PDF Version - Glidewell Dental Labs

glidewelldental.com

PDF Version - Glidewell Dental Labs

Chairside®

A Publication of Glidewell Laboratories • Volume 5, Issue 2

Periodontist Dr. Daniel Melker

Success with Biologic Shaping

Page 39

One-on-One with Dr. Paul Homoly

Maximize Your Profit

Page 24

The Deceptions of Rubber Gloves

Page 54

Dr. Frank Spear on

Tooth Positioning for Anterior Esthetics

Page 18

Dr. Michael DiTolla’s

Clinical Tips

Page 9


Contents

9 Dr. DiTolla’s Clinical Tips

In this issue, I detail my favorite articulating paper,

TrollFoil, which is a world apart from the cardboardthick

articulating paper of the past. Also highlighted

is the cordless NV MicroLaser; the Reduction Ring

for perfect preps; and the SONICflex LUX 2000 L,

which I now use to clean all my preparations prior

to cementation.

13 “Aesthetic & Restorative Dentistry:

Material Selection & Technique” –

A Book Review

Most dentists, myself included, haven’t bought a

dental textbook since dental school. However, when

I heard that Dr. Douglas Terry was co-authoring a

book with Dr. Karl Leinfelder and MDT Willi Geller,

I couldn’t wait to get my hands on a copy of it. Did it

live up to the hype? Find out in my review.

18 Too Much Tooth, Not Enough Tooth:

Making Decisions About Anterior

Tooth Position

Creating an esthetic smile requires thoughtful evaluation

by the dentist. But perhaps the most critical

point in this process is the starting point for tooth

positions, which includes developing a functional

treatment plan. How is this achieved? Dr. Frank

Spear, using a sequence from his Spear Education

program, explains.

24 One-on-One with Dr. DiTolla

Which is more profitable: 12 single units on 12 different

patients or a 12-unit complex-care case on a

single patient? The answer might surprise you, as

Dr. Paul Homoly explains in our latest one-on-one

discussion. Watch our in-person dialogue from our

first sit-down interview at chairsidemagazine.com.

39 Biologic Shaping

In order to achieve success with biologic shaping,

there are very specific steps and clinical prerequisites

that must be followed. Dr. Daniel Melker, periodontist

for Dr. Bill Strupp, outlines how we can avoid

weakening the tooth when performing conventional

crown lengthening.

Contents 1


Contents

45 Practice Management: Social Media and

Marketing the Modern Dental Practice

Twitter, Facebook, YouTube, MySpace, Google reviews

and blogs are terms every dentist needs to

know. Thanks to the Web and the simplistic beauty

of social media, the ability to generate patient-to-patient

promotion of your services has never been easier.

Officite’s Glenn Lombardi talks about the power

of this free marketing tool.

54 The Deceptions of Rubber Gloves

Do rubber gloves cause more harm than good?

Dr. Ellis “Skip” Neiburger explains how illogical fear

prompted obligatory glove use, a practice that was

mandated for use in dental practices nationwide

more than 20 years ago. Plus, why he believes we

should be given the option to practice barehanded

dentistry.

63 Patient Product Review

In our magazine’s first-ever Patient Product Review,

I introduce a unique product that will grab your patients’

attention: Breakfast dental floss. Get your patients

excited about maintaining good dental hygiene

with this bacon-pancake-coffee-flavored product.

64 Chairside ® Caption Contest

2

www.chairsidemagazine.com


Publisher

Jim Glidewell, CDT

Editor-in-Chief

Michael DiTolla, DDS, FAGD

Managing Editors

Jim Shuck

Mike Cash, CDT

Creative Director

Rachel Pacillas

Clinical Editor

Michael DiTolla, DDS, FAGD

Copy Editors

Melissa Manna

Kim Watkins

Magazine Coordinators

Sharon Dowd, Lindsey Lauria

Graphic Designers

Jamie Austin, Deb Evans, Joel Guerra,

Phil Nguyen, Gary O’Connell, Rachel Pacillas

Staff Photographers

Sharon Dowd, Kevin Keithley

Illustrators

Wolfgang Friebauer, MDT, Phil Nguyen

Ad Representative

Lindsey Lauria

(lindsey.lauria@glidewelldental.com)

If you have questions, comments or complaints regarding

this issue, we want to hear from you. Please e-mail us at

chairside@glidewelldental.com. Your comments may be

featured in an upcoming issue or on our Web site:

www.chairsidemagazine.com.

© 2010 Glidewell Laboratories

Neither Chairside magazine nor any employees involved in its publication

(“publisher”), Chairside makes Magazine any nor warranty, any employees express or involved implied, in or its assumes publica-

Neither

tion any liability (“publisher”), or responsibility makes any for warranty, the accuracy, express completeness, or implied, or or assumes usefulness

liability of any or information, responsibility apparatus, for the accuracy, product, completeness, or process disclosed, or useful-

or

any

ness represents of any that information, its use would apparatus, not infringe product, proprietary or process rights. disclosed, Reference or

represents herein to any that specific its use would commercial not infringe products, proprietary process, rights. or services Reference by

herein trade name, to any trademark, specific commercial manufacturer products, or otherwise process, does or not services necessarily

constitute name, trademark, or imply its manufacturer endorsement, otherwise recommendation, does not or necessar-

favoring

by

trade

ily by constitute the publisher. or imply The its views endorsement, and opinions recommendation, of authors or expressed favoring

by herein the do publisher. not necessarily The views state and or reflect opinions those of of authors the publisher expressed and

herein shall not do be not used necessarily for advertising state or or reflect product those endorsement of the publisher purposes. and

shall CAUTION: not be When used viewing for advertising the techniques, or product procedures, endorsement theories purposes. and materials

that When are presented, viewing the you techniques, must make procedures, your own theories decisions and about ma-

CAUTION:

terials specific that treatment are presented, for patients you and must exercise make personal your own professional decisions about judgment

regarding treatment the for need patients for further and exercise clinical personal testing professional or education judg-

and

specific

ment your own regarding clinical the expertise need before further trying clinical to implement testing or new education procedures. and

your own clinical expertise before trying to implement new procedures.

Chairside is a registered trademark of Glidewell Laboratories.

Chairside ® Magazine is a registered trademark of Glidewell Laboratories.

Editor’s Letter

Two years ago, the words social media and dentistry were

rarely mentioned in the same sentence. Today, hardly a

week goes by where I don’t get a flyer, e-mail or tweet

about a new Social Media in Dentistry seminar. I have

been involved with social media on a personal level for a

couple of years, but it had nothing to do with dentistry.

I use Yelp to make better decisions about which restaurant

to try in a new city and to see what dishes people

are raving about. One day while browsing Yelp, I noticed

that somebody had written a glowing review for a local

dentist, and for the first time I realized dentists were being

dragged into the social media age, like it or not.

