Explaining Dentistry in a Way Patients Understand

February 14, 2024 Clayton Davis, DMD

Explaining Dentistry in a Way Patients Understand 

Clayton Davis, DMD 

Here are some of the ways I communicate with patients to help them understand dentistry. I hope some of these will be helpful to you in enabling your patients to make good decisions about their treatment.  

Occlusal Disease: In helping patients understand occlusal disease and the destruction it can cause, I have long said to them, “The human masticatory system is designed to chew things up. When it is out of alignment, it will chew itself up.” I tell them, “Your teeth are aging at an accelerated rate. We need to see if we can find a way to slow down the aging process of your teeth.” The idea of slowing down aging is very attractive to patients, and if you relate it to their teeth, they get it.  

Occlusal Equilibration: Typically, I come at this from the standpoint of helping them understand that teeth are sensors for the muscles, and when the brain becomes aware our back teeth are rubbing against each other, it sends the same response to the muscles as when there’s food between our teeth. In other words, the brain tells the muscles it’s time to chew, and this accelerates wear rates on the teeth. Equilibration is really a conservative treatment to reduce force and destruction of the teeth.  

Diseases of the Jaw Joints: Regarding jaw joints and adaptive changes and breakdown, patients understand that joints have cartilage associated with them. Saying there has been cartilage damage in your jaw joint gets the message across simply. 

Treatment Presentation: When patients say, “I know you want to do a crown on that tooth,” I jokingly say, “Oh, don’t do it for me. Do it for yourself.” I never say, “You need to get this work done.” Instead, I say, “I think you are going to want to have this work done.” 

Conservative Treatment: I have always enjoyed John Kois’s saying that no dentistry is better than no dentistry, so when talking about conservative dentistry, I’ll tell patients, “No dentistry is better than no dentistry. We certainly don’t intend to do any dentistry that doesn’t need to be done.” Another way I speak about conservative dentistry is to say, “Conservative dentistry is dentistry that minimizes treatment. In the case of a cracked tooth, a crown is actually more conservative than a filling because it minimizes risk.” 

Moving Forward with Treatment: I love Mary Osborne’s leading question for patients after they’ve been shown their issues and treatment possibilities have been discussed. The question is “Where would you like to go from here?” With amazing regularity, the patients choose a really good starting point for their next steps toward improved health, steps that feel right to them. Always remember, people tend to support that which they help create. 

Dental Insurance: I typically speak of dental insurance as a coupon that can be applied to their dental bills. I’ll say, “Every plan sets limits on how much it pays. The way dental insurance works, it’s as if your employer has provided a coupon to go toward your dental bills.” 

Presenting Optimal Care: If I want to present optimal care to a patient who is ready to hear it, I ask permission by saying, “Mrs. Jones, if I were the patient and a doctor did not tell me what optimal treatment would be for my problems because the doctor was concerned that I couldn’t afford it or that I would not want it, I would think, ‘How dare you make that judgment for me. You tell me what optimal care would be, and I’ll decide for myself if I want it.’ So, with that in mind, Mrs. Jones, would it be okay with you if I presented you with the optimal solutions for your problems?” 

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Clayton Davis, DMD

Dr. Clayton Davis received his undergraduate degree from the University of North Carolina. Continuing his education at the Medical College of Georgia, he earned his Doctor of Dental Medicine degree in 1980. Having grown up in the Metro Atlanta area, Dr. Davis and his wife, Julia, returned to establish practice and residence in Gwinnett County. In addition to being a Visiting Faculty Member of The Pankey Institute, Dr. Davis is a leader in Georgia dentistry, both in terms of education and service. He is an active member of the Atlanta Dental Study Group, Hinman Dental Society, and the Georgia Academy of Dental Practice. He served terms as president of the Georgia Dental Education Foundation, Northern District Dental Society, Gwinnett Dental Society, and Atlanta Dental Study Group. He has been state coordinator for Children’s Dental Health Month, facilities chairman of Georgia Mission of Mercy, and served three terms in the Georgia Dental Association House of Delegates.

