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.

Team members can become a bit tunnel-visioned. Their day-to-day work life and CE are focused on topics related to their niched responsibilities, which puts them on an island of their own. One of my hopes is that all my team members — including hygienists, dental assistants, and administrative team members — will learn about all we do in our dental practices.

Faculty meetings at The Pankey Institute always invigorate my thinking about the Institute’s curriculum and the teaching I do with my own team members. Freshly energized by the last faculty meeting, I am writing my thoughts to hopefully inspire the many of you who are not faculty but, like us, have enthusiasm for leading your teams to a broad and deep understanding of the dentistry you practice.

In my own office, one of the things I look for in hiring is team members who are interested in learning, interested in dentistry and are even passionate about dentistry. They want to know as much about it as they possibly can. And one of the things I pay attention to is providing opportunities for them to learn about the many aspects of dentistry.

For example, I want my hygiene team to understand what happens in the restorative operatory. They don’t often get to see me working with a patient because they are busy with their own patients. But when they see a beautiful veneer case that we’ve done, I would love for them to have some background in the considerations and decisions that went into that treatment…the knowledge, the technique, the materials, and even the patient’s experience during treatment.

When hygienists see our patients, they may think something could appear better, for example, a crown margin. It helps them put what they are seeing in perspective if they have some understanding of the techniques, materials, and complexity. And I want to know the questions and concerns that occur in their minds as they do their hygiene exams. I also want them to understand the dentistry we offer in our practice so they can better answer questions and advocate for a treatment plan that hasn’t moved forward.

I want them to take CE that elevates their hygiene skills. I also want them to be fully integrated into our team and understand everything that happens in our office, so we can all work collaboratively to create more effective outcomes for our patients.

Accomplishing this requires that we set aside time and take advantage of open time. In my office, I regularly review a variety of cases with my clinical team before, during, and after treatment. This involves more than meetings in my consultation room. Sometimes, it involves chairside observation and conversations. Most of my patients are eager learners who appreciate the chairside teaching that I do with my team members. They are simultaneously learning and coming to a greater understanding of their dentistry.

I often hear that dentists return to their practices after a Pankey Institute continuum course or seminar with the inspiration to share what they learned with their teams—the enthusiasm for learning spills over naturally in the week following the dentist’s CE. Take advantage of that energy at that moment, and while you are excited make a commitment to continue sharing your knowledge on a regular basis, interesting case by interesting case.

In your dental practice, it’s important to create a restorative partnership with your assistants, hygienists & front office team. Make the handoff between your team seamless, build a stronger team & create lasting patient connections. Check out our three Pankey Team Courses that are coming up: Team Series.

Change can be difficult even when it has benefits for everyone.

Some people are simply averse to any kind of change. As a result, we may encounter pushback from staff while attempting to initiate changes in protocols, practice policies, or practice systems. Anticipating and preparing for potential negative feedback is the best way to defuse staff concerns and smooth the way for needed change.

There are two prerequisites to navigating change successfully. First, the staff must believe that we have their best interest in mind. This is a matter of trust that is developed over time. Secondly, the staff must feel safe in offering unfiltered feedback before and during the change initiative. As the leaders of our practice, we are responsible for creating a practice environment that makes both of these essential prerequisites possible.

The following suggestions will prove helpful in developing a change strategy.

1. Be prepared.

Before introducing any change initiative, we must have clarity regarding the necessity and advantages of the proposed change. Painting a clear picture for the staff that includes the specifics and anticipated benefits is an essential first step. Anticipating the staff’s concerns and potential questions as well as our response will help in creating a smooth presentation. Set the expectations for how everyone might feel throughout the different stages of the transition, for example: resistance, frustration, skepticism, excitement, relief, and high energy.

2. Seek early adopter support.

Identify those people that are likely to support your ideas and seek their help in moving a change initiative forward. Most likely, these will be the leaders of the clinical and administrative staff. Collaborate with them in creating the best possible change model. By allowing them to contribute their input, they are much more likely to buy into the concept.