It almost doesn’t matter how incredible a business is,

someone is going to write a negative review. For example,

Thomas Keller’s The French Laundry, often regarded as

the best restaurant in the U.S., has 10 1-star reviews on

Yelp! The point being, even the best of the best can have

a subpar day. Perhaps the reviewer was having a bad day

and it didn’t even have that much to do with the restaurant

itself.

The rest of the story is that The French Laundry has nearly

600 5-star reviews. It is pretty clear to most people

viewing the page for The French Laundry on Yelp that

the majority of customers had the meal of a lifetime and

a few disgruntled patrons hated the experience. People

don’t stop going to The French Laundry because of those

10 bad reviews, they continue to go based on the 600

positive ones.

Your dental office is bound to get a bad review. Maybe

your front office quotes the incorrect insurance amount

or your crown on tooth #9 doesn’t quite match. Invite

your best patients to leave positive reviews for you and

your office. Glenn Lombardi reviews how to do that in

our interview on page 45. Make sure that the majority

acknowledges your 5-star dentistry and 5-star service, just

in case you have that inevitable bad day.

Yours in quality dentistry,

Dr. Michael DiTolla

Editor-in-Chief, Clinical Editor

mditolla@glidewelldental.com

Editor’s Letter 3


Letters to the Editor

“Dear Dr. DiTolla,

I was planning to do a resin-retained

(Maryland) bridge on a patient of mine

to replace tooth #4. Tooth #3 has an

occlusal amalgam and a weak MF cusp,

for which I plan to do a MOF onlay preparation.

Tooth #5 is virgin, so a distal

rest and lingual wing are also planned.

I would like to use Prismatik Clinical

Zirconia or Cercon ® for this case, but

I need your expertise on preparation design

and material choice. I spoke to a lab

technician already but want information

from the head honcho. Mahalo.”

- Todd R. Okazaki, DDS, Haleiwa, Hawaii

Dear Todd,

You have three Maryland bridge

choices, none of them great as a permanent

restoration.

Your prep design ideas are excellent:

Go with the MOF onlay prep on

tooth #3 and the distal rest/lingual

wing on tooth #5.

Choice 1: PFM with metal wings and

ceramic pontic tooth #4. The upside

is you can bond to the metal with

resin (alloy primer with Kuraray Panavia

F); the downside is the MOF

on tooth #3 is ugly if you can see it

when the patient smiles.

4

www.chairsidemagazine.com

Choice 2: Composite reinforced with

fiber (Kerr Premise Indirect with

Vectris ® ). The upside is that any resin

cement will bond with it because it

is resin; this will give you the best

bond strength. The downside is that

the bridge is weaker than the PFM

Maryland.

Choice 3: Zirconia bridge (3M

ESPE Lava ). The upside is that the

bridge is as strong as the PFM and

better looking. The downside is you

can’t bond to zirconia, even with Panavia

F or Parkell C&B-Metabond ® . It

might be tough to get the distal rest

and the lingual wing to bond to the

tooth.

As you can see, there is really no right

answer, per se. When my patient declines

a single-tooth implant and we

decide to use a Maryland bridge, I

usually tell them that it is not a permanent

restoration like a fixed bridge

or an implant. When they agree to

that concept, I will usually go with

either Choice 1 or Choice 2, based

on their esthetic needs and the size

of their smile, thickness of their anterior

teeth, so on and so forth.

I have tried a zirconia Maryland

bridge or two and have not had good

luck. Bisco claims its new bonding

agent for zirconia, Z-PRIME Plus,

will bond resin to zirconia, but I

haven’t seen any independent confirmation

of this yet. We are currently

testing it in our R&D Department at

the lab to see if we can observe an

increase in bond strengths.

I hope that helps!

- Dr. DiTolla

“Dear Dr. DiTolla,

Thanks for the input. I’ve decided to go

with a resin-retained bridge for the following

reasons:

1) The patient cannot afford an implant.

2) The patient is female with no evidence

of parafunctional habits.

3) The location of the bridge.

4) Its conservative nature.

I prepped the case today. Tooth #3

ended up being an MOL inlay. The MF

cusp appears to be strong. I was wondering,

because the weak link appears

to be the bond strength to zirconia, is

it possible to incorporate female potholes

(micro ones) into the internal surface

of the zirconia so my cement (C&B-

Metabond) can fill in the females and

lock in the bridge mechanically? That

is, use mechanical rather than adhesive

retention to the zirconia. Why use Lava

instead of Prismatik Clinical Zirconia or

Cercon? Is it because it can be colored?

My experience is that Lava is the most

esthetic, but your lab tech recommended

Prismatik CZ. Also, would you be

able to send me a sample of Z-PRIME?

By the way, it would be an honor if

you used my name in your magazine

– only if you send me an autographed

copy, though. Thank you for sharing

your great practical ideas. Mahalo.”

- Todd R. Okazaki, DDS, Haleiwa, Hawaii

Dear Todd,

Typically the wings on a Maryland

bridge are too thin to place retentive

potholes.

We only have one sample of Z-PRIME

at the moment and it’s in the hands

of R&D to test how well it works.

Perhaps Bisco would be willing to

send you one?

I tend to use Lava as an example of a

zirconia-based material because it is

familiar to most dentists. Our Prismatik

CZ is colored the same way.

Thanks for letting us use the letter,

and I promise you’ll be receiving a

signed copy of the magazine! Take

some great before-and-after pictures

and they might find their way into

Chairside, too.

- Dr. DiTolla


“Dear Dr. DiTolla,

I’ve been in practice since 1971. Recently,

I’ve been having issues with missed

mandibular blocks. At first I thought

it was the anesthetic; then I started

to think I was at fault. So I started researching

my old anatomy books to see

if my technique slipped, and I even got

ahold of some CAT scans to study the

anatomy again.

But then the article by Dr. William Forbes

showed up in Chairside and it was very

enlightening! I was giving my blocks too

low! The photos and diagrams were very

helpful in regaining the proper technique

for the mandibular block. Once I

started to give them higher, I was back

on track to good anesthesia. Thank you

for a very educational article.”

- Dennis J. Nowak, DDS, Orland Park, Ill.

“Dear Dr. DiTolla,

I just wanted to say thanks for the help

your clinical videos have provided

throughout the years. I just cemented

my first BruxZir ® crown and it was

sweet! The patient loved the combo of

high strength and tooth-colored material.

Keep up the great work!”

- Ray A. Morse, DMD, Panama City, Fla.

CONNECT WITH CHAIRSIDE

FOLLOW US ON TWITTER

Find us @GlidewellDental

FIND US ON FACEBOOK

Search for Glidewell to see

what’s new.

ITUNES WATCH AND LEARN

Go the iTunes store and search

for Glidewell Laboratories.

SHARE YOUR THOUGHTS

Visit chairsidemagazine.com and click

on “Contact Us.” Or write to:

Glidewell Laboratories,

ATTN: Chairside magazine

4141 MacArthur Blvd.

Newport Beach, CA 92660

ACCESS OUR RESOURCES

Clinical videos, product information and

patient resources are just a click away at

glidewelldental.com.