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The Transition to Digital Dentistry Part 2

January 17, 2024 John Cranham, DDS

When my daughter Kaitlyn (currently in through E2 at Pankey) finished dental school in 2020, I strongly recommended that she learn analog first, then once mastered, make the transition to digital. This lasted about four months. I learned rapidly that this generation sees things in the digital realm far better than we do. She reminded me that “she grew up with a screen in her hand.” 

We began to focus on her learning the concepts of occlusion, esthetics, biology, tooth-by-tooth structural integrity, and visualizing and planning in the virtual (digital world). We quickly learned that, although she could easily visualize things on the computer, the patient is ultimately analog. We began to utilize an analog articulator for her to learn the hand skills of what we would do on the patient. 

A great example of this is equilibration. A “trial equilibration” on a virtual articulator is a 5-minute process that lets us determine if equilibration is an appropriate treatment option. The problem is that, unlike analog, you do not learn the brush strokes that will be required to perform this skill in the mouth. I have performed hundreds if not thousands of equilibrations. I know the brush strokes. For me, once I see on the virtual articulator that I can do the equilibration without too much tooth structure removal, I am ready to go to the mouth. For Kaitlyn, who has very limited equilibration experience, once visualized on the virtual articulator, then it’s time to go back to analog. She mounts the printed models on an analog articulator to perform a traditional trial equilibration. In this way, she learns the brushstrokes of this incredibly important procedure. 

I think it is extremely important that dentists, who are learning to equilibrate intraorally, work on mounted analog models to develop their equilibration skills. 

Returning to the consideration of the financial cost of bringing new technology into your practice—input devices (scanners and CBCTs), output devices (printers and mills), and software to manipulate the data all cost money. Doctors that are going down this road usually like technology and consider the dramatic increases in efficiency to ultimately increase the productivity and profitability of the practice. This is certainly something I have seen. The bottom line is dental stone will go away. We all must make the decision when it is appropriate to make the jump. 

Dr. Lee Ann Brady has invited me to audit all the Pankey Essentials courses over the next year. I am super excited about this. She has asked me to recommend ways to appropriately implement examples of digital technologies and workflows into these core classes. While younger dentists are drawn to digital information, it is important for us to remind them that our patients are ANALOG. We are training dentists to perform complex procedures on patients, not on computers. This requires great study and a commitment to understand timeless concepts, while simultaneously developing the hand skills to accomplish these procedures accurately and use digital workflows to make things more efficient. 

In 2024, The Pankey Institute is also implementing a digital hands-on course for those doctors who would like to make the transition over to virtual articulation and digital workflows—something that I am excited to be part of. Dentistry is in a great transition. I look forward to making sure the concepts that we have all built our practices around do not get lost in the digital world. 

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John Cranham, DDS

Dr. John Cranham practices in Chesapeake, Virginia focusing on esthetic dentistry, implant dentistry, occlusal reconstruction, TMJ/Facial Pain and solving complex problems with an interdisciplinary focus. He practices with his daughter Kaitlyn, who finished dental school in 2020. He is an honors graduate of The Medical College of Virginia in 1988. He served the school as a part time clinical instructor from 1991-1998 earning the student given part time faculty of the year twice during his stint at the university. After studying form the greats in occlusion (Pete Dawson & The Pankey Institute) and Cosmetic Dentistry (Nash, Dickerson, Hornbrook, Rosental, Spear, Kois) during the 1990’s, Dr. Cranham created a lecture in 1997 called The Cosmetic Occlusal Connection. This one day lecture kept him very busy presenting his workflows on these seemingly diametrically opposed ideas. In 2001 he created Cranham Dental Seminars which provided, both lecture, and intensive hands on opportunities to learn. In 2004 he began lecturing at the The Dawson Academy with his mentor Pete Dawson, which led to the merging of Cranham Dental Seminars with The Dawson Academy in 2007. He became a 1/3 partner and its acting Clinical Director and that held that position until September of 2020. His responsibilities included the standardization of the content & faculty within The Academy, teaching the Lecture Classes all over the world, overseeing the core curriculum, as well as constantly evolving the curriculum to stay up to pace with the ever evolving world of Dentistry. During his 25 years as an educator, he became one of the most sought after speakers in dentistry. To date he has presented over 1650 full days of continuing education all over the world. Today he has partnered with Lee Culp CDT, and their focus is on integrating sound occlusal, esthetic, and sound restorative principles into efficient digital workflows, and ultimately coaching doctors on how to integrate them into their practices. He does this under the new umbrella Cranham Culp Digital Dental. Dr. Cranham has published numerous articles on restorative dentistry and in 2018 released a book The Complete Dentist he co-authored with Pete Dawson. In 2011 He along with Dr. Drew Cobb created The Dawson Diagnostic Wizard treatment planning software that today it is known as the Smile Wizard. Additionally, He has served as a key opinion leader and on advisory boards with numerous dental companies. In 2020 he published a book entitled “The Cornell Effect-A Families Journey Toward Happiness, Fulfillment and Peace”. It is an up from the ashes story about his adopted son, who overcame incredible odds, and ultimately inspired the entire family to be better. In November of 2021 it climbed to #5 on the Amazon best seller list in its category. Of all the things he has done, he believes getting this story down on paper is having the greatest impact.