3. Present the change Initiative with humility and transparency.

“My way or the highway!” is the worst possible way to present any significant change. We gain acceptance by being as transparent as possible and patiently addressing staff questions and concerns. Seek collaboration and request input. Be more coach-like by using open-ended questions to draw out their underlying concerns, for example, “What concerns you about this?” and “What would need to happen for you to feel better about this change?”

4. Ask for their help.

There is something about asking for help that creates buy-in. Let your team know that you cannot achieve the desired result without their help. If the intended change is experimental in nature, let the staff know that it is reversible if the desired results are not achieved. Ask them how they think that they can positively contribute and re-affirm how important their role is in the process.

5. Consider scheduling more frequent staff meetings during periods of change.

Depending on the nature of the anticipated change, more frequent staff meetings may be necessary to address concerns and problems that may arise. For example, changing practice computer software seems to be problematic and frustrating for both clinical and administrative staff. Allowing more time to address the technical issues and frustrations of the staff has proven to the most effective means of addressing both issues.

6. Check in frequently with the staff:

Although checking in with our staff should be a common practice, it is most beneficial during periods of change. Simple questions like “How is it going?” or “What do you need from me now?” are a quick and simple way of letting your staff know that you recognize and appreciate their efforts in making the change a reality.

7. Celebrate the staff’s accomplishment:

Whenever the change is fully implemented there should be time for celebration. Consider doing something special for the team as a means of recognition for a job well done. An appropriate bonus and/or a special event away from the office are ways of expressing gratitude. Never pass up celebrating a team’s successful effort in achieving change.

How about a fun pre-pandemic memory? I was on a vacation cruise and had sought out a lounge to do my yoga privately early in the mornings. One morning, I arrived to find easels displaying paintings along the walls of the lounge and a team of people from the Art Gallery. One woman held up a camera and said, “Okay, go!” Then, four others ran along the sides of the room, picking up the paintings and rushing them up to the front of the room. Then they ran back, folded the easels, and moved them as well. The woman with the camera said, “You did it,” and everyone cheered and clapped.

Later that day, I ran into the woman who had held the camera. I had to ask… you know I did, “What were you doing in the lounge this morning?” She told me that every few months they do a quality control exercise to demonstrate they can breakdown the gallery in less than five minutes, because sometimes they only have five minutes to clear the lounge between events.

I had to ask… You know I did. “So, how well did you do?” She told me they were excited to do it this time in just over a minute. She was beaming from ear to ear.

So, that got me thinking…. You know it did. Turning a task into something fun can be energizing. In dentistry, we have to breakdown operatories and setup operatories all the time. What if, while following infection control guidelines and all things OSHA, there was still an element of fun in periodically demonstrating we can do this task at high speed? What record can we beat?

While I was on this same cruise in the Caribbean, it was flu season. There were bottles of hand sanitizer everywhere, and going into the dining room, there were four stations where you could stick your hand under an automatic dispenser. The cruise line did not want to leave it up to the honor system for passengers to clean their hands, so they had come up with a fun way to make us do it. Two men with Caribbean accents and funny attire greeted everyone coming into the room. They had Bluetooth speakers and danced as they said to everyone, “Washy, washy, yay, thank you.” So, every time I went into the dining room, I had a little dance with these gentlemen and sanitized my hands. For the entire cruise, everyone sanitized their hands upon entering the dining room!

During the final night’s dinner celebration… you know the one, where they bring in the blazing dessert and dance in a Conga line to “Hot, Hot, Hot,” the “Washy, washy” guys got on the microphone and thanked us for sanitizing our hands–and allowing them to help keep us healthy. Of course, we all cheered. We loved these guys!

So, that got me thinking… you know it did! They had found a fun and engaging way to improve our health and make us feel good about following the rules. I hope you noted that in my two cruise ship stories, having fun with systems increased the group’s performance. Research consistently demonstrates that when team members are enjoying themselves, work is performed at a higher caliber and with less stress. When patients are enjoying themselves, their participation in their own health is greatly improved.

I know dental care teams well, and they love a creative challenge. Where do you have systems that are trending boring that your care team might add a little fun and spice to? Have some great examples to share? Add them in the blog comments.

