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. 

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. 

Paul H. Henny, DDS 

Trust is commonly thought of as a firm belief in the reliability, truthfulness, and capability of another. But trust is about vulnerability . 

The more a person trusts, the more they are willing to allow themselves to be potentially hurt. They make a risks-benefit analysis, and when they feel they are ready, they decide to throw the dice.  

Conversely, when a person isn’t willing to trust, they have strategically chosen to minimize their vulnerability.  

Think about the times when you were personally unwilling to let someone into your life—when you were feeling too vulnerable. 

It’s easy for us to project our values without sensitivity to others’ often hidden concerns. When a patient says no to x-rays, to allowing us to proceed with a proper restoration, or other appropriate procedures, they don’t trust us enough right now. And when that occurs, it’s easy for us to instinctively respond by projecting our values onto the situation.  

A better strategy is to empathetically explore why a person responded to the situation the way they did—try to understand the situation from their perspective, and then focus on finding common ground in shared goals and values. Hopefully, with the right questions and empathy, we can build a bridge of trust and help our patients cross over to a place of more information on which to make the appropriate decisions for themselves. 

“No” often means “not yet,” as in “You haven’t convinced me yet that I should allow myself to be that vulnerable around you.” 

Co-Discovery requires a leap of faith on our part—a belief that most people will eventually do the right things for themselves. If we are unable to trust our patients on that level, then we’re going to struggle emotionally, demonstrate frustration, and to some extent inadvertently manipulate patients into doing what we want them to, a behavior that drives emotionally sensitive patients away. 

We need to trust our patients will make the leap as well. We need to willingly take the time and energy to continue in and trust the Co-Discovery process during which the patient starts to believe that we are the best resource to help resolve their problems and achieve their goals. When we allow our patients the time to make decisions based on what they think is in their best interest, they usually make healthy choices and appreciate the services we provide. This is how we succeed in helping them (and us) have a healthier, happier life. 

For an in-depth look at Co-Discovery and multiple essays on patient-centered dentistry, you are invited to read my recently published book: CoDiscovery: Exploring the Legacy of Robert F. Barkley, DDS, available at The Pankey Institute and on Amazon. 

In the year 1958, Dr. L. D. Pankey asked one of his most devout students to join him and teach the Pankey philosophy about dentistry and life to dentists around the world. And that’s precisely what they did. F. Harold Wirth, DDS, was one of the most dynamic speakers in all of dentistry. He rivaled Drs. L. D. Pankey and Bob Barkley in his ability to engage an audience and make his points clear using real (often funny) stories from his practice and life experiences.

Harold understood people on a very deep level—physically and emotionally. For this, he gave Dr. Pankey most of the credit. He had a very successful restorative practice in downtown New Orleans prior to meeting Dr. Pankey, but always felt that something was missing. L.D. Pankey showed him what that was, which turned Harold Wirth into a missionary for whole-person dentistry from that point forward:

“Give the case presentation to the person who makes the decisions,” Dr. Wirth said. “If I ever get to the point where I’m explaining what I’d like to do…If I’m not already about 90% into gaining their agreement, then I have messed up! Because I should have already won them over with the interview, the aura of my office, the literature that I’ve given them to read, and whatever else I’ve done before that time.”

Dr. Wirth said, “The case is constantly being presented: 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. Are you comfortable? Does your bite feel good? Are your teeth sensitive?”

These are questions that have to do with how the person FEELS. A case history is exploring what happened, but an interview is about how they feel! You need to understand the difference! How do you feel about your restorations? Are you comfortable? Are you satisfied with the appearance of your smile? Can you chew everything you want to chew?

Smile behavior is influenced by the individual’s feelings about their smile.

Smiles are an integral part of human communication. They make us appear more attractive, approachable, happy, agreeable, and attentive. Studies have shown that people who are happy with their smiles are more confident, have a greater sense of well-being, and this is also reflected in their behavior. In one study, subjects were shown photos of people with nice smiles. The subjects deemed these people as being more socially competent, with greater intellectual achievement and better psychological adjustment. These smiles are contagious and It’s easy to reciprocate when someone gives you that “genuine smile.” We’ve all seen this smile, but what makes it genuine?

There are a variety of smiles that reflect a wide array of emotions. From flirtatious to embarrassed, our smiles reflect our mood and communicate our thoughts. Or do they? When people are unhappy with the appearance of their smile they present a variety of guarding. There’s upper lip guarding, lower lip guarding, both lips guarding, covering one’s mouth with a hand, and of course close lip grins.