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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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E2: Occlusal Appliances & Equilibration

DATE: April 6 2025 @ 8:00 am - April 10 2025 @ 2:30 pm

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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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Functional Risk Part 3 – Occlusal Therapy 

July 1, 2022 Lee Ann Brady DMD

Why Occlusal Appliance Therapy Is My First Step Prior to Ortho, Equilibration, or Restorative

Occlusal changes on an appliance are easy and reversible. An appliance can immediately reduce elevator muscle activity and give the patient relief. The patient also experiences what changes to their tooth contacts could provide for them long term. We can test the changes that would be made by ortho, equilibration, and/or restorative.

As reviewed in Part 2 of this series, our goals are to stabilize the joint anatomy and reduce the activity of the elevator muscles because those muscles are what overload the joints and teeth. We also want to slow down the rate of damage to the dentition and move that rate back to a more age-appropriate pace. We also may need to reorganize a patient’s occlusion to manage occlusal forces to ensure restorations that last.

Removing Posterior Contacts Does Not Work for Every Patient

Over my years of clinical practice, I have found that changing the occlusion does reduce functional risk for most patients. But we all have patients with perfect occlusion who present with TMD symptoms. We have some patients who continue to parafunction after we move them into immediate posterior disclusion.

Studies show that proprioception causes the elevator muscles to engage in only 80 to 85% of the population. This means that when the brain receives the signal that teeth are touching, the brain elevates the masseter muscles in 80 to 85% of people. Tooth contact is the trigger. Because this proprioception does not occur for 15 to 20% of the population, it is not the universal trigger for excessive loading.

Over my years in clinical practice, I have learned there is nothing I can do that is 100% dependable to stop a patient from para-functioning. Some of my patients continue to excessively load after posterior contacts are removed. Their functional risk does not diminish.

If we cannot reduce elevator force and redistribute force enough on an occlusal appliance to eliminate or at least relieve TMD symptoms, then occlusal therapy via ortho, equilibration, or restorative will not satisfactorily help the patient. We will need to turn to other forms of therapy.

Other modalities I use are BOTOX to deactivate muscles, massage therapy, and physical therapy. There are also systemic medications, cold lasers, and TENS therapy we can use to reduce the activity of the muscles or reduce inflammation in the muscles and joints. Sometimes one modality will alleviate symptoms for a while and when symptoms return, we can try it again or try another modality.

An Exercise to Identify the Patients Who May Not Benefit from Occlusal Therapy

You can do what I call a poor man’s EMG on yourself by placing your hands on your masseter muscles. Put your back teeth together, clench and release, clench and release, clench and release to see how much masseter activity you have. Then move your teeth into protrusive edge to edge and try to clench a little bit, making sure your back teeth do not touch. If you now have a posterior tooth touching in the edge-to-edge position, then put a pencil or pen between your front teeth to separate your back teeth.

