Getting to Treatment: Letters to My Patients 

May 22, 2024 Laura Harkin

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! 

 

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Leading Patients with Simple Questions 

May 17, 2024 David Rice DDS

By David R. Rice, DDS 

I travel a lot for speaking engagements and often ride to and from the airport using Uber. As I make small talk with the drivers, inevitably they ask what I do for a living. One day, as I shared that I was a dentist, the driver said, “I’m finally straightening my teeth with those aligners.”  

I thought, “Okay, he’s either seeing a dentist or he’s doing this thing on his own.” Either assumption would’ve potentially painted me into a corner, so instead of assuming, I asked a simple, yet leading question: “Good for you. Is your dentist happy with the progress?” 

Leading questions like that help us walk a patient down the path we want. His response was, “Wait a second, this should be done with a dentist?” 

With one question, I got to the heart of the matter. From there, I responded and asked a series of simple (and again leading) questions: “Yes, seeing a dentist helps to know if you are a good candidate to move your teeth at all. How is the health of your mouth? Are your gums healthy? Do you have any cavities?” 

Now he was thinking, “Wow, not only should I be going to the dentist but there are things that could go wrong.” 

I asked him one more simple set of questions: “Would you like to know basic things that could go wrong? Or would you like to know what might really go wrong and harm you?” He, of course, wanted to know what could harm him. 

Simple, leading questions get to the point. So, when restoring a patient, I think about the simplest questions to ask to understand what the patient understands, what the patient really wants, and why. In short, I want to know what matters most to them and connect that to the dentistry I know they need. As an example, I might ask, “Do you want to replicate mother nature when we restore that tooth, or do you want to improve upon mother nature? Would you like to discuss preventing future problems that will save you time and money or just focus on today’s problems? 

These leading, simple questions prompt a response that enables me to determine if the patient wants just a slice of pizza—say a crown, the patient wants the whole pie—an optimal smile, or the patient wants something in between. Based on that input, I know how to best have a great conversation with the patient—a conversation the patient will appreciate and through which I can earn more trust.  

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 Ask Questions About How Your Patient Feels 

May 13, 2024 Paul Henny DDS

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.  

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Paul Henny DDS

Dr. Paul Henny maintains an esthetically-focused restorative practice in Roanoke, Virginia. Additionally, he has been a national speaker in dentistry, a visiting faculty member of the Pankey Institute, and visiting lecturer at the Jefferson College or Health Sciences. Dr. Henny has been a member of the Roanoke Valley Dental Society, The Academy of General Dentistry, The American College of Oral Implantology, The American Academy of Cosmetic Dentistry, and is a Fellow of the International Congress of Oral Implantology. He is Past President and co-founder of the Robert F. Barkley Dental Study Club.

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Partnering in Health Part 2: There Is No Suffering We Cannot Care About  

May 6, 2024 Mary Osborne RDH

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.

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Mary Osborne RDH

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

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Partnering in Health Part 1: The Missing Piece 

May 1, 2024 Mary Osborne RDH

By Mary Osborne, RDH 

There was a time when I thought “partnering in health” was just about getting people to take better care of their teeth. 

Many years ago, I had a patient who was excellent with her home care, but she showed up periodically with an acute periodontal infection. We asked about stress and her overall health, but she was not aware of any issues. We would treat the infection and she would be fine for a sometime. We knew she worked for National Public Radio, and one day we made the connection that her infections showed up concurrent with NPR’s fund-raising drives. That shared realization allowed us to help her see that her stress was affecting her dental health and her overall health. She was open to conversations about lifestyle changes that would help her be healthier. My relationship with her influenced my thinking and my ability to connect with my patients from a perspective of Whole-health Dentistry. I came to understand that I had been missing opportunities to influence the way people think and feel about health. I knew that I wanted my patients to see me as “a partner in health.” 

Unfortunately, most of our patients come to us with the perspective that we are fixers of teeth, not partners in health. 

In the culture today people are bombarded with information about what is healthy. From friends and families, social and news media, and a wide variety of health care practitioners, everybody expresses opinions on how they are supposed to take care of themselves. Why, then, are we surprised when our patients don’t know whom to trust? Why are we surprised when they shrug their shoulders or appear confused? It’s not always a case of conflicting facts but a case of various perspectives that people don’t know how to navigate. 