ADVERTISE/SUBMIT AN ARTICLE

Call 888-303-4221

Letters should include writer’s full name,

address and daytime phone number. All correspondence

may be published and edited for

clarity and length.

BruxZir ® Solid Zirconia

Letters to the Editor 5


Contributors

Michael C. DiTolla, DDS, FAGD

Dr. Michael DiTolla is Director of Clinical Education & Research at Glidewell Laboratories in Newport

Beach, Calif. Here, he performs clinical testing on new products in conjunction with the company’s R&D

Department. Glidewell dental technicians have the privilege of rotating through Dr. DiTolla’s operatory

and experience his commitment to excellence through his prepping and placement of their restorations.

He is a CR evaluator and lectures nationwide on both restorative and cosmetic dentistry. Dr. DiTolla has

several clinical programs available on DVD through Glidewell Laboratories. For more information on

his articles or to receive a free copy of Dr. DiTolla’s clinical presentations, call 888-303-4221 or e-mail

mditolla@glidewelldental.com.

Paul Homoly, DDS, CSP

Dr. Paul Homoly is a world-class leader in dental education. As a comprehensive restorative dentist

and educator, Dr. Homoly has helped dentists build prosperous practices for more than 20 years.

Dr. Homoly’s focus is to coach high-performance dental teams and the full spectrum of dental professionals

and to advance leadership and communication in dentistry worldwide. He recently released

“YES! On-Line,” an in-office DVD/online case acceptance training program for the entire dental team.

For more information regarding “YES! On-Line” or specific practice questions, call 800-294-9370, visit

paulhomoly.com or e-mail paul@paulhomoly.com.

Glenn Lombardi

Glenn Lombardi is president of Officite LLC, a leading national provider of customized Web sites, search

engine marketing and social networking solutions for the dental community. Since 2002, Officite has

built more than 4,200 Web sites for dentists worldwide and has delivered more than 210,000 appointment

requests. Glenn is a frequent speaker at National Dental Association and state association meetings,

including the Academy of General Dentistry and DC Dental. His presentations focus on professional

Web site development, optimization of a Web site for search engines and how to seamlessly

integrate the Internet into your practice to attract new patients and increase case acceptance. For more

information about the services offered by Officite, visit officite.com or call 888-282-9751. E-mail Glenn

at GLombardi@officite.com.

6

www.chairsidemagazine.com


Daniel J. Melker, DDS

Dr. Daniel Melker graduated from Boston University School of Dentistry in 1975 with specialty training

in periodontics. Since then, he has maintained a private practice in periodontics in Clearwater, Fla.

Presently, Dr. Melker lectures at the University of Florida Periodontic and Prosthodontic graduate programs

on the periodontic-restorative relationship and presents at UAB, UH, Baylor University and LSU.

He has published several articles in national dental magazines as well as The International Journal of

Periodontics & Restorative Dentistry and has twice been honored with the Florida Academy of Cosmetic

Dentistry Gold Medal. Contact Dr. Melker at 727-725-0100.

Ellis Neiburger, DDS

Dr. Ellis “Skip” Neiburger graduated from the University of Illinois College of Dentistry in 1968. After

postgraduate research in Oral Pathology and Forensic Dentistry at the U.S. Armed Forces Institute of

Pathology, Dr. Neiburger pursued a career as a paleopathologist. He was curator of anthropology at

the Lake County Museum for 17 years. Dr. Neiburger’s research on ancient anatomy and occlusion has

taken him throughout the world, and his studies in the areas of prehistoric pathology, dental computing

and clinical dentistry have been widely published. He is editor and vice president of the American

Association of Forensic Dentists and has written five books on dentistry. Dr. Neiburger is a general practitioner

in Waukegan, Ill., and can be contacted at 847-244-0292 or drneiburger.com.

Frank Spear, DDS, MSD

Dr. Frank Spear is one of the premier educators in esthetic and restorative dentistry in the world today.

He earned his dental degree and an MSD in Periodontal Prosthodontics from the University of Washington.

Dr. Spear is an affiliate professor in Graduate Prosthodontics at the University of Washington and

maintains a private practice in Seattle limited to esthetics and fixed prosthodontics. He is also founder

and director of Spear Education. Dr. Spear has received the Christensen Award for Excellence in Restorative

Education, the American Academy of Cosmetic Dentistry Achievement Award, the Saul Schluger

Memorial Award for Excellence in Diagnosis and Treatment Planning and the American Academy of

Esthetic Dentistry President’s Award for Excellence in Dental Education. To learn more about Dr. Spear

or Spear Education, visit speareducation.com or call 866-781-0072.

Contributors 7


PRODUCT........ TrollFoil

Dr. DiTolla’s

CLINICAL TIPS

CATEGORY...... Articulating Paper

SOURCE.......... TrollDental

New Milford, Conn.

800-537-8765

trolldental.com

I am unsure when the last significant innovation in articulating

paper took place, but I know we have come

a long way since the days of typewriter ribbon and

cardboard-thick paper. TrollDental hasn’t reinvented

the articulating wheel with this product, but minor

improvements make TrollFoil my favorite articulating

paper. First of all, it comes mounted in its own plastic

frame, and one less instrument on the bracket table is

fine with me. The double-sided foil is only 8 microns

thick, and it has no problem marking wet surfaces,

dry surfaces or highly polished surfaces, such as cast

gold or BruxZir ® .

Dr. DiTolla’s Clinical Tips 9


Dr. DiTolla’s

CLINICAL TIPS

PRODUCT........ NV MicroLaser

CATEGORY...... Diode Laser

SOURCE.......... Discus Dental

Culver City, Calif.

800-422-9448

discusdental.com

I am happy to report that yet another one of my favorite

products has gone cordless. To me, cordless is

about more than convenience; many times it determines

whether a dentist uses the technology or lets

it collect dust, especially when it comes to using it in

multiple operatories. The NV MicroLaser , manufactured

by Zap Lasers and distributed by Discus Dental,

is miraculously small when compared to the size of

my old diode laser, which is the size of a shoebox.

The NV MicroLaser weighs only 1.9 ounces and measures

just 0.6 inches in the section where you hold it.

Even better, the NV MicroLaser has done away with

the need for a fiber-management system with the introduction

of disposable cutting fibers that snap onto

the laser body. With presets for all common laser procedures

and a look and feel that would make Steve

Jobs jealous, the NV MicroLaser would seem to be the

prototype for all diodes to come.

10 www.chairsidemagazine.com


Dr. DiTolla’s

CLINICAL TIPS

PRODUCT........ Reduction Ring

CATEGORY...... Prepping Guide

SOURCE.......... The Reduction Ring

Englewood, Colo.

