When dentists are considering the purchase of a new digital technology for implementation in their clinical practice, they usually have three primary considerations:

• Will it increase accuracy?
• Will it increase consistency?
• Is it possible to increase efficiency without sacrificing quality?

Often the cost is a major consideration, and I will come back to the question of cost later in this two-part series.

Twenty years ago, with first-generation CEREC, the results were not close to what we could do in the analog world. But I jumped into using chairside CAD/CAM because, at the time, I was teaching with Dr. Peter Dawson and many doctors were buying the technology. We needed to be able to talk about how it fit with complete-care dentistry.

It was a difficult time because while we could do crowns (usually one or two at a time) in maximum intercuspation or on equilibrated patients in CR, the software was not sophisticated enough to do any kind of case planning. It did, however, provide me with the first glimpse at scanning and 3D digital technology, and I became excited about the possibilities. I started to think about the ability to scan mouths for diagnostic purposes and to do waxups. Virtual articulation was not there, and we didn’t have 3D printing to print our “outputs” so I continued to wait.

As recently as four years ago, my son would spend a day mounting stone models for me. Today, he has digital models mounted on a virtual articulator before the patient leaves their appointment. Digital and AI software platforms are evolving quickly. They enable more dentists and lab technicians to visualize optimal dentistry and design occlusions and beautiful smiles easily. For implant dentistry and orthodontics, these digital and AI software platforms remove obstacles and inaccuracies.

The ability to “stack” data sets on top of one another (pre-op model, waxup, CBCT, Face Scans, photos) allows us to see things in ways I could have never imagined. The things I dreamed about 15 years ago are here now and evolving at warp speed. I honestly don’t remember a time when I was more excited about day-to-day dentistry. A special shout out to Lee Culp (Sculpture Studios), who introduced me to these workflows, and continues to lead dentistry into the digital era.

In the digital world, we can make digital impressions, face-bows, and waxups to see if we need to equilibrate, orthodontically move teeth, or change the shape/contour of the teeth. Technology allows us an efficient, accurate workflow. An experienced digital team can mount models and a virtual articulator, in CR, in 10-15 minutes. The ability to scan in CR, MI, or any treatment position can be accomplished with ease. Trial equilibrations or diagnostic designs (waxups) also can be accomplished far more rapidly, with beautiful results.

As digital workflows take hold in mainstream dentistry, one of the great challenges we face is how the next generations of dentists will learn. In treatment planning, I have the benefit of having 30-plus years of experience working in analog. I have solidified the concepts of centric relation, anterior guidance, posterior disclusion, crossover, envelope of function, incisal edge position, and all the things that go along with visualizing optimum care for your patent. This knowledge was my foundation for determining if these technologies had evolved enough to make the shift to the digital realm.

In a conversation with a young dental practice owner, this doctor recited a long list of the things he would like to do. He also said he had colleagues, even mentors, giving him advice on how to run his practice. When I asked him questions to help him align his vision and values with the things he would like to do, we were able to narrow down the long list to three items that would be most impactful for his business. First, he was committed to being a great business owner, getting advice, and establishing an employee manual for his practice so that he could do the right things for the right reasons. Second, he wanted to create a brand for his practice, and that was going to involve marketing and training for his front office. Third, he was committed to getting advanced clinical training for himself and his clinical team.

As we started looking at courses for him and his front office and clinical teams to attend, I could feel his excitement rising. He blocked out time on the calendar for these courses. I could sense that he was crossing over from interest to commitment.

When you are “interested” – most often, it’s something that you approach at your convenience, while other things get in the way. What comes to mind are so many New Year’s resolutions for which people tend to be interested in losing weight, getting healthier, finding a new job, etc. but commitment is weak and it often wains after a few weeks.

When you truly want something to happen, you align other things, so it takes priority – you become “committed.” You take action, no matter what. In the case of the young practice owner, he blocked out his practice calendar and paid in advance for courses. That shows how committed he was.

When you’re thinking about goals for your practice, consider this: what goals will have the greatest impact on achieving your vision? Which ones are in true alignment with your values and will add to the practice culture you are building? Which should you prioritize? Then ask yourself, are you simply interested in doing them, or are you truly committed to doing them? If you’re committed, take action!

Deprogramming of the lateral pterygoid muscle is generally done by placing something in the anterior that eliminates posterior occlusal contact. I have two “go-to” deprogrammers. One is a leaf gauge or what is often referred to as a Lucia jig, and the other is a little device developed by Dr. Keith Thornton, who invented the TAP appliance. This second favorite is called a “Pankey Bite Stop” and is sold at The Pankey Institute store.

Using a Leaf Gauge

Every time you have a leaf gauge in the patient’s mouth and the patient is instructed to slide their jaw forward, then back and squeeze, the back teeth can’t touch. As the elevator muscles fire, they pull the condyle up into centric relation, stretching the lateral pterygoid and eliminating proprioception across the teeth.

I try to find the first point of contact on the forward motion and ask the patient to slide back and squeeze. By the time I do this 10 to 15 times, the pterygoid muscle has fully deprogrammed.

Using a leaf gauge to do occlusal deprogramming works especially well when the patient is already sleeping in a quick splint at night or wearing a full coverage appliance or an anterior-only appliance that has done the deprogramming for us.

