Consistent case acceptance is a skill it can take years to develop. Part of the reason it can seem so challenging is that a patient’s true motivations may not be clear from the outset. We have to hone that sixth sense that can tell us what information or guidance would truly speak to a patient.

Two aspects of case acceptance in particular often go ignored because they either seem too obvious or are just not as fun to dive into: offering individualized options and making sure patients understand insurance.

Individualized Options for Case Acceptance

You may think the concept of individualized options is a no brainer, but that isn’t necessarily the case from a patient’s perspective. If you’re willing to provide this extra level of specificity, you can put many ‘maybe’ patients right into the ‘yes’ category.

We accept that car and other big purchases are often paid in installments, so why not do the same with a large investment like dentistry? Offering financing or other piecemeal payment options to patients is a game changer. It also makes comprehensive dental care accessible to a broader demographic. That in and of itself is valuable.

When dealing with patients, break the payment options down into easily understandable terms. Tell them the total fee, but decrease the stress by making it clear that there are different ways they can arrange to pay, including pre-pay, pay as you go, and Care Credit. Using a term like Care Credit is helpful because everyone is familiar with the idea of credit. When they ask for more information, you can lay out the details of payment plans.

Understanding Insurance for Case Acceptance

The real role of insurance is a mystery to most patients. Some may deliberately avoid understanding it because of how convoluted and frustrating it can be. They may have an entitlement mindset complete with the belief that the only healthcare they can indulge in is the kind covered by insurance.

Before you ever even look in a patient’s mouth, my advice is to have the insurance talk in low-stress language. Explain the actual definition of insurance and describe how dental insurance functions more as a maintenance plan. Use analogies to clarify the fact that just like with car insurance, its more of a backup fund than a way to pay for necessary yearly interventions such as a new tire or oil changes.

During an occlusion-focused hygiene exam, there are certain things the hygienist should pinpoint. This will help them develop a deeper relationship with the patient as well.

A Hygiene + Occlusion Exam

What the hygienist should look for:

1. “Can you eat/drink cold things comfortably?”
2. Subtle wear facets – those shiny spots on the edges of teeth.
3. Chipping of the edges of teeth. Can you get the patient to line up an incisal “chip” with a sharp edge of a lower front tooth?
4. Fremitis – that subtle shimmying of an upper front tooth when you gently place your fingernail on the facial of a maxillary incisor and ask the patient to grind side-to-side and front-to-back.
5. NCCL – could that be from clenching or orthodontic expansion? Both/and?
6. Persistent marginal inflammation that could be a sign of clenching (or an imbalanced bite).

The hygienist’s role is to raise patient awareness –  to “discover” changes that can be brought to the doctor’s attention for long-term protection of the patient’s teeth.

The doctor’s arrival for an exam is the time that real skill and teamwork begins. The hygienist takes the lead and informs the doctor what they (hygienist and patient together) have been discovering/discussing.

Many times, the most significant questions come when I am behind and feeling rushed. Our goal, practiced for years, is for me to get in and out of the hygiene room in under 5 minutes. Therefore, our total goal together is to encourage the patient to schedule another appointment for a more thorough evaluation of any changes/discoveries.

The hygienist then supports and reassures the patient about the need for a more thorough understanding to protect their teeth and eating for a lifetime. They confirm the uniqueness of a full understanding of teeth, harmonizing bite forces, and oral-systemic health and well-being.

“This is what sets our office apart. Together we strive for the best in your total oral health prevention.”

A well-thought-out and choreographed hygiene appointment can truly establish you in the relationship-based sector of dental care.

When a patient has periodontitis, they suffer from a destructive inflammatory infection that significantly impacts their oral health and damages their periodontal structures. Understanding how occlusion impacts or worsens this damage is key to helping these patients prevent unnecessary trauma.

Periodontitis and Occlusal Trauma

Even before the 1960s, there was research linking occlusal trauma and progression of periodontal disease. More recent research has found that this link isn’t as strong as once thought. Still, a relationship has been identified between the extent of damage and whether the patient has an occlusal interference.

One crucial aspect of periodontitis is that it is unique to every patient. This means we have to be careful not to apply a blanket approach to all patients or rely too heavily on past data that may not help us treat our current patient. Their individual susceptibility to periodontitis must be assessed based on their distinct risk factors.

