Caring for a Dental Leaf Gauge

February 21, 2024 Lee Ann Brady

Caring for a Dental Leaf Gauge 

Lee Ann Brady, DMD 

In the Pankey Essentials courses, we use dental leaf gauges to train dentists in how to feel for the first point of occlusal contact, as a method for occlusal deprogramming, and as a tool for articulating models on an articulator in centric relation. Dental leaf gauges not only assist us in diagnosis and treatment planning but also in enabling our patients to discover the nature of their occlusion as we help them understand how malocclusion can manifest in TMD symptoms, parafunction, tooth damage, and more. 

In our Essentials 1 course, I am sometimes asked how to take care of leaf gauges, so I thought I would share my answer.  

Although they don’t last forever, dental leaf gauges do last a long time and you can autoclave them between uses. When you sterilize them, the leaves become sticky, so I separate them like a hand of cards before putting the gauge in the autoclave bag and separate them again when I take them out of the bag just before going to the mouth. 

Over time, with use, a leaf gauge will start to look a little beat up. I’m looking at one now. The Teflon screw that holds it together has turned color from going through the autoclave. I can see some ink stains from Madame Butterfly silk. It’s at the point where I think it looks too grungy to keep using. Although it might continue functioning for quite some time, I’m going to toss it and use a new one. After all, they are relatively low cost with a high return on investment.  

I’ve never seen a dental leaf gauge break after many trips through the autoclave. I tested cold sterilizing one and discovered the chemistry in the ultrasonic cleaner started to make the leaves brittle and they came out stickier than when autoclaved. So, my preference (and the protocol in my practice) is to bag them and put them through the autoclave. 

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Finding a Better Way 

September 18, 2023 DeWittWilkerson

In recent years, dentists, physicians, and the public have become highly aware of the interrelationships among occlusion, oral inflammation, airway problems, and systemic health. As dentists, we’ve stretched our care domain to coordinate patient care across all settings of care. Often, we are dismayed at the growing prevalence of chronic diseases among our aging patients. We want to help improve their lives. We know of ways to do this.

To do our best for our patients, it does matter if the patient has diabetes, cardiovascular disease, sleep apnea, gastric reflux, or poor nutrition. It does matter if we want to be master problem solvers in collaboration with our medical colleagues. Looking for oral and systemic health interrelationships every day with every patient is a basic element of many dental practices. Collaboration with physicians is a basic element of my practice.

Has your approach to patient care extended into at least the first phase of integrative dental medicine? This is the phase of sincerely asking the Why questions and searching for solutions. While I was in practice with Dr. Pete Dawson, for 40 years, I heard him say, “We’re going to ask why about problems until we don’t have to ask why anymore.” He called this “finding a better way.”

The 3 Pillars of Integrative Dental Medicine

In 2019, Dr. Shanley Lestini and I published a book titled The Shift: The Dramatic Movement Toward Health Centered Dentistry. In this endeavor, we were fortunate to have the support and input of two of the world’s most preeminent clinicians and educators, Dr. Peter E. Dawson and Dr. Bradly Bale. It was our goal to influence dentists and medical physicians toward fostering solutions together for their mutual patients in three pillar areas of integrative dental medicine:

  1. TMD and Occlusion
  2. Inflammation & Infection
  3. Breathing and Sleep Disorders

Finding a Better Way Is Up to All of Us

My goal in this essay is to fuel your passion for operationalizing what we all know will make us better doctors – that which will enable us to be truly health-centered dentists. It comes down to relentless curiosity about the causes of diseases, the modalities for eliminating those causes, and how our best “individualized” efforts with a patient will have the greatest positive impact on the prevention, elimination, and management of health conditions that adversely affect their quality of life.

“We’re going to ask why about problems until we don’t have to ask why anymore.” – Peter E. Dawson, DDS

In this era of heightened awareness surrounding the intricate connections between oral health, overall wellness, and the growing prevalence of chronic diseases, we, as healthcare providers, find ourselves at a crossroads. It is our commitment to improve the lives of our patients that propels us forward. Embracing the principles of Integrative Dental Medicine (IDM) beckons us to explore the “Why” questions and seek innovative solutions. Don’t miss your chance to embark on a journey that redefines the boundaries of healthcare with the upcoming course “Integrative Dental Medicine: Creating Healthier Patients & Practices” – for more information visit the course page.

