By Mary Osborne, RDH 

How can we make recommendations for care without fully understanding what the patient aspires to? The patient’s goals are the context or should be the context for recommendations that we are going to make as their partner in health. Too often, context is the missing piece in our conversations with patients.  

I’ve heard that Dr. Bob Barkley would say to his patients, “You know, Mrs. Jones, if I had taken X-rays of you every six months since you were born, we would have 80 sets of x-rays. And if I stacked them one on top of another and then thumbed through them, I would have a movie of the health of your mouth for the last 40 years. We would see how your teeth changed from health to the degree of breakdown we see today. We can’t do anything now to change that movie. That movie has already been made. But, if you like, you and I can work together to create the movie for the next 40 years. Is that something you’d like to do?” 

If we get agreement from the patient, “Yes, I’d like to work together with you to plan for the next 40 years,” that’s not a specific goal, but it begins to create a context for our recommendations. Instead of the provider setting the expectations of the patient, it becomes more of a mutual agreement to long-term planning, so that there’s a buy-in by both parties in the relationship. That’s moving toward a partnership.  

When we set a general mutual goal during the preclinical consults, it fits in well with our not knowing what we will uncover during the clinical piece of the appointment. Dentists and hygienists can be direct about it, and I think there is value in saying, “I’d like to come to a mutual agreement that we work together to understand what is going on in your mouth, and based on the circumstances we find, come up with the best solutions for you. Is that something you would like to do?” 

We can set expectations by saying, “As we go through this process, I will be asking for your input. We’ll take it slow and be thorough. We’ll discuss what you and I discover, and together we can think through the next steps you may want to take. How does that sound to you?” 

I think it is essential to this process to invite the patient to be in shared control by asking, “Would you like to proceed with the clinical examination? Do you have any questions for me before we begin?” 

When we come to the conversation as fellow travelers with the attitude that “the two of us can work together,” we open ourselves to working toward mutual agreement about what it’s going to take for this particular person to achieve the level of health to which they aspire. Starting as partners with the goal of improved health is a low-stress way of being in a relationship that is comfortable for both parties. 

By Mary Osborne, RDH 

How much time do you schedule for a new patient, non-emergency visit? Is your priority efficiency or effectiveness? Is your goal to gather as much clinical data as possible, or is it to begin to build a relationship of mutual trust? Both are possible if you see the new patient visit as more of a process than an event.   

Too often new patients are rushed through an assembly line: brief conversation, clinical exam, diagnostic records, and treatment presentation! Is that really the best way to help people make choices about their health?  

There is no one right way to schedule a new patient. Different practices are successful with different models based on the values of the practice, practice growth, and the personality and skills of doctors and team members. The most important determinant of success is our ability to meet each patient where they are and join them on a journey to health. I am not suggesting we should be without practice standards of care.  We have a responsibility to decide what we need before beginning treatment. Our challenge is to guide patients to understanding why we need what we need, and why that is relevant to their unique situation.   

We may anticipate that patients will resist this type of experience, but if we make it truly about the patient and are flexible, I have found that patients are more than willing to participate in an individualized process that best meets their temperament and circumstances. 

I remember seeing a new patient that I was told was a “very busy attorney” because his secretary said so when she made the appointment and his wife said so when she confirmed the appointment. I anticipated that he would be a driver and prepared to efficiently move him through his appointment.  

As I explored his health history with him he expanded on the specific answers to questions. Soon, he was leading the conversation. When I remarked that I wanted to make sure we were making good use of his time. He said, “Mary, what’s this about time?” I replied that I knew he was very busy. He said, “Mary, this is about me. I have time for me.” 

His statement has stayed with me because I realized that if the conversation had been about me going through my check list and not listening to him, it would not have been a worthwhile experience for him. It also wouldn’t have been a worthwhile experience for me. 

I have learned that when the patient feels in control of the process they are willing to give that time to themselves. A lot of aha moments occur as they learn about themselves while speaking. When patients feel like they are on an assembly line being moved through our system, they have every right to be resistant.  

Empowering patients to lead the process is both an attitude and a learnable skill. When we can lose ourselves in the moment, really listen, really encourage, and really care about the patient’s thoughts and feelings, it is easy to make connections to the next step we recommend.  It is my experience that I can more quickly become a trusted health advisor when I intentionally share control with my patient. 

Most patients are willing to invest more time in the process when they see the connection between their needs and what we recommend.  These are typically patients who have or have had complex health issues and are seeking to improve and retain health. They perceive the value of the extended process and how much value you place on spending in-depth time with them.  