As dentists, we must be able to spend time with our patients, to see those smiles, and to delve into why a patient may be guarding. In a sense, we must become esthetic psychologists. It is not an overstatement to say that as dentists, we don’t just change teeth; we can change lives. We can shape how others see our patients. If a patient cannot give a genuine unencumbered smile, perhaps, they’ll miss an employment opportunity or meeting that special someone. Perhaps they’ll be seen by others as unfriendly or unapproachable.

So, is there a “genuine smile” that can be quantified? In the 1800s, a French anatomist by the name of Guillaume Duchenne sought to answer that question. Duchenne, through stimulating facial muscles, found that the most genuine, sincere smile occurred when 3 muscle groups fired: the orbicularis oris and zygomaticus major in the mouth and the orbicularis oculi of the eye forming crows’ feet.

Most consider the resulting Duchenne smile to be the genuine smile that is spontaneous and sincere. Studies have shown that this type of smile can elevate mood, change body stress response, and is responsible for the release of endorphins, dopamine, and serotonin. In all, the Duchenne smile is the Holy Grail. It is certainly about the smile but a major component is the formation of crows’ feet around the eyes. Just think of the song When Irish Eyes Are Smiling. The Duchenne smile in all its splendor is sure to steal your heart away. My point is that we need to remember that the Duchenne smile is about the mouth AND the eyes; these elements are interconnected.

What we’ll need to evaluate as Dentists is whether Botox injections and plastic surgery affect the Duchenne smile. Certainly, in the case of the Botox smile, the answer is yes since the elevator muscles of the mouth are injected thus altering the Duchenne muscle contractions. Obviously, it is vital then to take a good health history and determine whether a patient is smile guarding or simply cannot fire the muscles that make up the Duchenne smile.

In making dental changes, we change lives. We shape how others see our patients and how they see themselves. This is priceless work. It is worthy work. But until a patient desires the best results that today’s dentistry can achieve and trusts us to execute the technical aspects of their new smile, we are in listening, understanding, and guidance mode. We are leading them forward with primary, essential care and taking them on a long journey to achieve what is possible. With each new dental restoration, they may smile more broadly and lift their head higher. They will feel the release of endorphins and serotonins. They will experience the positivity of greater self-confidence.

Artful comprehensive dentists are like behavioral psychologists who have the sincere intention of doing their utmost for the benefit of their patients.

You know what greater smile benefits are possible if the patient understands and wants to continue with aesthetic treatment. Patience is a virtue. So, spark the curiosity of your patients and lead gently but with confidence. Never forget that a patient who is concerned about the cost of elective treatment today will be thanking you profusely two to three years from now and saying the decision to move forward with a comprehensive smile makeover was one of the best decisions of their life.

In dentistry, we’re clear about the connections among the teeth, the muscles, the bone, and the joints—and how all these pieces are related to esthetics. We understand how those pieces fit together. Unfortunately, most patients don’t come to us with that understanding.

Dr. Bob Barkley used to talk about patients not understanding “the web”—the connection of how all the pieces come together.

Just as with a delicate spider web, if you touch any one aspect of it, you change everything. Bob Barkley would say to his patients, “I know you are concerned about that one tooth. That’s your job to be concerned about that one tooth. My job is figure out and to help you understand how what’s happening with that one tooth is related to everything else that is going on in your mouth.”

The exam is a process by which we can do exactly that. We can help our patients understand the connections in their mouths. The exam is also an opportunity to encourage our patients to have confidence in us. Confidence building starts with the new patient exam and continues in subsequent interactions. The more thorough the examination we do, the more in touch we are with what is really happening in our patients’ mouths and the more confident patients will feel about our ability to help them.

Our thoroughness and knowledge aren’t the only aspects of the exam that develop patients’ confidence in us. The gentler we are in our touch and the more careful to include the patient or others in the room during exams are important. These aspects of the exam communicate our character and the way we tend to approach our work. Patients anticipate our care and approach will be similarly open and comfortable during future consultations and procedures.

People don’t take risks when they don’t feel confident. Unfortunately, many patients do not have confidence in making decisions for themselves when they sit in a dental chair. They think of significant dentistry as a risk. For best long-term results and positive relationships, we always want the patient to feel as strong and confident about their choices as they can.