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DeWittWilkerson

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Understanding Smiles Part 3 

August 30, 2023 Bradley Portenoy, DDS

Give patients opportunities to discover what lies beneath their smile

Ewelina is part of my office team. She’s from Poland. She’s beautiful but early in our doctor-patient relationship, I realized she had a closed-smile grin. One day, I asked her if she was aware that she was guarding her smile. She wasn’t but the question made her curious. Later, she came by and said, “I realize it now.”

So, I raised another question, “Now that you notice this, what do you think about your teeth? Were you guarding them subconsciously?”

She thought momentarily and said, “I wasn’t happy with their appearance. I think I unconsciously I do guard my smile.”

So, I raised one more question, “At what point in your life did you say to yourself, I wish my teeth were more attractive?”

Her answer surprised me: “I thought about it when I got married and bleached them, and after I had kids, I thought my teeth looked more unattractive than they did years ago.”

I spoke to Laura Harkin, a dentist I admire, about this. She said that it’s common for women to become more critical of their appearance after having children. Their bodies have gone through so many changes. Ewelina seemed to guard her smile long before she had children so I wondered if there may be cultural differences between her old and new adopted home. I asked her if she became more self-conscious about her teeth after coming to the United States. She answered in the affirmative, “People’s teeth generally look better here than in Poland.”

I loved that there was a long thoughtful pause before her answer. I intentionally gave her time to think between questions. I offered to give her a smile makeover, which she readily agreed to. In doing my case workup, we found she had a two-step occlusion that needed to be corrected. When I got to my wax-up, the anterior changes were minimal and I did an equilibration on the wax-up to try out the results. This set the stage for the changes we would try out in provisional.

Provisional restorations are something I always do to test if the speech will be affected, whether the new occlusion is comfortable, and if the patient feels “good” psychologically about all the changes — not just the aesthetics.

While wearing the provisionals, she began to smile with a Duchenne smile. In photos, I could see a postural difference, too.

My ceramist did an amazing job duplicating in ceramic the provisionals that I created. When the case was completed, I asked Ewelina how she felt. She said, “Great, happy, healthier, cleaner, brighter, very happy.” Cleaner, brighter, healthier, happy – that was a huge learning moment for me! Not once did she mention her teeth, just the feelings around her treatment outcome. It began to dawn on me how much we not only change teeth, but we can change lives!

“I’m happy,” she said. “I think I smile more and I feel like they’re my natural teeth. It’s hard to explain, but I feel like these are the teeth I’ve had all along.”

“How does your bite feel?” I asked. “Were you surprised how the small adjustments made big differences?”

“Before, I felt a little muscle soreness and dull pain back here, but after a day or two of the adjustment, I felt nothing. I feel great,” she said with a big, broad smile.

I think if we spend a lot of time with our patients and develop relationships, it’s ideally like psychological therapy. We give patients opportunities to discover what lies beneath their smile, show them a vision of what could be, and lastly, help them to reach their full potential, as described in Part 1, with a beautiful, confident Duchenne smile.

We have a unique opportunity to not only restore teeth but also change lives through our efforts.

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Bradley Portenoy, DDS

Dr. Bradley Portenoy earned his Doctorate of Dental Surgery with Thesis Honors in Behavioral Science from SUNY at Buffalo School of Dental Medicine in 1985. Dr. Portenoy practices comprehensive relationship-based family dentistry in Rockville Centre, NY. He was one of the first dentists to complete the Pankey Scholar program at The Pankey Institute (2002) and has been on the Visiting Faculty of the Institute since 2005. Currently, he also serves on the advisory board of the L.D. Pankey Dental Foundation, Inc.