The entire team’s communication can deliver the message that everyone in the practice is keenly interested in them, and their appointment is uniquely planned to meet their needs.  

What has been your experience? Are you open to scheduling more time for conversations that typically garner trust and appreciation earlier in the relationship? 

By Daren Becker, DMD 

A 16-year-old girl presented with the worst case of ectodermal dysplasia I had ever seen.. She was missing all of her lower teeth except for her 12-year molars. She presented with a lower denture (made by a previous dentist) on two temporary implants in the canine position.  She had only a few maxillary teeth that were malformed; some of these were still her primary teeth.  The appearance of her smile made her look like she was a 9 year old child. 

She was embarrassed by her smile and realized she would need implants and restorative dentistry down the road. At the time, she was too young. Our hearts went out to her. 

Another dentist had recommended direct bonding, which certainly could have worked, but I thought that we could get a better aesthetic result for her with significantly less time in the chair. So, we captured preclinical digital impression scans with our iTero scanner and along with Matt Roberts at CMR Dental Lab in Idaho, we designed a digital wax-up for an improved occlusion and smile. From there, we had milled PMMA (Polymethyl Methacrylate) overlays created that we direct bonded onto the existing dentition as a long-term temporary solution. We did not need to prep any teeth, and we quickly gave her a broad beautiful smile that looked natural and age appropriate. 

She was in tears. We were in tears. Her mom and sister were in tears. It was the best day ever! 

Soon after, she got a part as an extra in a series filmed here in Georgia, and is thinking about a career in acting. Seeing her life change with simple, comfortable clinical procedures has been priceless. 

By Clayton Davis, DDS 

About 15 years ago, my wife and I were on a trip to New York City. My laboratory had told me about two dentists there who practiced together and did an amazing amount of cosmetic and restorative dentistry. Their best month was about six or seven times more than my best month, so I was curious. I knew they had studied with some of the same mentors I had. They had gone to Pankey and Dawson. They have a a comprehensive approach. While I was in New York, one morning I told my wife I was going to visit their Manhattan office and see what I could learn. 

Their office had reasonable furnishings (nothing fancy) and a reasonable level of equipment. It was tidy with nice staff. It seemed similar to what I have in my office. I sat down with the dentist who was there that day, and he shared with me what they do in their practice. They do a fair amount of marketing in health and beauty magazines that are circulated in the New York City area but otherwise it all sounded very familiar to my practice.  

A few moments later, there was a knock at the door. It was the hygienist, and she said, “Doctor, ready when you get a chance for your examination. Mr. Anderson is in today, you may not recall, but he had said that he wanted to get his veneers done after his daughter graduated from college. That was a couple years ago when he said that, and his daughter is graduating in June, so it’s time to bring that up again. I mentioned it to him today, and he’s scheduled to start that in July. So, when you want to come on in and talk to him about it, that would be great.” 

She walked away, and I looked at the dentist. I said, “What just happened? The hygienist handled everything about moving that patient forward for treatment. I can’t get mine to do that. As a matter of fact, we’ve had conversations, and they don’t seem to feel comfortable doing that.” 

He said, “I don’t know. We talked to them about it, and they’re tremendous about it. They really help our practice move patients into treatment.” 

I went home wondering how I could move my hygienists in the same direction, and an old business concept came back to me. If you want to improve something, you need to come up with a way to measure it. So, I came up with a form for logging what I call “Hygiene Points” and presented it to my hygienists. We talked about how we want to improve our ability to move patients forward with their treatment through the hygiene department. I simply asked them to score themselves on how it went at each appointment in talking to patients about any kind of treatment that came up. 

As each patient passes through hygiene, they receive a score. The lowest score, a score of 1, is for when I come into the operatory, talk to the hygiene patient, bring up some previously recommended treatment, and they go ahead and schedule it. A score of 2 is for when the hygienist finds a problem like a cracked tooth and says that it needs to be monitored. A score of 3 is for when I’m in hygiene and diagnose something new and get the patient to commit to schedule treatment. A score of 4 is for when the hygienist gets previously recommended treatment scheduled at the front desk without my involvement. A score of 5 is for when the hygienist takes an intraoral picture and points out a problem to me and I get a commitment to schedule. In other words, they say, “Let’s take a picture of this. I want Dr. Davis’s opinion on it when he comes in the room.” And then because the hygienist was concerned and I confirm in front of the patient that this is an issue that needs to be addressed, the patient schedules treatment. The collaboration and communication go so well, this is worth 5 points. And then the ultimate score is 6 for when the hygienist gets a commitment to schedule treatment for an obvious problem before I come in to confirm the diagnosis.  

