that are severely worn from attrition or erosion. If you are concerned that changing VDO will cause joint or muscle pain, put your mind at rest. My experience is that it won’t. If you are concerned it will cause pain, put that thought aside too. My experience is that it won’t.

We want to change the vertical dimension only as much as we needed to accomplish the esthetic and functional goals of the case. That will minimize the effect changing VDO may have phonetics.

Phonetics May Be a Challenge

Vertical dimension has impact on two phonetic sounds in particular—F, S and V. F and V are similar. When we say them, we touch the edge of our upper central incisors just on wet-dry line on the inside of our lower lip. Saying F and V has to do with mandibular lip position, and the patient learns to adjust that position when VDO is changed. In my experience, they adjust to this in two to four weeks. They learn to accommodate a new mandibular position that touches the lower lip more gently.

S is a totally different sound. People say S in one of three different ways.

1. Some people make the sound S by making a small air space that’s between their upper and lower incisors edge to edge.
2. Some people make the sound S by making that same small air space but with their lower incisal edges just lingual to their upper incisal edges.
3. Some people make the sound S by making that same small air space but with their lower incisal edges just labial to their upper incisal edges. And those are our Class 3 occlusion patients.

The air space needs to be a precise amount of distance. If you have too little space, the patient lisps. If you have too much space, the patient spits or sprays saliva. Neither of which the patient is happy about. If the patient is totally edentulous, the patient may adapt to the new VDO of their prostheses, but patients rarely adapt to correct their pronunciation of S if they have a new VDO on natural teeth. This means we need to be careful about altering VDO.

The only way to test if a patient will have a lisp or other phonetic challenge is to test the VDO with provisionals, not with a removable bite splint.

Correcting Lisps Created by Anterior Restoration

How much air space do patients need to pronounce S without a challenge? They need about 100 microns to not lisp or spray saliva. To correct for too large or too small a space, I learned the following trick I hope you find helpful.

Madam Butterfly Silk is about 94 microns thick. I have the patient sit up and hold the silk between their upper and lower incisors with a Miller forceps. While the articulator silk is between the teeth, I have the patient count from 60 to 70. As they count the entire series of numbers, they relax into the process and red ink is transferred to their incisal edges if the space is smaller than 94 microns. If we see red marks, including on the canines, we need to increase the air space. My experience is that it takes four to six passes with the articulator silk and patient counting from 60 to 70 to adjust the airspace sufficiently. As you are doing this, the patient experiences the positive benefit of the lisp going away. I then tell the patient to go home and “observe how you sound. Ask others how you sound. We may need to do a little more refinement.”

If the patient lisps edge to edge, I shorten the lower incisal edges because upper incisors are esthetic. If the patient says S with the lower incisors lingual and they have red marks on their lower lingual and on their upper labial, I pick the upper or lower incisors and make adjustments where they are structurally and esthetically least impactful. If they are Class 3 and say S with their lower incisors, labial to their upper incisors, I always adjust the lingual marks on the lower incisors.

The Pankey Institute is the world’s oldest, most prestigious learning center for advanced dentistry. Our Traverse City, Michigan dental practice has been involved with The Pankey Institute for the last 27 years. You will often hear or read that the purpose of the Institute is to narrow the gap between what is known and what is practiced. And the unique thing about this nonprofit organization is that the faculty promote and facilitate learning around the behavioral aspects of dental care as well as the technical aspects.

The technical things we do in dentistry are transactional. Those are the clinical procedures we perform every day. But the behavioral training we receive at The Pankey Institute is truly transformational. It transforms how we approach patient care, placing focus on building relationships of trust based on genuine concern for what is in the patient’s best interest. It transforms how we thoughtfully and collaboratively lead our patients to improving their oral health. It teaches and encourages us to provide the highest standard of clinical excellence so our patients can achieve optimal oral health, comfort, and beautiful smiles.

During our years of association with The Pankey Institute, we have learned how to predictably manage and treat complex dental cases, and how to help patients who, at first, are anxious and lack trust. We’ve learned how to understand where individual patients are coming from and work from that basis to open their minds to what is possible for them and help them access fine care.

The greatest benefit of returning to the Institute for continuing education has been the total immersion that we experience at the Institute as we learn from, interact with, and are mentored and encouraged by like-minded individuals. We’re learning from some of the best dentists in the world. They’re flat-out experts in what they do. They flat-out care about their profession and want to help other dentists become the best they can be. They also want to help the dental professionals on our care teams, whether they are clinical or administrative, become more effective in their roles.

The year 1994 was the first time I attended a course at the Institute in Key Biscayne, Florida. And now I have progressed through the Pankey continuum of courses to where I am part of the visiting faculty to help teach and mentor other dentists. And, I am now the Coordinator of the Pankey Scholar Program, which is the pinnacle of the Pankey Learning Experience.

Since 1994, our dental practice in Traverse City, Michigan, has grown to be the largest “Pankey practice” in the world, and we’re proud of that because of what it means for our patients. We have a common culture here–among our five dentists and all team members, and a vision of patient-centered, comprehensive care that is easily articulated. It positively impacts our work, our lives, and our patients’ lives. It has enabled us to provide a consistently wonderful patient experience.

The Pankey Institute is the voice, the home, and the hope of private care dentistry. The Pankey Institute experience and its supportive community of learners has helped our practice thrive as a private practice that offers expertise in restorative and cosmetic dentistry, including full-mouth reconstruction, implant dentistry, and IV sedation. At Traverse Dental Associates, we are facing today’s business challenges well, we are proud to provide the finest care, and we are strongly committed to private practice.

If you are new to the Institute and I have not met you yet, please let me know. You are the life blood of our profession and may one day be a standard-bearer, if not a missionary for The Pankey Institute, the Pankey community, and everything it represents. I look forward to meeting you.

Another dentist asked me, “What temporary cement do you use so your temporary crowns actually stay on?”

The cement I like is TempoCem from DMG America. It is easy to utilize and clean. But there is a more important question than what type of material I like to use. It is: “What is going on with the tooth before the prep is begun?”

I have found that the reason temporaries come off is because something in the functional movement of the patient’s mouth is interfering with the tooth. Before prepping a tooth for a temporary, I anticipate I may need to re-design the tooth first.

Before prepping the tooth, I take an intraoral photo of the bite marks to understand what is going on functionally. I explain to the patient what I am looking for and show the patient the evidence of excursive interferences on the tooth. My goal is to design the provisional and the crown to decrease the forces and increase the functionality of the tooth. I then modify the tooth and take another intraoral photo of the bite marks to show the patient the changes before making the impression of the natural tooth.

I realize many dentists check the bite marks and modify the tooth prior to making an impression without the added step of photography and patient education. But I suggest you try using before and after photo images chairside to educate your patients. This process engages the patient in understanding how their teeth function and why there has been damage to the tooth. I’ve learned it also “opens their eyes” and increases their appreciation for the additional dentistry I recommend based on my comprehensive examination of their mouth and diagnosis.