The Relationship Between Occlusion and The Periodontium

For each tooth, occlusal experience matters and may be one of the reasons that loss of attachment worsens. A 2001 study by Harrel and Nunn found that there was a correlation between amount of periodontal damage and existence of occlusal interference. Perhaps more interesting, they also found that changing the occlusion had a positive impact on the periodontal issue.

Even in light of this research, the relationship between occlusion and periodontium is hotly contested. Regardless of one’s opinion on this matter, there’s no denying that the periodontium is effected by occlusal force. When there is no occlusal loading, there may be over-eruption or drifting of the tooth. On the other hand, when the force is appropriate, the periodontium is healthy and stable.

We must remember that there is a spectrum of susceptibility to periodontitis. For those who are very susceptible and also have teeth experiencing occlusal trauma, the latter only serves to worsen the situation.

Amidst all the details that must be managed day in and day out at a dental practice, I’d like to bring to light something I find super important that is often neglected. Let me begin by asking a question: When is the last time you took a good look at your perio probes? I mean a really good look!

My guess is you will find different shapes, sizes, colors, materials, ages, and markings. Maybe this doesn’t seem like the worst tragedy in the grand scope of the world, and yet, having even two different probes in the office can set the stage for lack of continuity in your patient diagnoses. 

Why Perio Probes Matter

It does seem like there are as many choices in probes these days as there are stars in the sky, so how can you make the best decision when it comes down to buying?

Although I do recognize the need and desire to have options, at the end of the day I encourage you to consider which probe provides the LEAST probable chance of creating error. Although I have used (and observe people using) a huge variety of probes, my favorite by far is the UNC-15. Due to markings at every mm up to 15, there is virtually no guesswork in capturing and documenting data with a high level of accuracy.

As you make the decision of exactly which probe you will use exclusively in your practice, please also consider calibrating all dentists and hygienists on an ongoing basis. It is typically easy to notice that probing techniques will vary from person to person. Watching and learning from each other with the ultimate goal of having everyone in agreement about how you will probe is invaluable.

Lastly, remember that an accurate periodontal diagnosis can only be made when a comprehensive periodontal assessment is completed and documented. Your probe is designed to be used for measuring pocket depths, recession, bleeding, pus, and attached gingiva. Oh, and don’t forget to check for mobility and furcations while you’re at it.

Here’s to a future of more accurate and calibrated perio probing in your office!

When the tongue can’t function properly (especially the middle portion), a cascade of events can happen. This is a very important point because many assess proper tongue function by mobility alone, but this does not uncover a posterior tongue restriction.

Assessing a tongue by how far a child or adult can move it is simply not enough. The middle portion of the tongue must be addressed because it is the biggest driver in normal development.

Tongue Restriction or Dysfunction

Following the Functional Matrix theory, if there is a tongue restriction or dysfunction while in utero and the tongue cannot reach the palate, the facial muscles will be the biggest factor shaping the palate. This  results in a high, vaulted palate at birth.

In infancy, a lack of function may lead to an inability to nurse properly or create a proper seal. This can be worsened by a high vaulted palate. If the palate is not stimulated, oxytocin release is limited and the facial muscles continue to be the largest influence on the shape of the palate. Symptoms of this problem can show up in both mom and baby immediately or a few days after birth. They can include: 

• Swallowing too much air resulting in: gassiness, reflux, spitting up, colic, getting “full” on air, or not draining breast, which leads to frequent feedings.
• Increased effort needed to eat, so falling asleep when nursing, short nursing sessions, and poor sleeping/frequent waking.  
• Excessive non-nutritive sucking/thumb sucking to stimulate palate and release oxytocin.
• Incorrect latch, which can be painful and lead to cracking/bleeding nipples or not fully draining breast, which leads to mastitis, etc.  

So many times, a “simple” answer to these problems would be switching to bottles or special formula and/or reflux medications instead of addressing the real issue. This is all too often missed by the medical field. When the underlying dysfunction goes untreated because the symptoms have been pacified by those treatments, the dysfunction continues and more symptoms develop.

The function or dysfunction of a tongue can lead to more health issues than many realize. Recent research has linked tongue dysfunction to a myriad of issues such as skeletal and bite changes. These issues can also lead to sleep apnea and TMD among other things. 

