The Importance of the Pre-clinical Interview 

April 7, 2023 Daren Becker DMD

Occasionally we discover that we are not the right dental team for a particular patient or that the patient is not looking for what we offer. This doesn’t happen very often, but it can save a ton of time and help manage expectations if we find out before doing the comprehensive exam.

When new patients come into our practice, we always begin with a preclinical interview and then proceed to do a comprehensive exam. One new patient arrived and was seated in the consultation room. I came in and started the preclinical conversation. We started talking about her health history and dental history.

As we talked about her dental history, it becomes apparent that she had a history of “fixing things as they broke.” I explained that our exam process would allow us to find and treat issues early. I tried to help her understand that treating a cracked tooth as soon as the crack is observed could save the tooth and avoid the breakage she had experienced. I described to her what the exam would include, that I would describe and show her problems I saw, and that I would explain risk factors that could develop into future problems.

She said, “I don’t want you to do that. I just want you to make sure I don’t have any cavities and that’s it.”

I said, “Well, we can certainly do that. We can look for any teeth that have a cavity. Would you like me to tell you if I see anything else going on?”

“No,” she said, “I don’t want to know any more than that.”

We talked a little longer, and I tried to understand why she didn’t want to know. I said, “You know a tooth problem is a kind of like a tiny skin cancer they burn off instead of waiting until it grows and then you need a big Mohs procedure.”

She didn’t respond, so I said, “Let’s go to the dental chair, take a look, and see what we find, and we’ll take some x-rays.”

She said, “I don’t want x-rays.”

I explained that we couldn’t accurately diagnose cavities without x-rays. She then said, “I don’t think this is the right place for me.”

Fifteen minutes into our conversation, I heard myself say, “I think you may be right. We are here to help patients improve and maintain their oral health and to avoid having bigger problems.”

Before I could continue, she interrupted me, firmly saying, “No that’s not important to me.”

My response was, “Well then, it was nice to meet you,” and I stood up to walk her to the door.

I’ve known dentists who rush right into new patient exams without conversation in which they learn if the patient is motivated to improve and maintain their oral health. I told the team to not charge her for the appointment, and I told them, “That was the best preclinical interview we ever had because we stopped wasting her time and our time.”

Fortunately, most of the new patients who come to us have “Aha” moments during the preclinical interview and comprehensive exam. They immediately understand the value of what we are striving to do and are interested in the discoveries we make during the examination. They ask questions and want to know why conditions are the way they are. They want to know what can be done to lower risk factors. They may need nurturing over multiple appointments to accept treatment but we see them making progress with their emotions and decisions to move forward. The time we take with these patients is not wasted because it is quality time during which we build mutual trust.

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Daren Becker DMD

Dr. Becker earned his Bachelors of Science Degree in Computer Science from American International College and Doctor of Dental Medicine from the University of Florida College of Dentistry. He practices full time in Atlanta, GA with an emphasis on comprehensive restorative, implant and aesthetic dentistry. Daren began his advanced studies at the Pankey Institute in 1998 and was invited to be a guest facilitator in 2006 and has been on the visiting faculty since 2009. In addition, in 2006 he began spending time facilitating dental students from Medical College of Georgia College of Dentistry at the Ben Massell Clinic (treating indigent patients) as an adjunct clinical faculty. In 2011 he was invited to be a part time faculty in the Graduate Prosthodontics Residency at the Center for Aesthetic and Implant Dentistry at Georgia Health Sciences University, now Georgia Regents University College of Dental Medicine (formerly Medical College of Georgia). Dr. Becker has been involved in organized dentistry and has chaired and/or served on numerous state and local committees. Currently he is a delegate to the Georgia Dental Association. He has lectured at the Academy of General Dentistry annual meeting, is a regular presenter at ITI study clubs as well as numerous other study clubs. He is a regular contributor at Red Sky Dental Seminars.

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Using Digital Technology to Create an Analog Smile Mock-Up with Your Patient

February 21, 2022 Daren Becker DMD

Today we move between the digital and the analog world to accomplish the goals of aesthetic dentistry. A mock-up is a key tool in helping patients want aesthetic dentistry and visualizing what the changes will accomplish.

Lots of us have learned from masters like Dr. Susan Hollar how to hand-lay composite on the patient’s teeth so the patient can see their possible new smile. This trial smile technique is a fabulous way to motivate patients. It’s also a great way for us to learn what might be possible.

For many dentists, that technique is not natural for us, and it takes chair time. Another way we can model possible changes is through digital technology. In our office, we are using digital smile design as follows.

1. We do our initial records, which includes facial photos and an intraoral scan using our digital impressions intraoral scanning system.