888-228-8088

reductionring.com

As many of you probably know, I am a big fan of

depth cut-based preparation techniques. In my opinion,

they are a foolproof way of ensuring you get adequate

reduction and thus a functional and esthetic

restoration. Some dentists are too set in their ways to

consider trying a new prep technique, but the fact remains

that the majority of the posterior crown preps

we receive at the lab are under-reduced. Enter the Reduction

Ring. Unless your patients have translucent

cheeks, checking occlusal reduction on a molar visually

is substandard. With a 1.5 mm or 2 mm Reduction

Ring, you are able to watch the ring slide between

teeth to indicate if you have enough reduction on the

lingual cusp of that upper first molar. The best news?

No more calls from our technical advisors asking you

to re-prep and re-impress!

Dr. DiTolla’s Clinical Tips11


Dr. DiTolla’s

CLINICAL TIPS

PRODUCT........ SONICflex ® LUX 2000 L

CATEGORY...... Sonic Scaler

SOURCE.......... KaVo Dental

Charlotte, N.C.

888-275-5286

kavousa.com

If you have been to a course by Dr. Bill Strupp you

are probably quite familiar with this sonic scaler from

KaVo. Bill uses 3M ESPE Durelon to cement all his

temps for a number of important reasons. The two

main reasons are: 1) the temps will never fall off, and

2) since there is no leakage at the margin, the tissue

always looks pristine two weeks later. That said, when

you go to remove the temp it comes off easily, but all

the Durelon is stuck to the tooth. If you try to clean

it with a hand instrument, it will take approximately

30 minutes to clean the prep. With the SONICflex you

are finished cleaning the prep in about 15 seconds.

I now use the SONICflex to clean all my preps prior

to cementation. And with some of the new diamond

tips available for sonic scalers, I can actually refine

the margins of my crown preps and make them satin

smooth with the SONICflex, as well.

Waterlase YSGG is a registered trademark of BIOLASE Technology, Inc.

12 www.chairsidemagazine.com


Book Review

“Aesthetic &

Restorative Dentistry:

Material Selection

& Technique”

– BOOK by Douglas A. Terry, DDS; Karl F. Leinfelder, DDS, MS;

Willi Geller, MDT

– REVIEW by Michael DiTolla, DDS, FAGD

– CLINICAL PHOTOGRAPHY by Douglas A. Terry, DDS

Most of us purchased our last dental textbooks in dental school and probably rarely refer to them. I still pull out

my color atlas of human anatomy and local anesthesia book from time to time, but that’s about it. For the most

part, the books we studied from were boring but served their purpose: to educate. However, I have found that I’m a

visual learner. I learn better through pictures, and the better the photography is, the more drawn in to the subject matter

I am.

Toward the end of last year, I received an e-mail about a new book being completed by Dr. Douglas Terry, Dr. Karl

Leinfelder and Master Dental Technician Willi Geller. I was only familiar with Dr. Terry at the time and had actively followed

his numerous published articles. Many of these articles focused on direct composites, and you could clearly see

his skill and artistry. As a dentist who has focused exclusively on indirect restorations for the past 10 years, I told myself

I would reprint the next article on indirect restorations that Dr. Terry wrote.

Since the book arrived in mid-January, it has had its own reserved parking spot on my desk. It is 700-plus pages of

some of the most accomplished photography in dentistry, and more importantly, it is downright useful. “Aesthetic &

Restorative Dentistry: Material Selection & Technique” is an exhaustive work, but an absolute joy to read.

Dr. Terry covers composite resins as expected, but I was surprised and delighted to see him cover such diverse topics as:

principles of tooth preparation, ceramic materials, elastomeric impression materials, contemporary adhesive cements,

provisionalization and periodontal plastic surgery. It is exactly the table of contents I would have come up with, because

it contains all the topics that I love.

A number of dental journals publish articles in which amazing dentistry is accomplished with, for example, multilayered

direct composites. A patient with a fracture of an anterior tooth needs a large Class IV composite with an incisal

edge involved. The dentist takes an impression, pours a study model, repairs the defect, makes a putty matrix, and then

begins rebuilding the tooth. The result is absolutely gorgeous, but I don’t know a single dentist who routinely practices

like this. That is why it is so refreshing to see the practical knowledge Dr. Terry has included in this book.

I wanted to give you a sneak peek of the stunning visuals I am referring to, and Dr. Terry was kind enough to give

us permission to reprint one such case from the book. Following is a short photo essay on utilization of the total etch

technique for rebonding a fractured porcelain veneer. There have been other articles on the same topic, but none have

been done with the same style and simplicity of this case. Like our dental school textbooks, this book will certainly

educate you, but with a passion, clarity and detail rarely seen in dental publishing today.

Book Review – Aesthetic & Restorative Dentistry: Material Selection & Technique13


Figure 1: Preoperative facial view of fractured porcelain on a maxillary left central incisor.

Figure 2: The internal surface of the fractured

porcelain restoration was micro-etched with

silica coated aluminum oxide particles (Rocatec

/CoJet System, 3M ESPE ).

Figure 3: The fractured fragment was etched for two minutes with

a 9 percent buffered hydrofluoric acid gel (Porcelain Etch, Ultradent

Products ® , Inc.).

Figure 4: Application of an MDP-containing bonding/silane coupling

agent mixture (Porcelain Bond Activator mixed with Clearfil SE Bond

Primer, Kuraray).

14 www.chairsidemagazine.com


Figure 5: The fractured ceramic surface of

the intact veneer was etched with 9 percent

buffered hydrofluoric acid gel (Porcelain Etch,

Ultradent Products ® , Inc.).

Figure 6: The exposed tooth preparation was

etched for 15 seconds with a 37.5 percent

phosphoric acid (Gel Etchant, Kerr/Sybron).

Figure 7: Silane was applied to the etched

ceramic surface of the intact veneer and

lightly air dried.

Figure 8: An adhesive (All-Bond 3 , Bisco) was applied to the tooth structure and ceramic

surface and lightly air dried.

Figure 9: A dual-cured resin cement (Illusion

, Bisco) is placed onto the internal

surface of the fragment.

Book Review – Aesthetic & Restorative Dentistry: Material Selection & Technique15


Figure 10: The fragment was seated and

the excess resin cement was removed with

a #000 sable brush. It was then polymerized

from all aspects, facial, lingual, incisal and

proximal, for 60 seconds, respectively.

Figure 11: The final post-operative result reflects harmonious integration of form, color and

texture that can be achived from the reattachment of a fractured porcelain veneer restoration.

Purchase “Aesthetic & Restorative Dentistry: Material

Selection & Technique” at quintpub.com or amazon

.com. For an autographed copy of the book, log on to

everestpublishingmedia.net. CM

Contact the author, Dr. Douglas Terry, at 281-481-3470, dentalinstitute.com or

dterry@dentalinsititue.com.

Reference

Aesthetic & Restorative Dentistry: Material Selection & Technique. Douglas Terry,

Karl Leinfelder and Willi Geller. Everest Publishing Media, Stillwater, Minn., 2009.