Repeated comfortable interactions are needed for them to develop their confidence. Every time we find something good in their mouth, every time we point out health such as healthy gum tissue or a beautiful restoration, and areas not needing restoration, we are reinforcing healthy choices they made in the past. This can be a confidence booster to help them move forward in making next choices.

The examination process is an opportunity for the clinician to:

• Understand what the patient is experiencing emotionally and physically,
• Provide sensory learning experiences (see Art of the Examination: Part 1),
• Help the patient draw connections for deeper understanding of their health
• Explore options for what the patient might choose to do.

The examination is an opportunity for the patient to develop understanding of:

• The clinician’s ability to help them.
• The current condition of their teeth and other oral structures.
• The impact on them of what they are learning.
• The choices they can make to improve their health.

Every examination is a next opportunity to develop our patients’ confidence in us and in their ability to make healthy choices for themselves.

When leaves are turning red and yellow and grasses are turning shades of pink and brown, most of us start anticipating the coming holidays. It’s a season to list everything we still want to accomplish by the end of the year…and it’s also a time to think more about others.

Not everyone experiences happiness during the holidays.

It would be wonderful and remarkable if every patient in your dental practice has fond memories of the holidays and has family and friends with whom they celebrate. But proactively working year around to know your patients has provided you with glimpses into what your patients really might be feeling.

Getting to know each patient has revealed recent losses…a spouse, parent, son, or daughter. It has revealed the emotional impact of divorce, job loss, the chronic stress of work or caregiving, and then, there are a multitude of worrisome health problems.

An idea for uplifting these special patients: Mass-printed holiday greeting cards can be turned into something special that touches these patients on a deep level. Some effort needs to go into personalizing the cards with handwritten messages but the message can be as simple as, “We want you to know that we are thinking of you during this holiday season. You are someone we admire and care about.” That special touch…a small act of kind outreach can make a beautiful, memorable impression on special individuals you have come to know, think about, and may be praying for.

The entire practice team can help in listing the few dozens of patients who would benefit most from personal notes. Everyone can pitch in to write messages. Everyone can sign the cards. Social wellbeing among your team members will be elevated by creating an open afternoon on the schedule to do this as a “family” of compassionate caregivers. Add lunch or snacks to make it a team party.

Tip for a Thriving Team from Gallup’s Wellbeing at Work: Operationalize your mission. You will clearly communicate your mission of genuinely caring for patients when you demonstrate to your team that you do care by investing personal effort. Doctors, this means writing personalized messages right alongside your team—and with enthusiasm.

Many patients become hyper busy during the holidays.

Cancellations and lateness occur more frequently in December. Despite best intentions of keeping their dental appointments, some patients overbook and overextend themselves. My personal thoughts are to be patient with them and do four things.

1. If your practice is large with many patients coming through your door daily, it may not be your regular practice to make confirmation phone calls. In December, make the extra effort to follow up text messages with personal phone calls. Have team members organized to make as many calls as possible.

2. Build value for December appointments via a Happy Holidays newsletter that sparks enthusiasm for your practice. Include a digital photo of the holiday decorations in your reception area and remind your December patients that you look forward to wishing them Happy Holidays in person.

Here’s an idea: What if you were to put together oral health care gift bags for a local group home or shelter and communicate to your patients that those coming in for appointments in December will have the opportunity to put their name on a card in a gift bag? You would spread community awareness, the spirit of health, and giving back to your community as a wider dental family.

3. Update your wait list of patients who might come in on short notice. Have those names and numbers at the ready.

4. When open time occurs in your schedule, have a mindset of gratitude: “Wow, I guess we won’t feel so pushed today. We didn’t expect we would have this time to breath and catch up a little.”

Your patients want to know what to do if they have a dental problem over the holidays.

Have a clear plan that you and your team members can engage around to respond when patients have emergency or urgent needs over the holidays. Tell your patients via your media (recorded phone message, newsletter, Facebook page, website blog, etc.) what to do if a dental problem occurs. Clear communication from you tells them that you are thinking of them and want to make it easier for them to manage life’s exigencies…even during the holidays.

Here’s to a season of doing our best and thinking of others!

Before I come up with a treatment plan, I always do certain things in a certain order. That structure has allowed me to feel confident that I can treatment plan any case that walks into my office. That structure, or process, affects how I approach my exam, make my diagnosis, and ultimately make my treatment plan.