2. Either on the software in our office or at the lab, a 3-D version can be designed of what the new smile approximately could look like.This doesn’t have to be a definitive wax-up. Remember, we call it a diagnostic work-up. In fact, this is oftentimes where we discover the need for gingival changes and/or orthodontic procedures in order to achieve the desired outcome. I find this extremely helpful in communicating with the patient as I can show them what the compromised outcome would be if they choose not to correct the gingival levels or align the teeth if that is in fact appropriate.

We’ve learned it is very efficient to collaborate with the lab, the lab creates the 3-D design, and the lab emails us the STL digital file of the design. Alternatively, the lab can send printed models, matrices, or even milled/printed PMMA shells of the design.

3. On the 3-D printer in our office, we print the model from the STL file.

4. We make a matrix from that, either in a suck down material or a putty matrix, and we take that to the mouth, fill it with our temporary material (usually bisacryl), and seat it right onto the teeth.

5. After letting it set, removing the matrix, and peeling off excess material, the patient is wearing their trial smile. This last step takes all of two minutes.

Using this process enables us to do the lab work between appointments, and when the patient returns, they can very quickly preview the possibilities.

It is a wonderful communication tool, because the patient can look in their own mouth, not at a picture of someone else, not at pictures of other shapes of teeth, and say, “I like that,” or “I thought they would be shorter (longer, fatter, narrower…).” You can go in with your handpiece and reshape the temporary material or add material with flowable to make something more pronounced.

Patient participation in the tweaking of the design draws the patient into deeper engagement with and commitment to the smile they want. Now, we can scan the corrected and approved trial smile while it is in their mouth and take photos to send to the lab to help them as we move into the definitive design phase, including working out the occlusion and function.

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Daren Becker DMD

Dr. Becker earned his Bachelors of Science Degree in Computer Science from American International College and Doctor of Dental Medicine from the University of Florida College of Dentistry. He practices full time in Atlanta, GA with an emphasis on comprehensive restorative, implant and aesthetic dentistry. Daren began his advanced studies at the Pankey Institute in 1998 and was invited to be a guest facilitator in 2006 and has been on the visiting faculty since 2009. In addition, in 2006 he began spending time facilitating dental students from Medical College of Georgia College of Dentistry at the Ben Massell Clinic (treating indigent patients) as an adjunct clinical faculty. In 2011 he was invited to be a part time faculty in the Graduate Prosthodontics Residency at the Center for Aesthetic and Implant Dentistry at Georgia Health Sciences University, now Georgia Regents University College of Dental Medicine (formerly Medical College of Georgia). Dr. Becker has been involved in organized dentistry and has chaired and/or served on numerous state and local committees. Currently he is a delegate to the Georgia Dental Association. He has lectured at the Academy of General Dentistry annual meeting, is a regular presenter at ITI study clubs as well as numerous other study clubs. He is a regular contributor at Red Sky Dental Seminars.

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Digital Bite Splints: Part 2

August 24, 2017 Daren Becker DMD

(Link to Digital Bite Splints: Part 1)

If you’re hesitant to start testing out digital bite splints in your practice, read on to learn why one dentist prefers them for improved efficiency and accuracy.

In Part 1 of my thoughts on this topic, I explained the features I love when working with a lab to create digital bite splints. These bite splints have an incredible fit and allow for customizable retention. Below, I round out the rest of my perspective on why they’re a great option for many dentists.

Occlusal Schemes and Adjusting the Digital Bite Splint Design

I’ve played with different occlusal schemes for digital bite splints. I have utilized:

1. A universal flat plane appliance (upper or lower).

2. An anatomic retainer-type appliance we designed to have a little more detail.

3. One anterior repositioning appliance. It was created for a patient who had some recent trauma. We were trying to keep them from seating all the way for a short period of time.

The idea is that you can design the occlusal scheme any way you want. After we send the scan in and the lab does the initial design, they can send us back screenshots that show us what the design is.

When we look at those screenshots, we can make comments on them. If there’s a lot of change – if we want to shallow the guidance, steepen the guidance, or make it thicker/thinner – we can actually go online live with the lab as they enact the changes. We can watch it happen in real time.

Increasing Efficiency by Reducing Chair, Lab, and Adjustments Time

Digital bite splints are a nice, new way to do things. Personally, I think we’re getting a better result. It’s certainly saving us a ton of time, both in terms of lab time (model work time) and chair time because the patient doesn’t need a lot of reline time. Of course, keeping the nasty acrylic out of the mouth is another significant benefit.

You don’t have to spend a lot of time adjusting. The occlusal adjustments are nominal. If we get the records right with the scan, there is very little in terms of adjustments. In fact, that might be the downfall for some of us because we lose a portion of time for the patient to experience things. Sometimes, I’ll spend more time adjusting than I need to. I ensure the patient is engaged and experiencing what an even bite might feel like relative to their natural occlusion. But, in this case, I wouldn’t have to devote that time if I didn’t need to.

Digital bite splints are also really dense. Breakage is going to be a minor problem. They’re going to hold up and last a long time.