When I think of the small things my practice does on an everyday basis that have a big impact on patient relationships, patient satisfaction, and case acceptance, the first thing that comes to mind is what we call check-in and debrief.

Early in my practice years, way back when I was practicing corporate dentistry, when I walked into the operatory, the patient already had topical in place and my job was to get them numb. There wasn’t much of an opportunity to have a conversation. Over time, I learned the concept of check-in and debrief, which is really about how you can use the time at the beginning and end of the appointment to influence the relationship you have with the patient.

These are ideal times to build value for what the patient has agreed to do at that appointment and to tie the goals of the patient to the value of the treatment the patient is receiving, or you hope the patient will accept.

Usually, the check-in and debrief each take about two minutes. My assistants participate in this process with me, so they have increased understanding as well.

Previous Conversations Inform Me

I can be mindful and successful with my conversations if previous conversations with the patient were documented. My assistants take notes for me during my conversations with patients. I need to know:

• What is important to them,
• What they are hoping for, and
• What could get in the way of accomplishing what they believe is best for themselves?

My Check-in Conversation

During the check-in, I aim to converse about what we have planned to do and how this fits the overall goals of the patient. Usually, I enter the room and there is a little chit-chat. Then I ask, “What is your understanding of what we are going to do today?” The response helps me gauge the patient’s awareness. Following this conversation, I may ask, “What is your understanding of how this is part of your long-term health plan?” Or, if the patient has a stated a good understanding of what we are going to do, I say, “Yes, and this is how it fits into your long-term goals for your teeth.” They should now have a good sense of why the appointment time is of benefit to them.

My Debrief Conversation

During the end-of-the-appointment conversation, I aim to thank the patient for being cooperative, talk about what they can expect as a result of today’s appointment, and what they can expect as we move towards their preferred future. No matter what happened during the appointment, I want my patients to hear how much we appreciate them being our patients and being there today. When we talk about what to expect from today’s appointment, we can go over any post-op instructions, which are also presented in written form. Lastly, I want to give them hope that we are accomplishing steps on the road to their preferred future and that we can get there with their continued cooperation. I want to see the rays of hope register on their faces.

I believe all of this is of high value to the patient personally and in building value for the practice. It is well worth the time, and for me, it is a standard part of every patient visit.

Despite headlines you may have read, heart disease is still the number one killer in the U.S., followed by cancer and then (hopefully only temporarily) COVID-19. Gum disease is on the rise in this country. This condition affects much more than just a person’s mouth. We need to shut down the dangerous anaerobes that live in our tissue and bone that drive the oral and systemic inflammation. The bacteria that live in our mouth do not stay in our mouth! Hygienists are not only cleaning deposits off of teeth; they are managing dangerous bacteria and saving lives!

Patients see their dentist more often than they see their physician. The start to providing optimal care is having informative conversations with our patients when discussing their health history, their medications, and the tie in their periodontal and endodontic health.

Married to a cardiologist, it was beneficial for both my dental patients and his medical patients to receive integrative care, and to that end, we worked together to build a center for my restorative practice that includes oral-systemic health diagnostics, counseling, and treatment.

Pushing the Standard of Care

My practice, Complete Heath Dentistry of Columbus, is distinguished from other practices by pushing the standard of care to treat patients based on his or her risk factors for developing systemic health issues. Saliva/oral DNA testing enables us to take this proactive health approach. This testing allows us to learn if our patients have dangerous oral pathogens. It helps guide us on how to better treat our dental patients with periodontal therapy and with oral probiotics, as well as Perio Protect trays.

My husband, Dr. Eric Goulder, and I opened the first medical center in the United States with an accredited Cardiologist and Dentist to practice the Bale Doneen Method testing and care under one roof. We passionately believe a medical Bale Doneen provider cannot optimally help their patient without the assistance of a dental team that understands the value of their work.