The evolution of recent thought is that sleep apnea and TMD are chronic “end stage” diseases whose roots develop early in life. Interventions as early as birth may help prevent or at least curb the severity of these diseases.

Exploring Tongue Function

The tongue is used not only for speaking, swallowing, and tasting, but also for other less obvious functions. The most important may be the tongue’s function of protecting the airway. When touching the palate, the tongue releases oxytocin, which has a calming effect.

The tongue is a large factor in normal growth and development of the face including the nasal and oral spaces. The Moss functional Matrix theory in essence states that the soft tissues will dictate how the hard tissues form. Or, in other words, form follows function.

According to this theory, the tongue will influence development of the palate, nasal cavity, and overall facial form. It then stands to reason that normal function is important for normal facial growth and development.

Development of Swallowing Patterns

The normal function of a tongue begins at the 18th week in utero when the fetus begins swallowing. Infants are born with a congenital suckling/swallowing reflex. At birth, the infantile swallowing pattern (called a “Tooth apart” pattern) is characterized by positioning of the tongue between the gum pads and the jaw slightly apart.

Stabilization of the mandible is from facial muscles and the interposed tongue. The middle portion of the tongue must lift and touch the roof of the mouth to create a seal when nursing and also release oxytocin.

Then, as teeth erupt, children change to a transitional swallow pattern. They will fluctuate between the infantile tooth apart pattern to an adult tooth together pattern. In the tooth together pattern, the teeth are together and the tongue is to the roof of the mouth.

This transition may be altered if the tongue cannot learn the proper position. An altered swallow pattern such as a tongue thrust may occur. Issues that can alter swallower pattern can be a tongue tie, poor or hyperactive muscle tone, a high vaulted palate, delayed non-nutritive sucking habits, or essentially anything that will not allow the tongue to reach the proper spot.

To be continued …

The Pankey Institute has positively changed how I practice dentistry. My work–life ‘flow’ would not be what it is today if I had not integrated the philosophy and dental training. As Dr. LD Pankey said: “A tooth never walked in the door.”

I too have integrated my own personal touch at the practice and have said, “We don’t treat strangers in our practice.” I get a little chuckle from patients at times when I say this. I also get a warm and welcoming look because they can connect with those words. This statement is an invitation that helps them open up.  

Better Cases From a Better Practice Philosophy

My training at Pankey and learning about LD Pankey’s Practice Philosophy has given me insight into how to create, formulate, and execute my own. I strive to live that philosophy with my dental team and my patients. We have created a practice culture that allows me to do many comprehensive cases.

I integrate concepts of restorative dentistry that have resulted in a rewarding outcome for both the patient and dentist. Appreciation and gratitude from the patient along with pride and care from the team have continued to fuel me to deliver the best dentistry with my best self.

It all starts with a comprehensive exam. For the case shown in these pictures, I utilized a thorough examination complete with understanding, listening, and hearing what the patient’s goals were. This was followed by a focus on airway, occlusion, TMJ, and restorative and esthetic goals. Digital photography, mounted study casts, evaluation of occlusion, wax up, and communication with the patient and the laboratory enabled me to create a smile that the patient was very comfortable with both in function and in form.  

Treatment consisted of an occlusal equilibration to improve occlusal interferences, which had caused fremitus on #7 and instability in occlusion and discomfort. I placed a porcelain crown on #8 and veneers on #7, 9, and 10. The patient was also given take home whitening trays.  

The patient’s final comments were: “I love my new smile and my bite is comfortable” and “Oh, did I tell you that since the dental work was completed, my jaw has felt more relaxed and comfortable?”

The question of what makes something ‘aesthetic’ or pleasing to the eye is one that often plagues dentists. We are so concerned with our patients’ perceptions of beauty that it is always on our mind.

The sense of aesthetics is an innate quality that we all carry. This sensibility is intertwined with our own internal creativity and curiosity, as well as our desire to create. Many people conflate a particular affinity for aesthetics with a lesser ability in other more technical areas, but in reality these are not mutually exclusive.

As dentists, we balance the technical and the aesthetic every single day. It can be challenging to handle the needs of both these areas in concert.