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Understanding Smiles Part 2

August 23, 2023 Bradley Portenoy, DDS
Wax-ups are essential for my aesthetic case designs

Part 2 was originally presented to the Restorative Nation in February of 2023: It’s All In The Smile: Psychologic & Technical Considerations – Restorative Nation

My esthetic evaluation is similar to the curriculum taught in the Pankey Institute Essentials and Aesthetic Focus courses. I generally like to look at every aspect of a patient’s smile through photography, with emphasis on the following:
  1. Facial Height – To evaluate possible skeletal defects that can lead to a smile not appearing attractive, I measure the middle 1/3 of the face and the lower 1/3 portion of the face. If there is a one-to-one (1:1) ratio, then I can essentially rule out either vertical maxillary excess or loss of vertical dimension. If there is a one to greater than one (1:>1) ratio, I can look at vertical maxillary excess. If there is a one to less than one (1:<1) ratio, I can look for extreme wear and loss of vertical dimension.
  2. Lip Length — The average woman’s lip is 20 to 22 millimeters in height, and the male’s is 22 to 24 millimeters. Our lips, like everything else sag over time. We lose a mm of tooth display after age 41 at a rate of about one more millimeter per decade.
  3. Lip Mobility — How high does the lip rise when the patient smiles? The average amount of lip mobility is between six and eight millimeters. A hypermobile lip can give the “gummy smile” and fool us into thinking that there is a vertical maxillary excess
  4. Upper Lip Drape — Generally, we like the lip to fall at the free gingival margins of the canines and the central incisors.
  5. Lower Incisal Edges –We like the lower lip to cradle the lower teeth with the line formed by incisal edges following the shape of the lower lip.
  6. Gingival Heights — We like our gingival heights to be symmetrical. I like canines even, the centrals even with the canines, and the laterals a little lower.
  7. Central Incisor Length and Width — The average central incisor is about 10 to 11 millimeters in length, and the average width of a central incisor is about 75% of the length.
  8. Other Anterior Teeth Length and Width — The rule of Golden Proportions says that a central incisor should be proportional to a lateral incisor by a factor of 0.6, and the canine should be proportional to the lateral by a factor of 0.6.
  9. I photograph the patient in repose, their “regular” smile, and then their “biggest E” smile in order to get a sense of how they look when they present with the Duchenne smile. Patients often will give you some form of a guarded or half smile on photographs and that presentation can be misleading. We need to see their full tooth and tissue display to properly evaluate esthetics.

Once I have had a chance to evaluate the virtual patient via photos, printed study models mounted on articulators, and radiographs, I can then propose esthetic changes. I am a huge proponent of fabricating my own “working wax-up” as I like to call it. It is not presentation quality and can be made from wax or old composite. The importance is that it previews the changes that I am proposing, and I use those workups to either make a silicone index for provisionals or I send them to the lab for cleanup and completion. I always keep an original mounted study cast and then have a second model that I play with.

I always start my working wax-ups by placing upper incisors exactly where I want them in the most esthetic position, then I make the rest of the anterior teeth proportional to those incisors. Once the upper anterior teeth are in optimal position, I’ll place or wax the lower teeth to be parallel to the upper and in contact with the upper lingual surfaces of the anterior teeth. In E4 we teach all of the above concepts and discuss how vertical dimension can be evaluated and altered appropriately with the anterior esthetic evaluation. We then look at developing the axial inclination of teeth and posterior occlusal planes to be in harmony with the anteriors.

I encourage all dentists to practice with “working wax-ups.” It truly shows the patient our expertise and artistry in action not just what the laboratory fabricates for us.

Want to see some of the more complex cases I have done? I invite you to view the Restorative Nation video linked above.

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Bradley Portenoy, DDS

Dr. Bradley Portenoy earned his Doctorate of Dental Surgery with Thesis Honors in Behavioral Science from SUNY at Buffalo School of Dental Medicine in 1985. Dr. Portenoy practices comprehensive relationship-based family dentistry in Rockville Centre, NY. He was one of the first dentists to complete the Pankey Scholar program at The Pankey Institute (2002) and has been on the Visiting Faculty of the Institute since 2005. Currently, he also serves on the advisory board of the L.D. Pankey Dental Foundation, Inc.

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Understanding Smiles Part 1

August 21, 2023 Bradley Portenoy, DDS
Smile behavior is influenced by the individual’s feelings about their smile.

Smiles are an integral part of human communication. They make us appear more attractive, approachable, happy, agreeable, and attentive. Studies have shown that people who are happy with their smiles are more confident, have a greater sense of well-being, and this is also reflected in their behavior. In one study, subjects were shown photos of people with nice smiles. The subjects deemed these people as being more socially competent, with greater intellectual achievement and better psychological adjustment. These smiles are contagious and It’s easy to reciprocate when someone gives you that “genuine smile.” We’ve all seen this smile, but what makes it genuine?

