For support organizations and dental service organizations (DSOs) to scale, they focus on developing a branding patient experience and a predictably profitable business model. They seek to maximize:

• efficiency while serving the needs of consumers,
• provide a wonderful patient experience, and
• increase both their top and bottom financial lines.

Dentists who have chosen the private practice way of life may want to reflect on the following 12 things DSOs strive to do in 2022, and then apply these tactics to their own business model. These tactics have been among the top topics of conversation at DSO meetings in 2021 and 2022 and will sound familiar to those who follow The Pankey Institute. Why familiar? Because they are top topics also discussed among private practitioners and many are addressed within the Pankey Institute curriculum.

1.Monitor more aspects of your clinical and business operations to determine what is working well and what problems need solving. Then solve the problems as rapidly as you can. As the practice leader, open your eyes and ears, and lead.

2. Track key performance indicators and seek growth in those KPIs.

3. Cultivate a positive practice culture and work environment in which employees want to work and patients want to visit. Team members should constantly check in with each other to communicate what is happening “now” and intentionally tune their senses to know how they can help one another. The goal is both a wonderful patient experience and a wonderful team experience.

4. Design systems and protocols with intention, follow them, and assess them for improvement. Make sure team members understand the Whys.

5. Invest in training your clinical and business teams. Especially important in the last two years are to:

• • Realize the potential of each team member and affirm they are valuable to the practice.
  • Educate clinical and front office teams in how to best engage and support patients with special attention to facilitating the treatments patients need. DSOs have targeted implant treatment and doctor-supervised, clear aligner orthodontics as two niches to focus their education efforts on with staff and patients.
  • Educate front office team members in how to appropriately maximize lead conversion, so the cost of expensive digital marketing can be contained. With increased new patient acquisition, reserve more time on the schedule for new patient appointments. In 2022, if new patients must wait, they tend to go elsewhere.

6. Maximize clinical technology to improve the patient experience and increase the efficiency and accuracy of clinical records, diagnosis, treatment planning, dental lab communication, and manufacturing.

7. Maximize practice management technology to improve the patient experience and increase the efficiency and accuracy of business operations, for example, AI enhanced software that automates billing and online collections or reviews insurance claims for accuracy prior to submission.

8. Migrate to a Cloud-based PMS system to ensure the security of your data.

9. Block schedule to do more procedures in a single visit. Patients and clinicians benefit from this efficiency. Maximize spaces in the visit—as you transition from one procedure to another, to enhance relationships with conversation.

10. Deploy a dental assistant to assist in hygiene, for example, to help clean and turnaround hygiene operatories between hygiene patients. This way, the hygienist’s relationship time with patients is not shortened or eliminated in the race to meet clinical demand.

11. Ensure adequate front desk coverage, so there is always time for those personable conversations that ideally occur when each patient arrives and leaves their appointment. Manage your human resources so almost all phone calls are answered live during business hours by a receptionist well versed in optimal conversation with dental patients.

12. Frequently ask, “What is our branding patient experience? What can we do better to meet the desires and needs of our existing patients and the prospective patients we target?”

Looking at this list, I can’t help but think that Dr. L.D. Pankey would smile. Just because you don’t have a corporate support organization helping you run your business doesn’t mean you can’t do these things on a smaller scale and possibly do them better.

Stocks and bonds have both fallen in 2022, taking down portfolio balances. Meanwhile, inflation has shot up, tying the hands of many investors—retirees and others, who might otherwise be inclined to reduce spending in periods when our portfolios have lost money.

What Can We Control?

As long-term investors, some of us have experienced these moments before. One of the best ways to minimize worry in a volatile, uncertain market environment is to focus on what we can control.

What we can control is:

• our savings rate,
• our spending plan, and
• our spending rate

In retirement, the spending rate is often referred to as the burn rate.

We can use all three of these levers throughout our lives. Often, these levers influence long-term outcomes more than investment selection or even asset allocation. These three levers are often the main determinant of whether our plan sinks or swims.

We Can Invest More

Increasing our savings rate in down markets allows us an opportunity to invest more when markets are off 10%, 20%, 30%, or more. The process of buying more shares at a lower price point weekly, bi-monthly, or monthly allows us to lower our average cost per share. (This is Dr. L. D. Pankey’s Rule of “7’s” in A Philosophy of the Practice of Dentistry.)