With every patient, we discuss oral health risk factors for cardiovascular disease and strokes. We use saliva/oral DNA testing to proactively calculate the CVD risks of our patients with the recommendation they create a health plan with their doctor geared toward overall health. With focus on prevention and the elimination of disease, we work with patients to achieve optimal oral and systemic health.

Pushing Dental-Medical Integration

Across the country, dentists are teaming with cardiologists to better understand the oral-systemic connection and to help their patients discover developing risk factors for heart attack and stroke, among other diseases such as diabetes. You do not have to have a cardiologist under your roof to similarly help your patients.

You can explain to your patients that one of the most painless tests that can reveal hidden heart attack or stroke risks is a carotid artery scan (CIMT scan) that measures carotid intima-media thickness. It is an important test for individuals with few risk factors for developing cardiovascular issues. Under traditional care, 75 percent of heart attacks happen in people with normal cholesterol levels. Through this no radiation ultrasound procedure, the neck is examined so that a doctor can uncover whether or not a patient is heading for health problems. This screening detects atherosclerosis, a condition where deposits hide within the arteries. Also, it is possible to find the “age” of a patient’s arteries.

Through CIMT ultrasound testing, a cardiovascular problem can be identified 10-15 years prior to an event. While 50% of the population does not know they have a growing cardiovascular problem, this simple test provides an early diagnosis for lifestyle counseling and dental-medical treatment.

Working with your patients and their physicians, you can also recommend the NT-ProBNP blood test that is a part of the blood testing involved with the Bale Doneen Method. This test measures the amount of BNP in the blood.  When the heart is under stress, the body excretes high levels of this substance. If elevated levels are detected, it is a red flag that a person may be heading for a stroke or heart attack.

Dr. Eric Goulder and I are on a mission to push physicians to be proactive, to understand what is going on inside arteries, discover why the disease is present, and observe the disease stabilize after treatment. I encourage you to become familiar with the Bale Doneen Method if you have not already done so and become familiar with cardiologists in your area who can be of assistance to your patients. Two-way referrals are a natural outcome of developing these relationships, and patients are very appreciative.

When I was 19 years old, I started to work as a dental assistant and front office person. In 2003, after 9 years of temporary hygiene work and multiple associate positions, I opened my own dental practice. To obtain bank funding, I had to write a business plan and a vision statement. In 2001, I wrote the following vision statement for the practice I wanted to create. I often look at this statement and find that it still stands true and even more so as time goes on.

My Vision, circa 2001: To create an environment full of learning and growing, that is open and honest, in order to provide individual optimal care with compassion and mutual professional respect for each other and our clients.

Over my years in practice, I have increasingly realized that that a culture of collaboration in the practice is essential for providing the comprehensive quality care that I’ve learned at The Pankey Institute—the care I believe patients deserve to receive.

The Benefits of Team Collaboration

A healthy and positive office culture is not only important for patients, but also for the team, including the leader!

• Healthy Relationships: A culture that is inclusive, compassionate, empathetic, and safe creates healthy relationships that are supportive, understanding, and positive.
• More Appropriate Solutions: An environment that is based on abundance versus scarcity is one that allows an organization to build on all the strengths and positive aspects of every team member. In fact, it is my belief that all team members’ perspectives are valuable. Solutions are more creative and appropriate when there is input from all perspectives of the team. Diversity in thoughts and ideas provides a pathway toward implementation and outcomes that are sustainable, because collaborative agreements are better suited for everyone involved—the leader, team, and patients!
• Increased Trust, Individual Growth, Leadership, and Fun: The fruits of genuine collaboration are trust, appreciation, and ownership…and so much more! Genuine collaboration facilitates learning, growth, accountability, and individual leadership for all members of the practice team. Collaboration breeds shared responsibility, less isolation, and more fun!