There are a variety of smiles that reflect a wide array of emotions. From flirtatious to embarrassed, our smiles reflect our mood and communicate our thoughts. Or do they? When people are unhappy with the appearance of their smile they present a variety of guarding. There’s upper lip guarding, lower lip guarding, both lips guarding, covering one’s mouth with a hand, and of course close lip grins.

As dentists, we must be able to spend time with our patients, to see those smiles, and to delve into why a patient may be guarding. In a sense, we must become esthetic psychologists. It is not an overstatement to say that as dentists, we don’t just change teeth; we can change lives. We can shape how others see our patients. If a patient cannot give a genuine unencumbered smile, perhaps, they’ll miss an employment opportunity or meeting that special someone. Perhaps they’ll be seen by others as unfriendly or unapproachable.

So, is there a “genuine smile” that can be quantified? In the 1800s, a French anatomist by the name of Guillaume Duchenne sought to answer that question. Duchenne, through stimulating facial muscles, found that the most genuine, sincere smile occurred when 3 muscle groups fired: the orbicularis oris and zygomaticus major in the mouth and the orbicularis oculi of the eye forming crows’ feet.

Most consider the resulting Duchenne smile to be the genuine smile that is spontaneous and sincere. Studies have shown that this type of smile can elevate mood, change body stress response, and is responsible for the release of endorphins, dopamine, and serotonin. In all, the Duchenne smile is the Holy Grail. It is certainly about the smile but a major component is the formation of crows’ feet around the eyes. Just think of the song When Irish Eyes Are Smiling. The Duchenne smile in all its splendor is sure to steal your heart away. My point is that we need to remember that the Duchenne smile is about the mouth AND the eyes; these elements are interconnected.

What we’ll need to evaluate as Dentists is whether Botox injections and plastic surgery affect the Duchenne smile. Certainly, in the case of the Botox smile, the answer is yes since the elevator muscles of the mouth are injected thus altering the Duchenne muscle contractions. Obviously, it is vital then to take a good health history and determine whether a patient is smile guarding or simply cannot fire the muscles that make up the Duchenne smile.

In making dental changes, we change lives. We shape how others see our patients and how they see themselves. This is priceless work. It is worthy work. But until a patient desires the best results that today’s dentistry can achieve and trusts us to execute the technical aspects of their new smile, we are in listening, understanding, and guidance mode. We are leading them forward with primary, essential care and taking them on a long journey to achieve what is possible. With each new dental restoration, they may smile more broadly and lift their head higher. They will feel the release of endorphins and serotonins. They will experience the positivity of greater self-confidence.

Artful comprehensive dentists are like behavioral psychologists who have the sincere intention of doing their utmost for the benefit of their patients.

You know what greater smile benefits are possible if the patient understands and wants to continue with aesthetic treatment. Patience is a virtue. So, spark the curiosity of your patients and lead gently but with confidence. Never forget that a patient who is concerned about the cost of elective treatment today will be thanking you profusely two to three years from now and saying the decision to move forward with a comprehensive smile makeover was one of the best decisions of their life.

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Bradley Portenoy, DDS

Dr. Bradley Portenoy earned his Doctorate of Dental Surgery with Thesis Honors in Behavioral Science from SUNY at Buffalo School of Dental Medicine in 1985. Dr. Portenoy practices comprehensive relationship-based family dentistry in Rockville Centre, NY. He was one of the first dentists to complete the Pankey Scholar program at The Pankey Institute (2002) and has been on the Visiting Faculty of the Institute since 2005. Currently, he also serves on the advisory board of the L.D. Pankey Dental Foundation, Inc.

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Expansion of the Adult Palate 

August 16, 2023 Lee Ann Brady DMD

When I first came out of dental school, palate expansion with an orthodontic device was limited to children and young adolescents. We thought the palatal suture was closed and fused, and we could no longer use a fixed orthodontic device to change the shape of the maxillary arch and expand the palate. Today we know that we can do palate expansion for patients who are older, and we have the additional ability to do surgically facilitated orthodontic treatment.