16 www.chairsidemagazine.com


Too

Much

Tooth,

Not

Enough

Tooth

Making Decisions About

Anterior Tooth Position

– ARTICLE and CLINICAL PHOTOS by Frank Spear, DDS, MSD

The restoration or creation of an esthetic smile is always the result of focused observation, thoughtful

evaluation, and a systematic approach to planning and sequencing treatment. Restorative and

esthetic dentistry approached through this process will incorporate the five critical elements that contribute

to the beauty of a natural smile and result in a successful outcome for both patient and dentist.

These five essential considerations are tooth position, gingival levels, arrangement, contour and color.

Although each of these is important in the final result, the first step is the most important – and in

the esthetic process, the starting point for tooth position always is the incisal edge of the maxillary

central incisor. 1,2 As in denture prosthetics, this step is critical not only in the esthetic plan, but also in

developing the functional treatment plan – because it determines the appropriate positions of all the

maxillary teeth and subsequently, beginning with the lower incisors, determines the positions of the

mandibular teeth.

18 www.chairsidemagazine.com


Lip mobility as a factor in tooth display

Figure 1a: Average amount of

central incisor display in a 30- to

40-year-old woman with correctly

erupted central incisors.

Figure 1b: High lip mobility of more

than 10 mm combined with a resting

display of 3 mm.

In this article, I review the elements used in determining the correct position of the incisal edge of

the maxillary central incisor, step No. 1 in the diagnostic and treatment planning sequence called

Esthetics—Function—Structure—Biology, used in the Spear Education program. The practitioner must

evaluate three aspects to ensure correct placement of that edge, and I will describe them here.

■ The Elements Of Determining Incisal Edge Placement

The three factors the dentist must evaluate for correct placement of the maxillary

central incisor’s incisal edge are tooth display and lip mobility; the position of the

incisal edge relative to the position of the other teeth in the maxillary arch; and

phonetic considerations.

Tooth display and lip mobility. The first consideration is a combination of two

elements: the amount of tooth displayed at rest and lip mobility. Lip mobility is the

amount of lip movement that occurs as the patient smiles. 3 The majority of observers

will select as an ideal esthetic smile one that displays the full central incisor

and includes a slight amount of gingiva apical to the tooth. 4 The amount of tooth

that shows at rest will vary depending on the amount of lip movement during the

smile. As an example, if the patient’s central incisor is 10.5 mm long (an average

length) and the lip moves 6 mm from rest to full smile, assuming a display of the

gingival margin during full smile, 4.5 mm of tooth will be displayed at rest. If the

same patient’s lip is less mobile, moving only 4 mm from rest to full smile, 6.5 mm

of tooth will be displayed at rest to achieve the same esthetics. Conversely, if the

patient has a highly mobile lip, with 10 mm of movement, only 0.5 mm of tooth

will display at rest to meet the esthetic requirements of an ideal smile.

“As a general rule in

my practice, with the

patient’s lip at rest,

I always ensure that

at least the edges

of both central

incisors are visible

so that the patient

does not appear

to be edentulous.”

The preceding example illustrates clearly that placement of the incisal edge will be influenced dramatically

by the patient’s level of lip mobility and the desired appearance of the smile regarding tooth

exposure and gingival display (Fig. 1a,1b). As a general rule, the more mobile the lip, the less tooth that

can be displayed with the lip at rest to create a pleasing smile; the less mobile the lip, the more tooth

Too Much Tooth, Not Enough Tooth: Making Decisions About Anterior Tooth Position 19


Creating suitable incisal edge position in a patient with extreme wear

Figure 2a: Patient’s upper lip at

rest. No tooth is visible. This patient

is 50 years old and would typically

display 1 mm of tooth at rest.

Figure 2b: Measurement is aimed at

determining how many millimeters

to add to the patient’s central incisors

to achieve a normal amount of

tooth display for his age.

Figure 2c: Provisional restorations

are placed to give the patient 0.5 to

1 mm of tooth display.

display at rest that will be necessary to create a pleasing, full smile. In 1978, Vig and Brundo 5 examined

a sample of women and determined the following averages for tooth display at rest according to age:

• Age 30, 3 mm to 3.5 mm

• Age 50, 1 mm to 1.5 mm

• Age 70, 0 mm to 0.5 mm.

According to Vig and Brundo’s study, this change in display is less the result of tooth position than of

changes in the facial tissues relative to the skeletal base. I find this information especially useful with

patients who believe their teeth are too short. To begin, I evaluate how much tooth they display with

the upper lip at rest. I then ask the patient to smile, and I note the amount of lip movement. If I know

the amount of tooth display desired with the patient’s full smile, the patient’s lip mobility combined

with the average length of a central incisor helps me determine where to begin in testing placement of

the incisal edge. This is an especially useful technique with patients who exhibit extreme dental wear.

Often, these patients display no tooth with the lip at rest (Fig. 2a). Using Vig and Brundo’s 5 averages, I

can approximate display at rest on the basis of the patient’s age and know how much to lengthen the

central incisors to create an average tooth display with the lip at rest (Fig. 2b). I then can try this incisal

edge position as either a composite mock-up or a provisional restoration (Fig. 2c). By asking the patient

to smile fully, I can evaluate the smile and use this observation to refine the edge position. Whenever

the practitioner is lengthening the incisal edge, he or she must evaluate “f” and “v” sounds and modify

tooth shape and position for acceptability (see section on phonetics below).

The ultimate position of the incisal edge for patients with extreme tooth wear is a combination of tooth

display at rest, lip mobility, age and functional consideration based on what the occlusion will tolerate.

Vig and Brundo’s 5 averages of tooth display at rest are simply useful starting points from which to make

refinements to arrive at the most appropriate position for each patient. As a general rule in my practice,

with the patient’s lip at rest, I always ensure that at least the edges of both central incisors are visible

so that the patient does not appear to be edentulous.

Position relative to other maxillary teeth. The second consideration in establishing the correct maxillary

incisor position is evaluation of the incisal edge relative to the other teeth in the maxillary arch. 6,7

20 www.chairsidemagazine.com


Figure 3: Note the pleasing symmetry

of the central incisors, canines

and posterior teeth when they all

are on the same plane.

Figure 4: The classic reverse smile

line caused by the central incisors

being apical to the plane of the

posterior teeth.