The process begins by looking at the following five areas during the patient exam. I gather information in each of these areas in the following order:

1. The patient parameters of the case
2. The aesthetic parameters of the case
3. The functional parameters of the case
4. The restorative parameters of the case
5. The biologic parameters of the case

The first area I look at is the patient. What is the patient interested in? What are the patient’s circumstances, temperament, and dental health objectives? What is the patient’s current understanding of their dental health? How does that compare to my perception of their dental health? After answering these questions, I then move on to the four technical areas.

The first technical area I look at is the aesthetics of the teeth, gingiva, skeletal structure, and face. I then look at function, including the jaw joints, muscles, occlusion, and airway. The third area I look at is the restorative parameters of tooth structure, missing teeth, and the restorative materials and restorative techniques previously used in the mouth. And finally, I look at the biologic parameters, including caries, periodontal, and endo.

When I do my examination, I want information gathered in all five of these areas. When I sit down to do my exam diagnosis and treatment planning, I have all of that information in front of me and I’m going to always consider the five areas in the same order as I proceed with diagnosis and begin treatment planning.

When I plan the stages of treatment that will occur, the treatment sequence is in the order that is most appropriate for the case. For example, if the patient has a biologic health condition, perhaps, the need for a root canal or significant perio inflammation, I’m going to treat that condition at the front end of the treatment sequence, and not in the order in which I gathered information and reviewed it. The most appropriate treatment sequence will be the order in which I need to do restorative procedures to most predictably achieve the total best outcome.

Although my “structured approach” may not be the same as yours, I thought sharing mine with you could be of benefit to you. By establishing a process in which you gather and consider information in all five areas (Patient, Aesthetics, Function, Restorative, and Biologic), you will have all the information you need to consistently do diagnosis and treatment planning with efficiency and confidence.

For more information on this topic, I encourage you to take Treatment Planning and Case Presentation with me on June 11th – June 12th. This is a phenomenal way to solidify your knowledge and spend two days in sunny Key Biscayne, FL.

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

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

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

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

Previous Conversations Inform Me

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

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

My Check-in Conversation

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

My Debrief Conversation

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

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

Few people have worked as tirelessly to advance the thinking of L.D. Pankey and Bob Barkley as Rich Green DDS, MBA. Recently, I ran across some of Rich’s quotes that truly capture the nature of his experience in dentistry.

A behaviorist’s definition of learning is changed behavior demonstrated. As my personal growth allowed, I relaxed and thought more about creating an experience in which my patients had the opportunity to learn something, which would challenge them to change behaviors that had negative impact on their life and health. The more I looked at those “learning moments,” the more they appeared. The learning occurred as I helped patients clarify what was most important to them and what they wanted to learn. As I facilitated a learning process with my patients, they were able to discover for themselves those two things, and then they were able to take their own steps in personal growth…People tend to support what they help to create.

Below Rich is speaking of his long-term work with Don Clifton and The Gallop Organization.

As we studied the uniqueness of individual private practices, one finding was the tendency of a dentist and team to unwittingly create barriers to the patient’s progress when what they really wanted was to create pathways to greater health. The barriers were typically caused by an impatient or judgmental attitude and the “teach and tell” method of attempting to change behavior.

In this last passage, Rich speaks to the central theme Bob Barkley taught across the country following the publication of his book, Successful Preventive Dental Practices. In the mid 1960’s, Bob worked closely with Nate Kohn Jr, PhD to dramatically reorganize how he interacted with his patients. In so doing, he largely abandoned what Rich refers to here as “teach and tell,” in lieu of what Bob called “CoDiscovery.” Because Nate Kohn, Jr. had his PhD in Educational Psychology, he exposed Bob to the latest thinking in learning science – and much of it had been influenced by the work of Carl Rogers, PhD.

It fascinates me that we can now go back and understand how all of this evolved, as well as why Bob chose to do things in a very specific way. Perhaps most important is how it all evolved through the hearts and missions of both Bob and Rich. And this last point is key, because if the motivation behind a person’s use of CoDiscovery doesn’t emanate from their heart, from a deeply sincere desire to help others grow and realize greater health through that growth, it won’t work. Instead, it will be perceived as being manipulative and thwart the desired outcome.

The “unwittingly created barriers” will block the passage of the relationship to the next interpersonal level — the level necessary to establish enough trust to proceed to the needed care. CoDisovery is an intentional practice, born out of a personal philosophy toward life and practice. This heartfelt way of interacting with others sometimes feels slow, but it is the fastest way I know to truly help others.