Why is this important?

Because today we understand how the shape of the maxillary palate, the shape of the arch form, and the ability to put the tongue solidly against the roof of the mouth have a positive impact on eliminating apnea, hypopnea, and breathing issues.

At what age is palatal expansion with an orthodontic device no longer effective?

I asked this question to two board-certified orthodontists whom I respect. And interestingly, I got the exact same answer. They both said that until age 35 we can get palatable expansion with a fixed orthodontic device. And after age 35, it may work but it becomes unpredictable. The older a patient is beyond their mid-thirties, the less predictable the results are. The patient must understand this when they accept treatment.

When I inquired if they had attempted palatal expansion on a patient over 35, both orthodontists said they had done so with good results, but treatment is slower and thus takes longer. They explain to patients that they can try surgically facilitated ortho with a palate expander, and if it doesn’t work, there is a pure surgical solution. The patient can choose to skip over the orthodontic device and go straight to the surgical solution. They fully inform the patient about the options, and the risks and benefits of treatment. They’ve had adults over 35 choose to proceed with treatment.

Up until age 35, palate expansion with an orthodontic device is predictable and a treatment we can confidently recommend. There are alternative treatments for adults over age 35.

Can Invisalign or other aligners expand the palate?

Aligners do not expand the palate. They can, however, widen the arch and alveolar bone by 1 to 2 mm. Putting this in perspective, this is a widening of less than a tenth of an inch (about 0.08 in). Aligner treatment can be used to reposition the teeth to make more space for the tongue to press solidly or more solidly against the roof of the mouth. For many adult patients, this is a treatment modality that improves their airway.

The goals of palate expansion with an orthodontic palate expander or pure surgery are to achieve greater than 1 to 2 mm of expansion.

At the Pankey Institute

Comprehensive dentistry that addresses the airway and breathing is a common topic of conversation among dentists who participate in Pankey courses. We welcome these conversations. Because every patient presents with a complex of factors, I advocate for a holistic approach to looking at underlying causes of apnea, hypopnea, and breathing issues.

At Pankey, we have a very in-depth Essentials Series that cover an array of important dentistry topics. During our Essentials 1 course, we include a special Airway Management section for dentists to practice on a regular basis. Check out our upcoming course dates here.

Here are four Pankey Webinars you may want to view to develop your understanding of the importance of the airway in the patient’s total health and what dentists are doing to integrate airway support in their practice. It’s exciting to see the expertise that has developed among our faculty and participants. Some have developed into niche providers to better serve the needs of their communities.

  1. The Goals of New Orthodontics: How Airway Thinking is Impacting Dentistry
  2. Breathing and Airway Support
  3. Open the Airway Tonight and Other Tips from the Dental Sleep World
  4. Airway Centric Dentistry

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Lee Ann Brady DMD

Dr. Lee Ann Brady is passionate about dentistry, her family and making a difference. She is a general dentist and owns a practice in Glendale, AZ limited to restorative dentistry. Lee’s passion for dental education began as a CE junkie herself, pursuing lots of advanced continuing education focused on Restorative and Occlusion. In 2005, she became a full time resident faculty member for The Pankey Institute, and was promoted to Clinical Director in 2006. Lee joined Spear Education as Executive VP of Education in the fall of 2008 to teach and coordinate the educational curriculum. In June of 2011, she left Spear Education, founded leeannbrady.com and joined the dental practice she now owns as an associate. Today, she teaches at dental meetings and study clubs both nationally and internationally, continues to write for dental journals and her website, sits on the editorial board of the Journal of Cosmetic Dentistry, Inside Dentistry and DentalTown Magazines and is the Director of Education for The Pankey Institute.

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Brux Checker® Foil: A Great Way to See Tooth Wear Patterns

June 26, 2023 Lee Ann Brady DMD

Sometimes we suspect a dental patient has tooth wear or damage from attrition. In these cases, we want to help the patient understand what they do with their teeth while sleeping. We also want to see for ourselves the patterns of wear. I recently learned about the Brux Checker® diagnostic material during the 2022 Masters Week at The Pankey Institute.