Think about where you place your trust. How do you decide whom to trust about decisions—whether it’s about your health, or about your finances, or about how you raise your children? When I ask myself that question, two criteria surface. They need to know their subject and to know me. I want that person to know what it is they’re talking about. I want them to be well informed. I also want someone who knows me, who understands my values. I want that person to have a sense of who I am and what is important to me. 

As we get to know our patients over the years, most of them come to see us as trusted advisors when it comes to their dental health—but fewer see us as trusted advisors when it comes to their general health. If we jump too quickly to making recommendations about their overall health, we are more likely to meet resistance. If we want to cross the bridge into influencing our patients’ overall health and wellbeing, I believe we need an invitation to cross that bridge.   

The Missing Piece in our quest to influence the overall health of our patients is the failure to invite patients to share their perspectives on health. Beginning a conversation with a new patient with the question, “What can you tell me about your health in general?” is an invitation for them to talk about their experience of their health, not just details. Instead of “reviewing” health histories, what if we “explore” health histories? As we connect and get to know each other we can learn to listen beyond information to hear attitudes, beliefs, fears, biases, concerns, barriers, etc. As you understand their perspectives on health issues that come up in conversation, it’s easy to ask if they would like your perspective on that issue. These conversations often lead to more questions and answers that invite more and more invitations from our patients to be their partner in health. 

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Mary Osborne RDH

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

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Stories About Stories 

April 22, 2024 J. Michael Rogers, DDS

By Michael (Mike) Rogers, DDS

Close to my office there is a small strip center that includes a realty group and a small church. At one end, there is no sign to show what it is, but it has a drive-through window. Every day there is a significant line of cars going up to that window. Cars line up waiting their turn, and the line is so long the cars snake through the parking lot, out into the street, with hazard lights flashing. 

I have a friend who loves to create stories about what is going on in strangers’ lives. Why is someone driving so fast? What meal are they going to create with food in a shopping cart? Why are two people arguing?  

Fantasized from some level of observation, my friend has captured what this drive-through is all about. He believes that because the drive-through is adjacent to a church, you can pull up to the window and are given a donut along with a prayer. It’s a small ministry for people to have a better day. That’s not a bad narrative but no real basis for the story. I say that as the line of cars grows longer, the prayers gain power. I get a warm feeling of their impact on others. 

I find we make up stories in my office as well. We make them up about why someone didn’t show up for an appointment, why someone didn’t move forward in care that has been advised, or why someone won’t pay a balance. Our tales are based on some level of observation, but they are tales none the less. 

I try to remember to look at these moments in three ways. 

  • What do I know? 
  • What do I think I know? 
  • What do I want to know? 

We practice this in our office. I encourage my team to not live in “what I think I know.” This state of mind too often leads to creating stories that reflect a judgement. If I hear a team member begin to create a narrative based on a circumstance with the phrase “I think…,” I try to politely make them aware of what they are doing. They most certainly recognize when I do it and politely let me know. I just grin to hide my disappointment in myself. Maybe someday, I’ll say, “thank you.” 

In relationship-based practices, we have such marvelous opportunities to help people be healthier. Asking questions about what we’d like to know and sometimes creating self-discovery for the patient as well. We often get repeated moments to connect and learn with each other. The need to make up stories is dissolved when we get to hear their story. Sometimes that story is fun, other times hard. We get to walk along that story with them. What a gift to live a life in that connection! 

Recently, a member of the realty group on one end of the strip center came in to see me. I couldn’t resist asking what the line of cars is about. It turns out it is an Ignition Interlock site for people that have had a recent DUI. You go up to the window for your installation time of the small handheld breathalyzer to prevent your car from starting after drinking alcohol. 

I haven’t shared that with my friend. I like his story better. 

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J. Michael Rogers, DDS

Dr. Mike Rogers is a graduate of Baylor College of Dentistry. He has spent the last 27 years developing his abilities to restore patients to the dental health they desire. That development includes continuing education exceeding 100+ hours a year, training through The Pankey Institute curriculum and one-on-one training with many of dentistry’s leaders. Dr. Rogers has served as an Assistant Clinical Professor in Restorative Sciences at Baylor College of Dentistry, received a Fellowship in the Academy of General Dentistry and currently serves as Visiting Faculty at The Pankey Institute. He has been practicing for 27 years in Arlington, Texas.

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“Provisional” Versus “Temporary” 

April 12, 2024 Kelley Brummett DMD

Kelley Brummett, DMD 

After you do a crown preparation, do you tell your patients that you’re going to make them a temporary or a provisional?  