In a normal Class I occlusion, the incisal edge of the central incisor will be on approximately the same

plane as the tips of the canines and the buccal cusp tips of the premolars and molars. When this arrangement

exists, the maxillary central incisal edge position is esthetically pleasing, and the smile line

exhibits symmetry with the lower lip (Fig. 3). 9

When the maxillary central incisal edge is coronal to the plane of the posterior

teeth, it is caused most commonly by overeruption of the teeth as a result of

Class II malocclusion or of restorative dentistry completed without consideration

of edge position. The teeth appear too prominent in the face, and the smile line

exhibits an exaggerated curvature. Bringing the edges apically to the plane level

with the posterior teeth is an excellent starting point when correcting front teeth

that appear too long. After the anterior teeth are placed on the same plane as the

posterior teeth, either through orthodontics or provisional restorations, the practitioner

then can refine the position for the most pleasing appearance. 7,8

When the maxillary central incisal edge is apical to the plane of the posterior

teeth, it creates a reverse smile line (Fig. 4). Common causes of this are undereruption

resulting from a Class III malocclusion, ankylosis caused by trauma or a

patient’s habit (such as tongue thrusting and thumb sucking). Perhaps the most

common cause of this tooth position, however, is wear of the anterior teeth resulting

from a protrusive bruxing habit or chemical erosion while the posterior teeth

sustain minimal wear.

Placing the maxillary central incisor’s incisal edge visually on the plane of the posterior

teeth, either orthodontically or restoratively, will resolve most of the esthetic

problems and create a position from which the dentist then can make refinements.

Although this is a useful method of starting to position central incisal edges, it cannot

always be used. When posterior teeth are missing, worn away, overerupted or

improperly restored, one must use the first and third considerations alone.

Phonetics. The third consideration in appropriately positioning the maxillary

incisal edge is phonetics, specifically the “f” and “v” sounds, as described

in classic prosthodontic texts. 9-11 Most technique discussions men-

“Given the importance

of esthetic success

in practice today,

and the fact that every

facet of treatment

is affected when a

dentist decides to

change a patient’s

incisal edge position,

it is critical that

dentists learn, become

comfortable

with and use these

techniques when

evaluating patients.”

Too Much Tooth, Not Enough Tooth: Making Decisions About Anterior Tooth Position21


tion using “s” sounds as well; however, whereas this certainly is an important consideration, the

“s” sound is the result of the interaction between the maxillary and mandibular incisors. 12 In the

Esthetics—Function—Structure—Biology treatment planning protocol, we first position the maxillary

incisors to the ideal esthetic position and then modify the mandibular incisors and the lingual aspect

of the maxillary incisors to correct the “s” sound, the final position and shape being determined

by the movement of the mandible during speech. Enunciation of “f” and “v” sounds creates light

contact of the central incisors with the “wet-dry” line of the lower lip. Dimpling or trapping of the

lower lip signals that the contact impingement by the teeth is too great and indicates teeth that are too

long and must be shortened. One difficulty in using “f” and “v” sounds to evaluate length and position

is that they can tell the dentist reliably whether the teeth are too long, but they do not offer much

insight into whether the teeth are too short. Even when the maxillary central incisors are severely worn,

formation of “f” and “v” sounds will look correct because speech is so adaptable to shortening of the

maxillary incisors. Because restorative dentistry usually is involved in lengthening maxillary

central incisors, using phonetics is an excellent consideration in determining whether teeth have been

lengthened too much.

■ Conclusion

The focus of this article is the esthetic considerations of the maxillary central incisal edge as part of

the Esthetics—Function—Structure—Biology process of diagnosis. Clinicians should recognize that all

changes made to the position of the maxillary central incisor must address the functional etiology that

placed the central incisor in a position other than one that creates the ideal smile. They also must understand

clearly how the functional component, the occlusion, must be altered to produce a predictable

result with the new incisal edge position.

In this article, I have presented three considerations in evaluation and positioning of the maxillary central

incisal edge. Given the importance of esthetic success in practice today, and the fact that every facet

of treatment is affected when a dentist decides to change a patient’s incisal edge position, it is critical

that dentists learn, become comfortable with and use these techniques when evaluating patients. CM

Dr. Frank Spear is founder and director of Spear Education. To learn about Dr. Spear or Spear Education, visit speareducation.com or call 866-

781-0072.

DISCLOSURE: Dr. Spear did not report any disclosures. The views expressed are those of the author and do not necessarily reflect the opinions

or official policies of the American Dental Association.

■ References

1. Boucher CO, Hickey JC, Zarb GA, eds. Prosthodontic Treatment for Edentulous Patients. 7th ed. St. Louis: Mosby; 1975:224.

2. Sharry JJ. Complete Denture Prosthodontics. 3rd ed. New York City: McGraw-Hill;1974:234.

3. Martore AL. Anatomy of facial expression and its prosthodontic significance. J Prosthet Dent 1962;12(6):1020-1042.

4. Tjan Ah, Miller GD, The JG. Some esthetic factors in a smile. J Prosthet Dent 1984;51(1):24-28.

5. Vig RG, Brundo GC. The kinetics of anterior tooth display. J Prosthet Dent 1978;39(5):502-504.

6. Frush JP, Fisher RD. The dynesthetic interpretation of the dentogenic concept. J Prosthet Dent 1958;8(4):558-581.

7. Lombardi RE. The principles of visual perception and their clinical application to denture esthetics. J Prosthet Dent 1973;29(4):358-382.

8. Lombardi RE. A method for the classification of errors in dental esthetics. J Prosthet Dent 1974;32(5):501-513.

9. Pound E. Esthetic dentures and their phonetic values. J Prosthet Dent 1951;1(1-2):98-111.

10. Watt DM. Tooth positions on complete dentures. J Dent 1978;6(2):147-160.

11. Pound E. Recapturing esthetic tooth position in the edentulous patient. JADA 1957;55(2):181-191.

12. Rothman R. Phonetic considerations in denture prosthetics. J Prosthet Dent 1961;11(2):215-223.

Reprinted with permission from the American Dental Association (ADA): Spear FS. Too much tooth, not enough tooth: making decisions about

anterior tooth position. JADA 2010;141(1):93-96. Copyright ©2010 American Dental Association. All rights reserved. The American Dental Association

makes no representation and accepts no responsibility for the accuracy, timeliness or comprehensiveness of the cover image.

22 www.chairsidemagazine.com


– INTERVIEW of Paul Homoly, DDS, CSP

by Michael DiTolla, DDS, FAGD

I finally had the opportunity to sit down and

talk with Dr. Paul Homoly about a topic that

should be of interest to most dentists: profitability

on typical crown & bridge cases.

Most dentists have spent a fair amount of

time thinking about their single-unit crown

fee, and almost by default. It is probably

one of the more productive procedures

in our offices. But have you always assumed

that productivity is linear for larger

crown & bridge cases? If so, read on

for some eye-opening perspectives. To

watch video footage of this interview,

visit chairsidemagazine.com.

24 www.chairsidemagazine.com


Interview with Dr. Paul Homoly

25

Interview with Dr. Paul Homoly


Dr. Michael DiTolla: Paul, it’s nice to have

you back at Glidewell. This is the first inperson

Chairside ® interview that we’ve had

the opportunity to do together. Usually for the

magazine, we interview people over the phone.