Steps Towards the Creation of a Collaborative Team

1. Establish your WHY. The first step is to create a shared vision of your purpose. Why do you do what you do every day? What brings you joy?
2. Stay in Kindness. An office culture built on mutual respect and trust allows for more effective collaboration. Be humble and focus on the strengths of each team member. Stay centered in giving one another the benefit of the doubt. Others will reciprocate with kindness when you are kind and fair. I always think, Do the right thing and the rest will follow.
3. Share. Share your expectations of how you will achieve your shared purpose and vision. Be vulnerable by sharing your needs and desires for achieving the shared purpose and vision.
4. Formulate agreements. Come to shared agreements to help, support, and keep one another accountable in the process of collaboratively reaching your shared vision of your purpose.
5. Celebrate. An important, solidifying step is to enjoy the process of collaboration, celebrate your successes, and have fun along the way!

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Christine Shigaki, DDS is a private practicing dentist in Seattle, WA.
She can be reached at cshigaki@gmail.com

It was August of 1995 when I first walked through the doors of The Pankey Institute.

At that time, I had only one year of experience under my belt as a licensed hygienist, and I believed I had won the “dental lottery” by having spent the past six months working for a Pankey Institute trained dentist. Dr. Steve Ratcliff was passionate about the Institute and his philosophy of care that was inspired by what he was learning there. He proudly shared everything possible with me about how he wanted our practice to develop.

It was a hands-on perio course at the Institute where I eagerly learned about non-traditional use of Gracey currettes, utilization of ultrasonics, and the current science of periodontal disease and its management with Dr. Sam Low. I remember being so nervous and so excited. There were hygienists from all over the country with similar desires, challenges, and dreams, and together we formed a sweet community of our own, learning and growing together with an even better understanding of what was possible as a dental hygienist.

It’s difficult to believe that 25 years have flown by, and it’s so cool that here I am about to lead the 2020 version of that very same program. Appreciating the magnitude and beauty of Quid Pro Quo, I’m honored to now be teaching with Dr. Sam Low to support hygienists toward their full scope of practice.

Our program will focus on two key components of the hygiene chair:

1. What it means to be a Restorative Partner in your practice by deepening the art of co-discovery and patient engagement.

2. Understanding current science around the diagnosis and management of periodontal disease, including hands-on utilization of power instruments, air polishing, and adjunctive therapies.

There are many pieces and parts to my enthusiasm about this program, The Pankey Hygienist.

What brings me the most joy is knowing that I get to share “my version” of Dr. L.D. Pankey’s philosophy with the doctors and hygienists in attendance. The Institute was certainly a game-changer for our practice and our patients 25 years ago. It continues to be a life-changing experience for me each and every time I get to be within this community, whether it is at the Institute, at an offsite event, or visiting other dental practices inspired by their own time with the Institute. I’m not just grateful. I’m “over the moon” grateful for this life.

A patient’s feeling of comfort and trust is increased when you demonstrate you appreciate your team.

Showing appreciation to your team in front of patients demonstrates you respect the people who support you in serving patients. This only raises their opinion of your quality of care.

• When patients witness you calmly moving through moments of stress with instructions to your team delivered in a calm tone, a smile, and thanks, it speaks volumes to patients who are eager to have confidence in their care.
• When you spend time informing team members well and empowering them with knowledge of “the why” of your diagnoses and treatment plans, they naturally and appropriately prepare patients for your case presentation, answer questions, and encourage patients to move forward. Expressed gratitude for this support is a positive affirmation that creates growing team confidence, competence and job satisfaction. And this fosters a happy work environment and employee retention. Patients are highly attuned to team happiness and are relaxed among your loyal team members they have come to know. Again, this increases trust.
• A team’s feeling of appreciation will be undermined, and individuals easily become stressed when they are chronically overworked or asked to perform tasks they are not well prepared to do. Be alert to lead them through stress with assurances and demonstration that you care enough to take measures that will restore work balance and comfort.

There are multiple situational stresses that occur every day in your practice that produce the flow of stress hormones, 112 of them to be exact. And when there are stress hormones building up in the bloodstream, the physiological and psychological consequences are noticeable to patients. Fortunately, PankeyGram readers and participants in Pankey Institute courses and study clubs receive a constant flow of fine examples of colleagues showing appreciation for their teams. Showing gratitude doesn’t always have to be done in a big way or at great expense. A positive spoken affirmation in any given moment is going to release some oxytocin. And that’s what we want!