Provisionals are more than temporary restorations. They are part of a process. They’re the dress rehearsal to the final outcome. They are the prototypes for the final restorations.  

The “provisional” process is an opportunity to gain trust with the patient while modifying the length of teeth, the shape, or the color. It is also a way to communicate with the patient how their functional and parafunctional findings may have contributed to the destruction of their teeth. 

As the patient comes back to have their bite checked and to talk about what they like and don’t like, we are building trust. We’re involving them in understanding what they feel and think. We’re listening to improve their conditions. 

I’ve had patients who were fearful about moving forward with extensive treatment because they couldn’t envision the transition from the prep appointment to the final. What would those temporaries look like? What would they feel like? How would they function?  

So, when I am discussing a case with a patient, provisionals are all part of one treatment fee. We talk about the prep process, the provisional process, the lab process, and the final seating process—all as one process for which there is a fee. We discuss how the provisionals will guide us in optimizing the lab plan to achieve the desired comfort, function, and aesthetics.  

Whether it’s a single tooth or whether it’s multiple, I encourage you to help the patient understand that what you are providing in the interim between a preparation and a seat of a restoration is called a “provisional.” 

A provisional protects the underlying tooth structure. It keeps tissue in place. It helps the patient feel confident. It allows us to understand what might be going on functionally. It helps us communicate better with the lab. It’s more than a temporary restoration. It’s a guide on our journey toward predictable and appreciated relationship-based dentistry. 

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Kelley Brummett DMD

Dr. Kelley D. Brummett was born and raised in Missouri. She attended the University of Kansas on a full-ride scholarship in springboard diving and received honors for being the Big Eight Diving Champion on the 1 meter springboard in 1988 and in 1992. Dr. Kelley received her BA in communication at the University of Kansas and went on to receive her Bachelor of Science in Nursing. After practicing nursing, Dr Kelley Brummett went on to earn a degree in Dentistry at the Medical College of Georgia. She has continued her education at the Pankey Institute to further her love of learning and her pursuit to provide quality individual care. Dr. Brummett is a Clinical Instructor at Georgia Regents University and is a member of the American Academy of Cosmetic Dentistry. Dr. Brummett and her husband Darin have two children, Sarah and Sam. They have made Newnan their home for the past 9 years. In her free time, she enjoys traveling, reading and playing with her dogs. Dr. Brummett is an active member of the ADA, GDA, AGDA, and an alumni of the Pankey Institute.

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Using Topical for Optimal Patient Comfort

March 29, 2021 Lee Ann Brady DMD

In a previous blog, I wrote about how we use multiple flavors of topical in my dental practice and the positive patient experience this creates. In this article, we will look at the topical application technique we use to create maximum patient comfort.

I have often debated in my mind whether topical actually makes patients feel more comfortable when anesthetic will be injected. The scientific literature confirms it works great on the surface of mucosa, but it does not reach nerves under the gums or in teeth. From working with my patients, I know it makes a difference to them in how they perceive the injection feels. And there are studies in which patients overwhelmingly self-report that the initial pinch feeling of the needle entering the tissue is reduced after topical.

Before applying topical, thoroughly dry the area so the topical goes directly on the tissue you want to numb. If topical is applied to saliva, its effectiveness is greatly reduced. Ideally, let the topical work for 60 seconds but minimally 30 seconds prior to beginning the injection. My technique is to thoroughly dry the mucosa, swab the dry area with topical, leave the cotton tip applicator in place against the mucosa, cover it with a 2×2, and have the patient close to hold it in place while I watch the clock for 60 seconds to make sure I am not rushing.

To deliver anesthetic I use The Wand computer-assisted anesthetic delivery technology. While I am waiting for the 60 seconds, I explain to the patient that the anesthetic delivery may be different than they have experienced before and how the anesthetic will be delivered.

In my last blog, I wrote about the value of offering patients a choice of topical flavors. I can also fill some of the 60 seconds by asking the patient if the topical administered tastes like the flavor of topical they selected. As soon as the 60 seconds have passed, I immediately remove the 2×2 and cotton tip applicator and begin delivering the anesthetic.

There is good science behind some types of topical acting faster than 60 seconds, so you may want to do some research and select one of these types.

Even if you think topical is not effective, think about the placebo effect topical has on the patient. We are doing something to improve their comfort. We are actively doing something to make the procedure more comfortable and to help them through the process. I believe this act of caring has value to the patient that even exceeds the value of the numbing effectiveness reported in clinical trials.

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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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