During Masters Week, Dr. Ricardo Armanetto from Genoa, Italy, showed us this material, which is 0.1 mm in thickness. One side of the material is red, and the other is foil. The material can be placed in your MiniStar®, BioStar®, or Vaquform thermoformer to create a suck-down device that your patient wears over their upper arch overnight. A suggestion is to make two of these devices and ask your patient to wear one for one night and one for a second night.

If the patient is para-functioning during sleep, they will wear the red off the device in the places where their teeth are touching within 0.1 mm of each other. You will see which teeth are touching and grinding.

In thinking about using Brux Checker, the following cases came to mind:

  • Brux Checker is designed as a patient education tool. I want to use Brux Checker for patients I think are para-functioning because of signs of wear and attrition—and now I need them to take some ownership of their parafunction. This is an easy, inexpensive way to do that, in addition to the QuickSplints I use in my practice.
  • I also want to use Brux Checker with patients I have equilibrated to double-check my equilibration. Sometimes, when the patient is in the dental chair, it is difficult for the patient to find a posterior interference that I failed to clear out. I want to ensure they are not damaging their teeth while para functioning on molars during sleep.
  • Similarly, after placing dental restorations, I can use Brux Checker to fine-tune the occlusion after seeing what happens during the night versus in my dental chair.
  • In the case of Class IV corners or incisal edge repairs that people want to be replaced in composite and the composite pops off, they may not know that they parafunction and there is a need to fine-tune their occlusion. I don’t know if I can get one of these patients to wear a Brux Checker during the daytime, but it should be easy to get them to wear one of these devices during the night. If the red wears off the foil at the spot where the composite has been used to repair a Class IV corner or incisal edge, there will be no question about the stress they are placing on the repair.

You can see that I’m thinking beyond patient education to using Brux Checker to help me fine-tune someone’s occlusion. I know there are places where people bring their teeth together at night that they can’t show me in the chair.

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Lee Ann Brady DMD

Dr. Lee Ann Brady is passionate about dentistry, her family and making a difference. She is a general dentist and owns a practice in Glendale, AZ limited to restorative dentistry. Lee’s passion for dental education began as a CE junkie herself, pursuing lots of advanced continuing education focused on Restorative and Occlusion. In 2005, she became a full time resident faculty member for The Pankey Institute, and was promoted to Clinical Director in 2006. Lee joined Spear Education as Executive VP of Education in the fall of 2008 to teach and coordinate the educational curriculum. In June of 2011, she left Spear Education, founded leeannbrady.com and joined the dental practice she now owns as an associate. Today, she teaches at dental meetings and study clubs both nationally and internationally, continues to write for dental journals and her website, sits on the editorial board of the Journal of Cosmetic Dentistry, Inside Dentistry and DentalTown Magazines and is the Director of Education for The Pankey Institute.

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The Art of Influencing Our Patients Part 4: An Opportunity to Collaborate

June 23, 2023 Mary Osborne RDH

After practicing dental hygiene for more than twenty years, I went to work in the office of Dr. Doug Roth who was attending courses at The Pankey Institute. He had a copy of Dr. Bob Barkley’s book, Successful Preventive Dental Practices. Reading that book was a revelation for me. Although I never knew Bob Barkley, his work so resonated for me that I had the feeling he had read my thoughts about working with patients.

I had believed for some time that more was possible in dentistry. I had worked with good dentists and felt as though I took good care of my patients in the time I was allowed to spend with them. We were kind, thorough in our exams, and conscientious in treatment recommendations. Sometimes they took our recommendations, and sometimes they did not. I did not think there was much we could do to change that.

As a result of Bob Barkley’s book and the courses Doug was taking at the Pankey Institute, we incorporated a new model for bringing new patients into the office. Instead of moving patients quickly through an exam and treatment recommendations, we invested time and attention to get to know patients in a different way before we recommended significant treatment. I had no idea of the depth of connection we could have with patients, and the impact we could have on their health and well-being!

We spent “engaged” time with patients over a variety of appointments. We came to understand that the clinical tasks we had to accomplish were a small part of caring for patients. We began to see every interaction, with every patient, as an opportunity to get to know them and what was important to them to help them make healthy choices.