The first couple of months that we used this scoring, we recorded a baseline monthly total.  After that, the competitive instincts of the hygienists kicked in and they wanted to improve their total score each month. I did not give them a reward incentive, and over two years, more production was coming out of hygiene. The old saw “You can improve what you measure” has certainly increased restorative collaboration and revenue in our practice, and the pursuit of higher Hygiene Points has been fun. 

By Kelley Brummett, DMD 

A situation occurred in my office when I was working with a patient who needed a 30-year-old PFM crown replaced on #8. I was struggling with the shade because the adjacent teeth were an in between color. What I did was take a shade photo of the brightest one, which was B1, and then I took a shade photo with A1–because those were the two shades that matched the best. They weren’t what we were looking for. So, I made a provisional out of the A1 shade and a a provisional out of the B1 shade. I took the extra time to place both of them onto the tooth and let the patient look with me and help me decide. The patient chose the A1 shade. 

After I placed the A1 provisional, we sent  photos to my lab. These photos included the first shade photos of B1 and A1 alongside the tooth, photos of the B1 and A1 provisionals, and photos of the provisional I placed on the tooth from various aesthetic views. I then talked to the lab over the phone while we viewed the photos together so they could create the right in-between shade.  

At the end of the process, my patient expressed gratitude for taking the extra steps and meeting her expectations for a beautifully blended smile. 

By Lee Ann Brady, DMD 

When you are managing the care of an older patient, I encourage you to take time to look up their medications and the medication you are considering prescribing, even something as simple as antibiotics or pain medication. 

A resource I use when I am writing prescriptions and also managing existing pharmaceuticals that my older patients are taking is the Beers Criteria published by the American Geriatric Society (AGS). The AGS Beers Criteria® lists the Potentially Inappropriate Medications (PIMs) that are typically best avoided by older adults in most circumstances or under specific diseases or conditions.  

Some listed PIMs should not be written for people over age 65 and some are okay with caution or in moderation. There is a long list of medications people can take until they are ages 65 to 70 without a problem. After that age, there are side effects. 

Some of the medications cause adverse reactions on their own or in interaction with other medications. Some of these PIMs are common over-the-counter antihistamines. 

By Laura S. Harkin, DMD  

My dad and I were enjoying our favorite lunch spot years ago when he turned to me and said, “Laura, isn’t it amazing? There’s an incredible sense of trust that our patients have in us. Sometimes, we give our best recommendation for treatment, and it is declined as if it weren’t important or a priority. I’ve recognized that, more often than not, our patients eventually choose to move forward, proving that it was more a matter of timing and circumstance than lack of value.” 

Trust is the cornerstone of our practice. It was transferred from patients to Grandpa to Dad and to me. I do believe that every morsel is earned through guidance, thoughtfulness, and skill. Trust is an entity that requires constant nurturing. In private practice, one should recognize that a doctor’s trust in their patient is equally as important as a patient’s trust in their provider. With synergy there’s the opportunity for optimal health. Even as a child, I had a very clear understanding of the care my dad had for his patients. This feeling is innate and deeply imbedded in me. I imagine that he felt the same.  

I don’t consider myself “a writer,” but I’ve always enjoyed the art of letter writing. I grew up writing frequently to my grandparents and friends and always loved picking out stationary that reflected my personality. Recently, I reread the letters that my grandfather typed on his old typewriter and my oldest brother scribbled on his Grateful Dead CD inserts – crafted just for me. It seems fitting then that I enjoy writing personalized letters to my patients. In fact, I’m pretty sure I salvaged my mental health during COVID by writing “updates” to my patients during months of closure. I digress. 

The letters that I write to my patients are most often in reference to comprehensive treatment. They provide a bird’s eye glimpse of our most recent findings, diagnoses, and treatment recommendations. My older patients, especially, appreciate my thoroughness, organization, and systematic approach to recommended treatment. These letters certainly aren’t handwritten, but the hard copy renders a sense of care that’s transferred from my hands to theirs. We must remember that individuals comprehend and retain information differently. The one-on-one, verbal, treatment consultation can become lost in the shuffle of everyday. Add dental language and complicated procedures to the mix, and that’s simply a recipe for confusion.  

Whenever I present complex treatment to a patient, I write a letter in everyday language to support our conversation. It’s stored in their digital chart as part of their dental record. In my first paragraph, I state my patient’s chief complaint. A summary of clinical findings followed by bullet point. Next, I provide my best treatment recommendation, an appointment sequence, and the financial investment. Photographs are also a helpful insert to aid in explanation for family members who were unable to attend the consultation. I think there’s value in a tangible letter taken home to revisit.  