Using a Pankey Bite Stop

I use a Pankey Bite Stop when I judge a leaf gauge will not suffice. The device is relined with Bite Ridge, placed over the upper incisors, and left to set. The patient is instructed to “sit on it.” I usually set a timer for 15 minutes. My instructions to my patient are not to try to touch their teeth together. The teeth may or may not touch. I instruct them to relax and try to NOT think about their teeth.

Using this device, you do not need to have the patient move forward, back, and squeeze if you allow 15 minutes. Because the posterior teeth do not touch, the proprioceptive message that normally tells the patient’s brain to activate the pterygoid muscles is eliminated and the lateral pterygoid starts to release.

What if the patient needs more?

With some patients, I realize that they will need to sleep in a QuickSplint for a couple of weeks. In our Essentials One course at Pankey, we use the Quicksplint as an overnight deprogrammer to allow us to capture very accurate diagnostic records. In my practice, we use this device as a durable deprogrammer, in addition to all the other things that it does. They are easy to fabricate chairside. You can read more about their use here. In our Essentials One course at Pankey, we use the Quicksplint as an overnight deprogrammer to allow us to capture very accurate diagnostic records. In my practice, we use this device as a durable deprogrammer, in addition to all the other things that it does.

In the year 1958, Dr. L. D. Pankey asked one of his most devout students to join him and teach the Pankey philosophy about dentistry and life to dentists around the world. And that’s precisely what they did. F. Harold Wirth, DDS, was one of the most dynamic speakers in all of dentistry. He rivaled Drs. L. D. Pankey and Bob Barkley in his ability to engage an audience and make his points clear using real (often funny) stories from his practice and life experiences.

Harold understood people on a very deep level—physically and emotionally. For this, he gave Dr. Pankey most of the credit. He had a very successful restorative practice in downtown New Orleans prior to meeting Dr. Pankey, but always felt that something was missing. L.D. Pankey showed him what that was, which turned Harold Wirth into a missionary for whole-person dentistry from that point forward:

“Give the case presentation to the person who makes the decisions,” Dr. Wirth said. “If I ever get to the point where I’m explaining what I’d like to do…If I’m not already about 90% into gaining their agreement, then I have messed up! Because I should have already won them over with the interview, the aura of my office, the literature that I’ve given them to read, and whatever else I’ve done before that time.”

Dr. Wirth said, “The case is constantly being presented: Every time the patient comes in, you’re doing a presentation. As a matter of fact, I think the interview is forever ongoing. It might only be one word, but every time the patient comes into your office, you should be interviewing them. Are you comfortable? Does your bite feel good? Are your teeth sensitive?”

These are questions that have to do with how the person FEELS. A case history is exploring what happened, but an interview is about how they feel! You need to understand the difference! How do you feel about your restorations? Are you comfortable? Are you satisfied with the appearance of your smile? Can you chew everything you want to chew?

Umbrella liability coverage provides additional liability protection over and above your existing policies. A personal umbrella is going to provide that coverage over your auto insurance, your boat insurance, and your renters or homeowners insurance.

Typically, you must have a minimum amount of coverage in each of those areas. Usually, it’s $300,000 in bodily injury for your auto and about a hundred thousand in property damage. And then also for your homeowners, you usually need a minimum of $300,000 in liability coverage for your homeowners or renter’s policy. For example, if you have an auto claim where you’re at fault, and there is a half million dollars in bodily injury and the underlying limits on your policy are $300,000, your policy will pay the $300,000. The additional $200,000 that you owe would be paid by the umbrella. With a one-million-dollar umbrella, you have $1.3 million in coverage.

Umbrellas Provide a Lot for Relatively Little

By buying an umbrella policy, you’re adding a lot more protection at a very low cost. They come in increments of a million dollars, and you can buy several million more.

The beauty of this is that that policy may only cost a few hundred dollars a year depending on the features you might add to it. Umbrella policies might protect against some unusual things, for example, slander and liability claims. If you have a second home that you visit or rent, the umbrella will usually cover the liability.

Life is full of surprises, so it is wise to have a lot more coverage than the minimum homeowners and renters insurance policies provide.

Commercial Property Insurance

I think every dentist needs at least a one-million-dollar umbrella covering their commercial property. If something happens on your property for which you are liable, a lawsuit can run into high dollars—some run into multiple millions. If you have $1.5 million in commercial assets, at least $2 million in total liability coverage would be appropriate. Someone could have a $2-million-claim by tripping and falling, even if your commercial assets do not amount to that much.

Professional Liability Insurance

Regarding professional liability, you can’t buy an umbrella but you can buy more base coverage. Base coverage is usually available in million-dollar increments. If you have concerns, contact your insurance providers, as well as other providers to compare policies and costs. It could be inexpensive for you to have the extra financial security of an umbrella.

Additional Considerations

• When purchasing umbrella liability insurance, the extra millions above the first million are usually less expensive than that first million.
• If you have children under the age of 25 who are drivers under your auto insurance policy, an umbrella policy will have an added charge to cover the extra risk of the young driver.
• If someone were to injure you or your auto and they are underinsured, your auto insurance liability umbrella might kick in and cover your expenses. That’s something to look into and consider when making insurance choices.