Many investors in accumulation mode prioritize “maxing out” their contributions to tax-sheltered retirement savings vehicles—IRAs, 401(k)s, and more recently, health savings accounts. Yet another type of tax-advantaged contribution has been seeing an increased uptake: after-tax 401(K) contributions.

My recommendation is that you talk seriously with your business accountant to determine if your current business cash flow will support more contributions to your retirement plan, savings, and/or possible after-tax investments.

Consider After-Tax 401(k) Contributions

If there is a knock against after-tax 401(k) plans, it is that many people who have access to them are not using them! They have much to offer.

Plans that offer after-tax contributions, allow investors to stash a full $61,000 in a 401(k) ($67,500 for people over 50), including pretax or Roth contributions, employer matching funds, and after-tax 401(k) contributions.

Assuming the 401(k) is a high-quality one, after-tax contributions tend to beat investing in a taxable brokerage account on an after-tax basis. That’s especially true if the plan offers automatic in-plan conversions. These plans are especially appropriate for high-income, heavy savers, who have access to them.

Required Minimum Distributions Can Be Reinvested in an After-Tax Account

For those already retired, our main lever for the health of our plan is how much we withdraw from our portfolio. If we can find a way to take a bit less when our portfolio is down, we will leave more of our portfolio in place to recover when the market goes back up. One question that inevitably crops up in the realm of portfolio withdrawals is the role of required minimum distributions (RMD’s) and whether they could cause us to prematurely deplete our assets.

The short answer is no! It is always appropriate to evaluate the amount of the RMD, and realize we are not required to spend it all. We can reinvest it in an after-tax  investment account and/or increase our Emergency Fund, as a cushion for future unknown events of which persistent inflation could be one example.

Take a Long-Term Perspective

Focusing on what we can control—especially our savings and spending rate, can provide peace of mind in volatile times, and so can taking a long-term view. Learning more about the history of the stock market and the detailed history of stock market declines, broadens our understanding and can minimize the noise.

The dominant long-term trend is up, and the periodic bear markets, even bad ones like 2007-2009, have been fairly modest blips along the way. It can be easy to lose sight of that long-term view when the market logs one bad day after another.

It is worth training our gaze on the long-term and what we can control by:

• living on less than we make,
• saving a greater percentage of our compensation, and
• becoming more aware of controlling our spending plan and burn rate

To learn more about personal finance, I invite you to sign up for the Pankey Institute course titled Creating More Financial Freedom which will be held March 30 – April 1, 2023.

Complex dental cases often need support from multiple specialties for a final successful outcome. The approach to work out these cases can be a “multidisciplinary approach” or an “interdisciplinary approach.”

In the case of “multidisciplinary treatment planning,” each of the dental professionals makes their own plan for the treatment they will provide and they seek the help of other disciplines as the need arises. A fairly common example is when a patient finishes orthodontic alignment and then sees a dentist for esthetic restorations.

“Interdisciplinary treatment planning” takes another approach. Treatment is preplanned among the restorative dentist, specialists, and the laboratory team prior to commencement. What is notable in this approach is that you communicate, you collaborate, and you create the plan together as a team. As a restorative dentist, my role is to sit at the center of the specialist, the lab technician, and the patient. In my experience, involving the lab technician from the beginning produces best results and a more efficient process of treatment.

Avishai Sadan — my colleague and the dean at USC, says interdisciplinary treatment planning results in “being able to formulate a custom-tailored treatment plan that addresses patient present and future needs and to execute it to the highest clinical level possible, using state-of-the-art techniques and technologies.” This statement defines for me the best way to do dentistry.

The Benefits of Interdisciplinary Treatment Planning

The foremost benefit is to our restorative patient, whose well-planned dentistry optimally solves current and future needs. Not only are restorative results at the highest clinical level, but we can practice what we enjoy doing most at our highest skill level, while enjoying collaboration with others who are working at their highest skill level. Liability is lower, and we learn from each other.

As a team, we have developed a smooth process of communicating, contributing knowledge, and deciding what will be an optimal course of treatment. We document with photos the procedures each of us performs so we each have complete documentation of the cases we do together.