It’s really nice to have you live in the studio,

to be here together and to look at charts

and information together. We’ve had fantastic

response from your previous Chairside

articles, and I’m really excited about what

we’re going to talk about today. I know this

is something that I struggled with when I

was in private practice, and it’s a topic that

dentists don’t spend enough time thinking

about – it’s almost like a dirty word. And that

dirty word is “fees.” This has to do with profitability

and whether we’re ethical and whether

we should be giving our services away. It’s

scary for me to think that there are dentists who

go through all this college, all this dental

school and then take a big risk – $750,000

on a practice and staff it and practice for

30 years with the best intention to practice

the best dentistry – but then never really

give much thought to the fees, just kind of inherit

the fee schedule from the dentist whom he or

she bought the practice. Thirty years later this

dentist discovers that because his or her fees

were set at the wrong place, after dedicating

his or her entire life to helping patients, there’s

nothing to show for it. Is this a scenario you

commonly see?

Dr. Paul Homoly: Yes, absolutely. Or the dentist

reads a magazine that says, you should

be charging $830 for a crown, so that’s where

he or she sets the crown fee. Talking about

money in dentistry is always dangerous because

money isn’t really part of our culture.

When you think about it, how much did

we study money when we were in dental

school? And how often is money discussed

from the main podiums in front of large audiences?

Typically the biggest groups and

the biggest draws in dentistry have to do

with pursuing clinical excellence. And the

money is kind of like the dirty little secret

behind it. But ask yourself this, Mike: How

much excellence can a dentist produce if

he or she is not profitable? How long can

this dentist retain great staff members if he

or she’s not able to pay competitive wages?

What quality of dental laboratory must a

dentist use if he or she can’t afford premium

lab fees?

Money and profitability are almost an antecedent to clinical

quality because the dentists who are most profitable

are the same dentists who can afford good equipment,

take time off for rejuvenation, use the best labs and pay

the best salaries. So, for us to talk about fees – that’s really

the first domino that must fall. Every dentist needs to be

really smart about setting his or her fees. And without that

wisdom, dentists won’t prosper.

Hufford Financial Advisors (huffordfinancial.com) partnered

with Indiana University and the AGD in 2007, and

together they surveyed 1,630 AGD dentists. When the surveys

came back, Mike, 70 percent of AGD dentists were

unable to retire and less than 10 percent expressed confidence

in their investment decisions. Money isn’t a part of

our culture. I encourage you to contact Hufford Financial

Advisors to request a copy of the Financial Preparedness

Study for Dentists.

MD: And the AGD is a totally voluntary organization, you

don’t have to join. You get AGD credits, which count for, in a

real sense, nothing. It’s kind of a bonus above and beyond,

it goes toward your state credits. But to pursue fellowship in

that academy, like I did, is really just about trying to do the

right thing and being a constant student of dentistry.

PH: Becoming a better dentist.

MD: Wow, and AGD dentists are very focused on clinical

quality. I think organized dentistry plays a small role in this;

granted, we didn’t learn much about money in dental school,

nor were we ready – we needed to learn how to control a

handpiece and not kill someone. But even after graduation,

I noticed that I received continuing education credit every

time it was a clinical course. But God forbid I go to a practice

management course where zero hours were offered. What

message does that send to the dentist, when you literally don’t

get any credit for learning how to run your practice?

PH: The message is that it’s not important or it’s wrong

to learn.

MD: It’s wrong to learn.

PH: So let’s talk about fees. A typical dentist goes into practice,

reads a practice management article and looks at a fee

schedule. So you’ve got a whole list of numbers. You’ve got

the ADA code, you’ve got the procedure itself and you’ve

got a fee. And that fee schedule makes a lot of sense when

you’re only doing one tooth at a time. So let’s say your

crown fee is $800. You’re doing one crown. How much

time, judgment, risk and skill go into doing one posterior

unit, Mike?

MD: That’s pretty simple and straightforward. It’s not a

buccal pit amalgam; it’s more difficult than that. But in the

26 www.chairsidemagazine.com


grand scheme of things, that single-unit crown is pretty basic.

That’s something we do every day.

PH: It’s pretty basic. And if you look at the most common

procedures a dentist performs, typically there are 10

to 12 procedures they’ll do 80 to 90 percent of the time.

Most of the time, those procedures are done one tooth

at a time. In these instances, working off a fee schedule

makes sense. Now, Mike, tell me this: If you were to do

two crowns, let’s say in the same quadrant, one right next

to the other – does doing two crowns take you twice as

long as doing that one crown?

MD: No, because I can anesthetize them both at the same

time, I can break contacts on both of them at the same time

with a bigger bur. Making the temporaries, they’re going to be

connected, so there’s just a little bit of bisacryl material.

PH: Take the impression at the same time. Take the bite

at the same time.

MD: That’s all going to be at the same time, as well, as opposed

to if they were in two separate quadrants. So, it’s not

twice as difficult – maybe 1.3 times more difficult.

PH: What if there were three crowns in the same quadrant?

Does the same apply?

MD: Yes, it would not take three times as much time to do

three crowns, but it would be slightly more difficult.

PH: It would be slightly more difficult. I think the fee

schedule, Mike, makes sense up to those 3 units per quadrant.

If my fee for a crown is $800 and I do two crowns,

it’s $800 times two. If I do three crowns, it’s $800 times

three. That makes perfect sense.

Now, let’s jump to complex-care dentistry, Mike. Let’s say

you’re doing 12 crowns. If you’re doing 12 crowns, chances

are real strong that you’re going to change the plane

of occlusion. If you’re doing 12 crowns, chances are really

good that you’re going to change the anterior guidance,

there may be vertical dimension involved, certainly changing

condylar position. Of the anterior guidance, vertical

dimension, plane of occlusion, condylar position, you’re

changing three or maybe even four of those variables.

MD: Whether you want to or not!

PH: Whether you intend to or not (laughter). Now,

let’s say you’re charging $800 per unit and you look at

your 12 units. How much sense does it make to take

your $800 per unit fee and multiply it by 12 for this kind

of complex-care case? How much more complexity is

there in the 12-unit case as opposed to 12 crowns done

one at a time?

MD: It’s huge! It’s a much bigger difference.

There is a much higher degree of difficulty in

pulling off that 12-unit case, not to have the

patient lisp afterward, be able to function

well with those teeth without breaking them

off in the anterior. There are a lot of factors

involved. But as a dentist, you would tend to

think: Well, if I did 12 single-unit crowns on

12 different people, that’s a lot of work! This

12-unit case is going to be great, I can do

it all on one person at one time. But it fails

to take into account all the systems that

you’re changing and the degree of difficulty

with successfully completing a big restorative

case like this.

PH: Sure, it’s not only the degree of difficulty

in terms of what you know to be true about

occlusion, but it’s also the degree of difficulty

relative to your planning. How much

planning, preoperative planning, are you to

do, Mike, for 2 units in the same quadrant?

How much planning do you do for a case

like this?

MD: None. You get them in the hygiene room

before they go home that day and prep it.

PH: You put them in the chair, you can see

the end result and you prep the case. Now,

let’s say you were going to prep me for 12

units and you were going to change those

four variables. How much planning would

you have to do? How much time would you

have to put into that case?