Over time we discovered with our patients:

  • The status of the dental health
  • The challenges of their current conditions
  • The implications of these conditions if nothing was done to intervene
  • Interventions they and we could do to change the trajectory of disease.
  • A possible preferred future of choice
  • Considerations involved in various treatment choices.

When we met patients where they were instead of where we thought they “should be” we found that some were ready sooner than others. We stopped giving patients solutions to problems they did not yet own. We came to understand that if we gave patients the time and attention they needed to own their existing conditions they were more curious about what Dr. Barkley called their “Probable Future” and more likely to pursue a “Possible Future.”

Without this spirit of collaboration and intentional patient development, we cannot do our best work.

Our influence develops throughout a process in which the patient is learning, in touch with their body, and engaged in thinking about the implications of the various aspects of their oral health. Because the conditions we discover today and our patient’s choices will impact their future health, we have a moral obligation to share what our experience tells us is likely to happen (the probable future) if they do nothing or if they choose a stop-gap treatment.

It is also our responsibility to help them see a preferred future that is possible for them when they are ready.

By engaging them in the exam process, creating opportunities for them to experience learning about their health, and welcoming them into collaboration, we enable them to partner with us in shaping their future. We must help them understand the implications of any choice they might make including its limitations, so they are fully informed to make true choices.

We have been trained to be efficient, and most dental clinicians have pride in their efficiency. But by prioritizing being “effective” over being efficient we make better use of our time and theirs. We experience an increase in trust, in our patient’s confidence in their decisions, and a more comprehensive view of treatment. Patients begin to see dentistry as a vehicle to create optimal health, function, and esthetics. Patients are more likely to keep their appointments, follow through on suggestions, and pay for our care with gratitude.

When we invest time in the early stages of our relationships, everything down the road flows more easily.

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About Author

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Mary Osborne RDH

Mary is known internationally as a writer and speaker on patient care and communication. Her writing has been acclaimed in respected print and online publications. She is widely known at dental meetings in the U.S., Canada, and Europe as a knowledgeable and dynamic speaker. Her passion for dentistry inspires individuals and groups to bring the best of themselves to their work, and to fully embrace the difference they make in the lives of those they serve.

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The Art of Influencing Our Patients Part 3: An Opportunity to Engage

June 19, 2023 Mary Osborne RDH

Many times, patients have some sense about their overall health, but have no idea about what is going on in their mouths. They tell us they’ve never looked in their mouths. Our challenge is to engage them during the exam process in such a way that it raises their curiosity and awareness.

Our goal should be for patients to be so engaged in the exam that they continue to pay attention to their mouths, even when they leave our office. As they are driving home, we would like them to be touching their facial muscles. We would like them to be paying attention to how their teeth come together when they take out a nightguard in the morning. We would like them to notice if there are points of bleeding when they floss. As they go about their lives, we hope they pay more attention to all the things we talked about.

Think of engagement as being like the gears on a bicycle. If the gears on your bicycle are not engaged, the bike will not move forward. You may be inclined to pedal harder, but you are still going nowhere. Similarly, if a patient is not engaged, you might be inclined to give them more information. But you might as well stop talking because you are probably going nowhere.

Engagement has been described by educators as when the student is working at least as hard as the teacher.

We all know what patients look like when they are engaged. They ask questions, they touch their faces, they lean forward, or they point to images on the computer monitor. They give us signals that they are paying attention. On the other hand, when a patient’s eyes glaze over and they blankly nod, it’s a good indication they are not engaged. When you notice that polite smile, stop talking and look for a way to engage them in the process. You might ask them a question. “I know I’ve been giving you a lot of information, and I’m curious, what are your thoughts about what we have discovered so far?”

One of the things I like to do when I begin the exam process is to ask the patient to hold a mirror in case I have some questions for them as we go through the exam. Most patients will take the mirror and put it on their lap. I look for the first opportunity to ask any kind of question that involves the mirror. I might ask them to bring the mirror up to their face and show me in the mirror an area they mentioned as a concern. I might ask them to point to changes made in their mouth by orthodontics and restorations and inquire about how they feel about those changes. Once they do, they are more engaged and understand that what they are telling me has relevance. They begin to see themselves as part of the process with expertise about themselves.