The others who are on my interdisciplinary team refer patients to me because they are comfortable with the process we have developed and value the quality of the restorative dentistry I do. My practice is distinguishable from dental practices that do not do interdisciplinary treatment planning. Patients who are referred are commonly told about this interdisciplinary planning approach before they arrive. They anticipate a high level of personal attention and a course of treatment that all doctors agree upon. Case acceptance is high when all doctors and the lab team agree on what is best for the patient. Communication and agreement among the providers is so complete, the patient can be optimally informed about what to expect at each stage of treatment.

Why Occlusal Appliance Therapy Is My First Step Prior to Ortho, Equilibration, or Restorative

Occlusal changes on an appliance are easy and reversible. An appliance can immediately reduce elevator muscle activity and give the patient relief. The patient also experiences what changes to their tooth contacts could provide for them long term. We can test the changes that would be made by ortho, equilibration, and/or restorative.

As reviewed in Part 2 of this series, our goals are to stabilize the joint anatomy and reduce the activity of the elevator muscles because those muscles are what overload the joints and teeth. We also want to slow down the rate of damage to the dentition and move that rate back to a more age-appropriate pace. We also may need to reorganize a patient’s occlusion to manage occlusal forces to ensure restorations that last.

Removing Posterior Contacts Does Not Work for Every Patient

Over my years of clinical practice, I have found that changing the occlusion does reduce functional risk for most patients. But we all have patients with perfect occlusion who present with TMD symptoms. We have some patients who continue to parafunction after we move them into immediate posterior disclusion.

Studies show that proprioception causes the elevator muscles to engage in only 80 to 85% of the population. This means that when the brain receives the signal that teeth are touching, the brain elevates the masseter muscles in 80 to 85% of people. Tooth contact is the trigger. Because this proprioception does not occur for 15 to 20% of the population, it is not the universal trigger for excessive loading.

Over my years in clinical practice, I have learned there is nothing I can do that is 100% dependable to stop a patient from para-functioning. Some of my patients continue to excessively load after posterior contacts are removed. Their functional risk does not diminish.

If we cannot reduce elevator force and redistribute force enough on an occlusal appliance to eliminate or at least relieve TMD symptoms, then occlusal therapy via ortho, equilibration, or restorative will not satisfactorily help the patient. We will need to turn to other forms of therapy.

Other modalities I use are BOTOX to deactivate muscles, massage therapy, and physical therapy. There are also systemic medications, cold lasers, and TENS therapy we can use to reduce the activity of the muscles or reduce inflammation in the muscles and joints. Sometimes one modality will alleviate symptoms for a while and when symptoms return, we can try it again or try another modality.

An Exercise to Identify the Patients Who May Not Benefit from Occlusal Therapy

You can do what I call a poor man’s EMG on yourself by placing your hands on your masseter muscles. Put your back teeth together, clench and release, clench and release, clench and release to see how much masseter activity you have. Then move your teeth into protrusive edge to edge and try to clench a little bit, making sure your back teeth do not touch. If you now have a posterior tooth touching in the edge-to-edge position, then put a pencil or pen between your front teeth to separate your back teeth.

With no back teeth touching and contact on the centrals, try to clench and release two or three times while feeling your masseters. Most of you will find your masseters do not move or move a lot less when no back teeth are touching. Some of you, even with your back teeth separated, can still clench in protrusive and can still increase the muscle activity almost the same amount as when your back teeth touch.

I do this exercise with my patients, but when they move into protrusive, I put a bite stop over their front teeth or have them bite on a Lucia jig we have lined for their bite registration. If you do this test with your patients, you can use an EMG or feel the muscle activity with your hands.

If the patient can still generate almost the same force or the same force with their back teeth separated, you have identified one of the around 15% of people who might not benefit significantly from occlusal therapy. You’ve also identified someone who might not do well on an anterior-only appliance because, if they can generate that same force on just two teeth, they are at risk for those teeth becoming sore and moving.

Interested in Learning More?

The Pankey Institute Essentials courses and multiple focus courses include hands-on exercises and over-the-shoulder training designed to help dentists develop mastery in reducing functional risk and treating TMD symptoms.