Treatment letters are also an irreplaceable resource for my team. When a patient calls to schedule treatment previously presented, my stored letter immediately becomes a reference for scheduling appointments, including time allotments and space in-between subsequent visits. In my office, we offer a courtesy for treatment paid in full. This amount is figured in the financial investment portion of my letter so that conversations regarding immediate payment or a payment plan can easily flow. Should a case not be accepted prior to a routine recare visit, this letter serves as an excellent reminder during team huddle. It’s inefficient to page through multiple chart notes and software-driven plans with no explanation of the diagnoses which caused a need for restoration in the first place.  

In my first few years of practice, it was hard for me to accept that I needed to view this document as fluid with a potential need for multiple modifications to suit my patient’s desires and limitations. For example, financial concerns often lead to the need for phased treatment or a compromise from the ideal. I’m committed to openly discussing what may occur if no treatment is rendered or if a compromised approach is chosen. Likewise, I believe in the importance of presenting the financial component of extensive treatment myself. As the dentist and business owner, I must “own” the fee that I’ve carefully determined to reflect indirect and direct time, the skill level and support to be provided by my team, the technical excellence of my laboratory technicians, and my own knowledge. The fee that I present is steadfast, barring an unanticipated need such as root canal therapy. Should there be a need for additional chair-time or visits, it’s included in the quoted fee.  

Finally, my letters include my expectations for post-treatment maintenance. For example, if we are to complete a hybrid case in conjunction with a surgeon, I’m careful to share the importance of periodontal health and frequent maintenance visits to prevent peri-implantitis. In patients who have pre-existing medical conditions that when uncontrolled can be contradictory, I stress the importance of regular monitoring. Ultimately, I strive to empower my patients to choose and achieve oral health, Undoubtedly, oral health positively impacts overall health. My personal letters are a distinguishing trait of my practice that convey the level of care to be carried from presentation through treatment and in maintenance. Consider the value in this extra step! 

By Lee Ann Brady, DMD 

A patient chipped a tooth on her lower hybrid denture and loosened an implant screw. The denture had been placed 18 years ago, so she had an old titanium bar with denture teeth and pink acrylic. That day, I put the screw back in and smoothed out where the tooth was chipped. During this visit we had a great conversation about the future of her hybrid denture. 

I have had a similar conversation with several patients in recent months. They have the original, traditional bar retained hybrid denture that is nearing the end of its lifespan. And so, what are the options? 

1. If the bar is in great shape, new denture teeth and a new denture base can be milled and placed over the existing titanium bar. 

1. Alternatively, we can get rid of the bar and go to something that is all zirconia. 

If there is a preference for the first option, the first requirement is to make sure the titanium bar is in good condition. After 18 years, we would take it off and have the laboratory examine it under microscopy.  

If converting to all-zirconia and the patient has had upper and lower dentures, we must consider if one arch can be converted without converting the second arch. A zirconia arch is going to wear an opposing original denture fast if there is parafunction, and the zirconia arch is likely to fracture the opposing original prosthetic teeth. 

We have options today we can think about with our patients, but many have in their minds that when they got their hybrid dentures years ago, the dentures would last. All the time, energy, and dollars to freshen up or replace their denture is a big deal to them. Shifting their mindset from “I thought I was done investing in dentistry” to “My denture is at the end of its lifespan” is a big hurdle. So, the earlier we can start those conversations before they need to invest, the easier they can transition their minds to accept care with grace when the time comes. 

When your bar retained hybrid denture patients visit for perio maintenance and your exams, inform them of the lifespan of their denture is at most 20 years and set expectations for discussing the best available options at some point in the future.  

Paul Henny DDS

I wrote about this topic last October in The Never-Ending Interview and wanted to revisit it to connect the timeless teachings with my most recent thoughts. Bear with me as I recount some of the history from that previous article. 

Dr. F. Harold Wirth had a very successful restorative practice in downtown New Orleans but he always felt that something was missing until he met Dr. L.D. Pankey and was influenced by his teachings. Dr. Wirth became a missionary for Dr. Pankey’s philosophy of dentistry and life, and he gave Dr. Pankey most of the credit for developing a deeper understanding of people, both physically and emotionally.  

One of Dr. Wirth’s key messages from the podium was that dentists are always presenting the case, even from the beginning of their first encounter with the patient. Another key message was that the patient’s feelings matter in accepting care and the patient interview should be forever ongoing. 