What technology are you considering using in your practice? Please leave your thoughts in the comments!

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Daren Becker DMD

Dr. Becker earned his Bachelors of Science Degree in Computer Science from American International College and Doctor of Dental Medicine from the University of Florida College of Dentistry. He practices full time in Atlanta, GA with an emphasis on comprehensive restorative, implant and aesthetic dentistry. Daren began his advanced studies at the Pankey Institute in 1998 and was invited to be a guest facilitator in 2006 and has been on the visiting faculty since 2009. In addition, in 2006 he began spending time facilitating dental students from Medical College of Georgia College of Dentistry at the Ben Massell Clinic (treating indigent patients) as an adjunct clinical faculty. In 2011 he was invited to be a part time faculty in the Graduate Prosthodontics Residency at the Center for Aesthetic and Implant Dentistry at Georgia Health Sciences University, now Georgia Regents University College of Dental Medicine (formerly Medical College of Georgia). Dr. Becker has been involved in organized dentistry and has chaired and/or served on numerous state and local committees. Currently he is a delegate to the Georgia Dental Association. He has lectured at the Academy of General Dentistry annual meeting, is a regular presenter at ITI study clubs as well as numerous other study clubs. He is a regular contributor at Red Sky Dental Seminars.

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Digital Bite Splints: Part 1

August 23, 2017 Daren Becker DMD

The future of dentistry is here: digital bite splints. I’ve used bite splint therapy in my practice successfully for years. I was comfortable with my preferred traditional process until I learned I could work more efficiently and more accurately with the latest technology.

There is no reason to fear implementation of a digital workflow in your practice. In this two part series, I’m going to lay out the reasons why I’ve chosen to switch to digital bite splints for goals like protecting teeth and restorations, deprogramming muscles, and treating TMD.

They’re the productivity solution you didn’t realize you needed.

Less Effective Splint Fabrication Methods

My past process for fabricating occlusal splints (bite splints) was traditional. It included making records, alginate impressions, facebow, mounting, and several bite records (protrusive and centric). We would design and fabricate with cold cure acrylic that we would make by hand, then adjust and modify as needed.

That process works great, which is why most dentists use it. Alternately, some dentists send them off to the lab and have the same process done, possibly in a cured acrylic. But the outstanding process we have transitioned to in my practice is a completely digital designed and fabricated bite splint.

Why I Love the Digital Bite Splint Fabrication Process

The first step for a digital bite splint is to do an intraoral scan of the patient’s dentition. Any scanner can be used. We then send the scans to a restorative lab, where a software package specifically made for appliance design is utilized. The lab designs the appliances to our specifications and then they are milled out of a solid block of acrylic. This leads to an amazingly dense result that polishes unbelievably well.

The fit is incredible because we can get such an accurate scan with no distortion. With an impression, we usually have distortion of the alginate, distortion of the stone, or distortion of the acrylic as it sets, which is why we have to reline them. I have only had to reline two CAD/CAM designed and milled splints since we’ve been doing them. These bite splints are easy to adjust and it’s easy to read the dots on them. They just drop right in with almost no adjustment needed.

You can also dial in the retention on the software, so we’ve played with it a little bit to figure out what we want in terms of retention. We’ve got it just about right where they’re not too loose and not too tight. They have a nice snug fit that’s stable and retentive enough, but doesn’t squeeze the teeth too much.

Keep your eye out for Part 2 of this digital bite splint blog series. Next week, I’ll describe how we play with different occlusal schemes and work with the lab on customization in real time.

What advancements in dental technology are you hesitant to implement in your practice and why? We’d love to hear your thoughts in the comments!

(Link to Digital Bite Splints: Part 2)

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About Author

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Daren Becker DMD

Dr. Becker earned his Bachelors of Science Degree in Computer Science from American International College and Doctor of Dental Medicine from the University of Florida College of Dentistry. He practices full time in Atlanta, GA with an emphasis on comprehensive restorative, implant and aesthetic dentistry. Daren began his advanced studies at the Pankey Institute in 1998 and was invited to be a guest facilitator in 2006 and has been on the visiting faculty since 2009. In addition, in 2006 he began spending time facilitating dental students from Medical College of Georgia College of Dentistry at the Ben Massell Clinic (treating indigent patients) as an adjunct clinical faculty. In 2011 he was invited to be a part time faculty in the Graduate Prosthodontics Residency at the Center for Aesthetic and Implant Dentistry at Georgia Health Sciences University, now Georgia Regents University College of Dental Medicine (formerly Medical College of Georgia). Dr. Becker has been involved in organized dentistry and has chaired and/or served on numerous state and local committees. Currently he is a delegate to the Georgia Dental Association. He has lectured at the Academy of General Dentistry annual meeting, is a regular presenter at ITI study clubs as well as numerous other study clubs. He is a regular contributor at Red Sky Dental Seminars.

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