We want to engage as many of the patient’s senses as we can…seeing…hearing…touching… tasting. As I examine the mouth, I might say, “I notice that when I slide the perio prob into this deeper space between the tooth and the gums, there is bleeding. Do you ever see or taste bleeding there?” Their personal involvement in the exam gives rise to questions that are opportunities for them to connect what is going on in their mouth with their self-care behaviors and the choices they will have about seeking treatment from us.

We don’t want our patients to just comply with our recommendations. We want them to be actively engaged in understanding, planning, and working toward improved health. We want them to feel responsible for their choices and to partner with us in improving their health.

Engagement leads patients to take ownership of their health and make healthy choices.

After the next exam or consultation you do with a patient, consider:

  • How engaged was the patient?
  • How much “work” were they doing relative to how hard you were working?
  • What did you do to activate engagement?
  • If you could do it all over again, what “one more” question could you have asked the patient?

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About Author

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Mary Osborne RDH

Mary is known internationally as a writer and speaker on patient care and communication. Her writing has been acclaimed in respected print and online publications. She is widely known at dental meetings in the U.S., Canada, and Europe as a knowledgeable and dynamic speaker. Her passion for dentistry inspires individuals and groups to bring the best of themselves to their work, and to fully embrace the difference they make in the lives of those they serve.

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The Art of Influencing Our Patients Part 2: An Opportunity to Develop Patient Understanding & Confidence

June 16, 2023 Mary Osborne RDH

In dentistry, we’re clear about the connections among the teeth, the muscles, the bone, and the joints—and how all these pieces are related to esthetics. We understand how those pieces fit together. Unfortunately, most patients don’t come to us with that understanding.

Dr. Bob Barkley used to talk about patients not understanding “the web”—the connection of how all the pieces come together.

Just as with a delicate spider web, if you touch any one aspect of it, you change everything. Bob Barkley would say to his patients, “I know you are concerned about that one tooth. That’s your job to be concerned about that one tooth. My job is figure out and to help you understand how what’s happening with that one tooth is related to everything else that is going on in your mouth.”

The exam is a process by which we can do exactly that. We can help our patients understand the connections in their mouths. The exam is also an opportunity to encourage our patients to have confidence in us. Confidence building starts with the new patient exam and continues in subsequent interactions. The more thorough the examination we do, the more in touch we are with what is really happening in our patients’ mouths and the more confident patients will feel about our ability to help them.

Our thoroughness and knowledge aren’t the only aspects of the exam that develop patients’ confidence in us. The gentler we are in our touch and the more careful to include the patient or others in the room during exams are important. These aspects of the exam communicate our character and the way we tend to approach our work. Patients anticipate our care and approach will be similarly open and comfortable during future consultations and procedures.

People don’t take risks when they don’t feel confident. Unfortunately, many patients do not have confidence in making decisions for themselves when they sit in a dental chair. They think of significant dentistry as a risk. For best long-term results and positive relationships, we always want the patient to feel as strong and confident about their choices as they can.

Repeated comfortable interactions are needed for them to develop their confidence. Every time we find something good in their mouth, every time we point out health such as healthy gum tissue or a beautiful restoration, and areas not needing restoration, we are reinforcing healthy choices they made in the past. This can be a confidence booster to help them move forward in making next choices.

The examination process is an opportunity for the clinician to:

  • Understand what the patient is experiencing emotionally and physically,
  • Provide sensory learning experiences (see Art of the Examination: Part 1),
  • Help the patient draw connections for deeper understanding of their health
  • Explore options for what the patient might choose to do.

The examination is an opportunity for the patient to develop understanding of:

  • The clinician’s ability to help them.
  • The current condition of their teeth and other oral structures.
  • The impact on them of what they are learning.
  • The choices they can make to improve their health.

Every examination is a next opportunity to develop our patients’ confidence in us and in their ability to make healthy choices for themselves.

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About Author

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Mary Osborne RDH

Mary is known internationally as a writer and speaker on patient care and communication. Her writing has been acclaimed in respected print and online publications. She is widely known at dental meetings in the U.S., Canada, and Europe as a knowledgeable and dynamic speaker. Her passion for dentistry inspires individuals and groups to bring the best of themselves to their work, and to fully embrace the difference they make in the lives of those they serve.

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I AM INTERESTED IN

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