He said, “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.” 

He said, “Ask questions that have to do with how the person feels. A case history is exploring what happened. An interview is about how they feel! You need to understand the difference!” 

We might ask, “Since I last saw you, have you noticed any changes in your oral health? How do you feel about these changes?” We might ask, “How do you feel about the appearance of your teeth?” or “How do you feel about the restorations we did?” We might ask, “At your last visit, you talked about the possibility of doing ortho; how do you feel about that now?” We might ask, “You mentioned last visit that you weren’t looking forward to Thanksgiving because it was difficult to eat all your favorite foods. Would you feel good about revisiting the possibility of replacing your denture with something more stable?”  

Do you feel better after a long conversation with someone who knows you well on the emotional level? I know I do. Over time, those kinds of conversations cause us to feel more positive and hopeful. They occur when a person gifts us their full attention while making no attempt to judge. And because we experience no judgment, we share more feelings, which leads us into an even deeper level of self-understanding. 

Doctor-patient conversations that tap into how a patient is feeling on an emotional level enable patients to grow in trust and to become more open to the possibilities we offer.  

In her recent blog series, Mary Osborne has encouraged us to journey toward health with our patients as fellow travelers because we all have health issues we hope to resolve. We can make connections over shared feelings and hopes. These connections bond us so we can pursue a mutual, positive goal with our patient.  

What I love and sticks with me from Mary’s blog is that the medical health review during each preclinical interview is an ideal time to check-in about feelings regarding health in general. So, if you and your team are not doing that now, you might want to add a question about the patient’s feelings about their current health. It’s ideal if the doctor or hygienist  asks the question. It may be as simple as “How do you feel about your overall health?” Wait for the patient to think and speak.  

One of my favorite quotes is this: 

Any kind of gesture that pulls another living soul out of despair is indistinguishable from magic. – Michael Xavier, Author 

The medical history review is a prime opportunity to demonstrate we care. Expanding our preclinical interview to routinely ask one or more questions that surface feelings related to health will give us opportunities to touch hearts on a deeper level. This will engender greater trust so patients more readily accept us as partners in their health.  

By Mary Osborne, RDH  

Think for a moment: Is there a change you think you could make in your life that would contribute positively to your health? Is there anything you could be doing—or not doing—that could improve your overall health and wellbeing? Most of us can think of something we could do, or do more consistently, to improve our health. Next, ask yourself if the reason you have not made the change you need to make is because you do not have enough information. Our clinical training taught us that if we give people the right information they will change their behaviors. It’s easy to get disappointed in ourselves and our patients when that turns out to not always be true.   

Reflecting on our own past and current health challenges is a way to remind ourselves that health is a journey, not just a set of strategies. What makes perfect sense to us now, may not have been relevant 20 years ago. Often we have heard the relevant information before but were slow to act on it. We may have conflicting priorities, such as time, or money. We may have had fears or doubts. When we can look at our own journey with understanding and compassion we are better able to see our patients that way.   

I remember a patient who came to us with a lot of dentistry that needed to be done. As we talked with her about recommendations for treatment, her eyes welled up with tears. “It’s nothing,” she said when I asked her what the tears were about. Eventually she shared with us that she and her family had been saving up to build a deck on their house. Doing the dentistry she knew she needed would mean they could not build the deck. There was a time when I might have thought, “What’s more important, a deck or your dental health?!?” But I was moved by her struggle. I can’t judge what a deck may mean to her and her family, but I can relate to her sadness in letting go of something they had been saving toward.   

As you advise patients, it’s helpful to share that are you on a path to better health yourself, and that it is not always easy. In this way we can step outside of the role of “expert” and come to our conversations as fellow travelers. And when we do come as fellow travelers, we bring our empathy, our humanity, and we allow ourselves to feel compassion. We are likeable.  

One of my favorite books is Dr. Rachel Naomi Remen’s Kitchen Table Wisdom: Stories That Heal. She quotes the psychologist Carl Rogers, who said:  

Before every session, I take a moment to remember my humanity. There is no experience that this man has that I cannot share with him, no fear that I cannot understand, no suffering that I cannot care about, because I too am human. No matter how deep his wound, he does not need to be ashamed in front of me. I too am vulnerable. And because of this, I am enough. Whatever his story, he no longer needs to be alone with it. This is what will allow his healing to begin.  

Because we are on a journey of becoming healthier just like everyone else, we can sit side by side with a patient. We can say, “I get it. It’s not always easy.” We can allow ourselves to feel compassion—that urge to genuinely help someone, and gently invite them to understand they are no longer alone.