A Pankey Take on Aesthetics

Dr. Pankey had a particularly eloquent way of describing aesthetics. He clearly had a great appreciation of the world. This is why he combined his appreciation for aesthetics with the needs of dentistry, which resulted in multiple insights about the complexities of aesthetic dentistry.

Dr. Pankey’s aim was to learn the ins and outs of dental aesthetics to maximize quality of patient care. He had a vision of organizing all of the information he had acquired and making it available to more dentists.

The S Curve

An important tenant of dental aesthetics is the ‘S’ shaped curve that visually stimulates a sense of beauty. This has to do with the way it moves the eye and creates a flowing movement. The curve is a common aesthetic aspect of teeth and tissue, especially in the tips of every papilla to the zenith point.

We see the S shape as a result of the emergence profile or the angle of the entrant line of each tooth. Contour also plays a role in this specific part of the smile’s appearance. All in all, it’s important to pay attention to this aesthetic nuance in your work.

What do you think is the most important consideration for aesthetics in dentistry? 

Every patient has a story that makes their case unique. When we embrace their path to treatment and make an effort to understand their motivations, we can provide even more excellent care.

A great example of this simple lesson came in the form of my patient Anne. I knew Anne well, as she ‘grew up’ in our practice and had been a regular patient for many years. This fact added an unexpectedly challenging element to her case. I knew I needed to re-familiarize myself with her interests and background instead of taking our past relationship for granted.

Restorative Case For a Future Hygienist

Anne is nineteen and currently training to become a dental hygienist. Her personal dental experiences spurred her interest in the field. She’s excited to provide patient care that improves both oral health and self-image.

All of these details about Anne informed how I approached her treatment. Her primary esthetic concerns were a peg lateral #7 and a congenitally missing #10. She also had canted axial alignment, mottled enamel, and uneven gingival zeniths with a high smile line.

We decided on comprehensive restorative treatment approach that would correct these problems and provide her with a result she could readily show off. The treatment consisted of orthodontics, an implant for #10, and periodontal surgery to reposition gingival levels. We also moved ahead with occlusal equilibration and a diagnostic wax up.

To round out the case, we did tissue sculpting on #10 in addition to esthetic/functional testing and refinement via provisionals. Anne got beautiful e.max veneers on #5, 6, 7, 8, 9, 11 and 12. Finally, she got an implant supported e.max crown on #10.

Matt Roberts CDT handled the lab side of Anne’s case and did a stellar job. She can now go forth confidently into her career and help others embrace treatment that can change their lives.

What case put a smile on your face recently? We’d love to hear what you think in the comments! 

In my last blog, I discussed the possible scenarios that could occur when your patient answers their phone during an appointment. Now, I’ll explore how you can leverage smartphones to your advantage in your dental practice.

Leveraging Smartphones in the Dental Practice

Which scenario would you hope might happen with you the most? Are these all valuable experiences? Do you KNOW YOUR PATIENT more by observing each behavior? Do you KNOW YOURSELF more from your level of engagement and influence on the outcome? How will you modify your future interactions for each patient from what you have learned?

Let’s face it, for the past couple of decades we’ve had it easy. If we chose, a whole wall could be filled with charts of Baby Boomer patients. Boomers are everywhere in great numbers, most have comprehensive needs, most have the means to care for themselves, most have a high level of trust. It was an ideal patient population and still is.

Now we have Millennials. Frankly, they are initially a tough personality for more seasoned practitioners to relate with (we look at them like spoiled kids). The stark reality is that they outnumber Boomers and have plenty of dental needs. They are the future of our workload.

To relate with Millennials, they need information fast. They need to see to believe and establish trust. Fortunately, they have a camera in their pocket. Sure, I still take my full photo series and we keep the intra-oral cameras in our rooms, but when I see the slightest glimmer of doubt in a Millennial, I ask if they can open the camera on their phone. Then I pull out a photo mirror.

It’s almost as if saving the image in their device’s storage is connecting to their memory bank. They look at it several times. They text the picture to friends and post on social media. They seek validation. From cracked teeth to gingival needs to caries – for my millennials, seeing is believing. (Now if I can keep them off social media while I’m prepping their teeth.)

Here are two photos of a tooth that a skeptical patient refused to crown because there were no symptoms. The “just fill it Doc” attitude changed with two simple snaps on their phone using a mouth mirror.

To be continued …