With no back teeth touching and contact on the centrals, try to clench and release two or three times while feeling your masseters. Most of you will find your masseters do not move or move a lot less when no back teeth are touching. Some of you, even with your back teeth separated, can still clench in protrusive and can still increase the muscle activity almost the same amount as when your back teeth touch.

I do this exercise with my patients, but when they move into protrusive, I put a bite stop over their front teeth or have them bite on a Lucia jig we have lined for their bite registration. If you do this test with your patients, you can use an EMG or feel the muscle activity with your hands.

If the patient can still generate almost the same force or the same force with their back teeth separated, you have identified one of the around 15% of people who might not benefit significantly from occlusal therapy. You’ve also identified someone who might not do well on an anterior-only appliance because, if they can generate that same force on just two teeth, they are at risk for those teeth becoming sore and moving.

Interested in Learning More?

The Pankey Institute Essentials courses and multiple focus courses include hands-on exercises and over-the-shoulder training designed to help dentists develop mastery in reducing functional risk and treating TMD symptoms.

 

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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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Little Guys Matter

August 1, 2017 Glenn Kidder DDS

Why Focusing on the Lower Anterior Teeth in Restorations is Important for Esthetics and Function

If you ignore the lower anterior teeth in a restoration, you may be sacrificing a significant amount of potential case benefits.

The process of improving dental techniques is one of constant refinement throughout our careers. We build upon techniques and begin to see our blind spots with each new case.

This blog is about specificity and detail-oriented technique. Excellent clinical dentistry balances the patient’s desire to improve their smile esthetics with effectively conveying the overall importance of planned changes to their health.

Incorporate the approach I discuss below into your restorative work and you’ll see the benefits extend widely to both final case esthetics and patient satisfaction. After all, those twin goals entwine throughout everything we do in the dental practice.

Restore Lower Anterior Teeth for Esthetics and Function

Have you ever noticed cases in various dental publications where nice restorative work has been completed on the upper anterior teeth, but the lower incisors were completely ignored? Oftentimes the lower anterior teeth (the little guys) are crowded, uneven, worn, and/or damaged.

This discordant aspect is visually jarring and detracts from the perceived beauty of the final result. The pristine nature of the upper anterior teeth throws the correspondingly less appealing look of the lower anterior teeth into greater relief.

The little guys are important for esthetics and function. They show considerably more on speech as we age, something very few patients realize. They are also critical for distribution of forces as we move into protrusive and excursions. The Pankey Institute recognizes the importance of lower anterior teeth as a vital aspect of complete dental care.

This is a periodontal case where a simple equilibration substantially improved esthetics and force distribution. Patients really appreciate an enhanced smile. They immediately feel better function and stability.

What commonly overlooked areas or techniques do you use to improve restoration esthetics and function? We’d love to hear from you in the comments!

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Glenn Kidder DDS

Dr. Glenn M. Kidder has served on the visiting faculty at the Pankey Institute in Key Biscayne, Florida for the past 23 years. He facilitates several courses which deal with occlusion, TMJ disorders, splint therapy, and equilibration in restorative dentistry. He also serves as the Essential II Coordinator in the Department of Education at Pankey. He is past president of the Greater Baton Rouge Dental Association. He was instrumental in the start up of The Greater Baton Rouge Community Clinic which has provided over five million dollars of free medical and dental care to the working uninsured in the Baton Rouge area. He is past president of Cortana Kiwanis where he has 33 years of perfect attendance. He has been married for 35 years to Stacey Kidder, a psychotherapist. They have three sons who are LSU graduates—two are dentists. Dr. Kidder is in private practice in Baton Rouge, Louisiana where his practice is limited to the treatment of temporomandibular joint and occlusal disorders. He is a Diplomate with The American Board of Orofacial Pain, a Fellow in The Academy of General Dentistry, a Fellow in The Pierre Fauchard Academy, a Fellow in The International College of Dentists and is a 32 year member of the American Equilibration Society. He is an assistant clinical instructor in the Department of Prosthodontics at LSU School of Dentistry.

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