MD: Hopefully I’m going to put in a couple of

hours ahead of time and get some lab-fabricated

provisionals, which will add some expense, a

Diagnostic Wax-Up. The patient’s expectations

are going to be higher.

PH: You’ll be shooting photographs. You’re

going to be taking models. Your team’s going

to be pouring and mounting those models.

You’ll be talking to the lab. What if the

patient has gum issues or bone issues or

missing teeth and needs implants? Now you

have to get on the phone and call your specialist.

How much time does that take, you

playing phone tag back and forth? Sending

the models back and forth? So there’s a

huge additional component of time involved

in these cases that doesn’t appear on your

fee schedule. Know what’s not on our fee

schedule, Mike? We get all these ADA codes,

Interview with Dr. Paul Homoly27


ut you know what there’s not an ADA code

for? Wisdom. We don’t charge patients for

our wisdom.

On the flight from Charlotte to Orange

County, I was reading the recent AACD

journal accreditation cases. What magnificent

dentistry is being done within that

organization. I just love looking at those

cases. But what I’d be really curious to find

out is, how much profit are they generating?

I wonder how much profit there is

considering the amount of time they’re

spending on incisal edge matrixes and reduction

guides and customized incisal guide

tables and custom shading.

MD: And that’s one of my pet peeves in journals,

as well. They will show a direct composite,

where they’re rebuilding a mesial incisal

angle and a lot of the facial on an anterior

tooth, and they’ll do a model, a Diagnostic

Wax-Up and then a putty matrix of it to help

build up the lingual of the composite. And

I’m looking at all this stuff going, “This is

insane! You’ve got to charge $1,000 for this

composite to be able to do it like this,” which is

fine if you can get it. But you’re right. I think

the average dentist who looks at it and tries

it would lose a lot of money, because we’re

just charging this straightforward fee without

any wisdom built into it.

PH: At the heart of advanced restorative

dentistry is wisdom. What have we learned

from the previous cases? For example, take

the profession of law. You walk into a law

firm and there are 50 attorneys. You’ve got

the old ones and the young ones. Now,

whose hourly fee is going to be the highest

and why?

MD: You would think that those who have

been there the longest would be the highest

paid because they have seen the most cases.

Especially if your case is a little bit more

difficult, they might go, “You know, I tried

something like this 14 years ago and read

about it. Here’s what we need to do.” A young

attorney might not have that experience

or wisdom.

PH: Yes, so you’re paying lawyers a premium

fee for their wisdom. Patient comes

to you with a severe overbite, jaws clicking,

periodontal problems, muscular problems and phonetic

problems. That’s a difficult case. There’s a lot of risk

there. A case like that requires a lot of wisdom. And really,

I think the point of this article is or where I’d like

to go is, how does a dentist take what they’re doing now

and begin to assess: What’s the risk? How much wisdom

do I need to apply? But do it in a practical way so

you’re not guessing what your fees need to be. There’s

a more objective way of looking at what the fee needs

to be when you really understand your fee based on

time, skill, risk, remake or change in patient medical

history. Patient medical history is a real big one, Mike.

Most rehabs are going to occur in a patient’s fifth or

sixth decade of life. They’re going to be in their 50s or

60s. How many of these folks are still employed? So let’s

say you’re going to do a big case, a $12,000 to $15,000

case. Even by today’s fees, sometimes it costs as much

as $10,000 per quadrant depending on if you’re doing

sinus elevations, bone grafts, implants, progressive loading,

multiple units. If you take a high-fee case, a $20,000

case, on a person who’s in their late 50s or early 60s,

that person is typically still in their income-producing

years. And they’re kind of at the peak of their earning

power. Now, you have a case that’s supported by posterior

implants and fixed bridgework. The anterior teeth are

all porcelain in the anterior guidance. What’s the probability

that you’re going to have a problem somewhere in

that case 10 to 15 years down the line, Mike? What’s the

probability?

MD: Off the top of my head ... maybe 85 percent?

PH: I’d say 100 percent (laughter).

MD: Well, I was putting a few weak-muscled patients in

there, patients who won’t be able to chew anymore.

PH: The patient’s medical history changes. So, one thing

we don’t recognize as we read the journal articles is what

the case will look like 20 years from now. Show me that

case when the patient’s sugar level is 250 and spinning

out of control. Show me that case when the patient loses

partial control of their hand or their eyesight starts to go

and they aren’t able to clean their mouth.

MD: Or Sjogren syndrome patients, who run out of saliva

and the teeth just deteriorate from underneath it.

PH: Or from all the medication they take. The difference

now is that the patient is retired and they’re living

off their retirement income. Now the case has a problem.

Now you’re going to have to assign a fee. The fee

to the patient now feels much greater than it did during

their income-producing years. The point I’m making

here is, when you initially do the case you cannot take

shortcuts. If there’s a question between doing 2 units or

28 www.chairsidemagazine.com


3 units of implant to support a bridge, use three. Will it

be more difficult to sell the case with three implants?

Yes, it will. But if you do not engineer the case for the

lifetime of the patient, when they do have failures and

remakes in their retirement years, you are going to have a

huge management headache. Second point about fees is

that, if you’re not doing many complex-care cases

– let’s say you’re doing one or two or three a year,

Mike – that’s what I call a hobby. It’s like the old guy

that sits with the beret at the state fair building

with the ship in a bottle. He loves it because he

loves doing it, not finishing it.

400

MD: But dentists want to chase the big cases, right? They

go, they take courses: “If I get just one big case per

month, it will pay the bills.” Really, in terms of profit,

what you’re saying is, for a 12-unit case, where you’re

almost doing that full maxillary arch, the dentist would actually

be better off doing four 3-unit bridges on four different

patients in terms of profit than one 12-unit

case on a single patient?

PH: Absolutely. Because you can do four

3-unit bridges without having to spend

the time and planning that you do with

Profit per Hour

MD: Isn’t that like somebody who goes golfing just

three times a year? They go out there but they’re terrible

at it. Can you be good at something you do three

times a year?

PH: You can’t be good, you can’t be fast, but you

can still enjoy it. So, it doesn’t make any difference

what you charge for a case like that. Enjoy it, have

fun with it. But I think for the majority of us doing

complex-care dentistry and trying to make a living

at it, if we’re doing one or two cases a month

or one or two cases a week, the importance of

setting the right fee becomes especially important.

Without the right fee, what will happen with

complex-care cases? Your gross will go incredibly

high but your net will begin to dip. You’ll feel like

hell, you’ll feel more stressed, and the overall quality

of your practice and other cases will begin to suffer, too.

The big cases will pull the rest of the practice down.

MD: How confusing must that be for a dentist to see the gross

go up, be high-fiving people: “We had a great production day!

Woo hoo!” And then the net goes down so far it becomes depressing.

PH: That was me. My first 10 years in practice, I pursued

quality. I was like a sled dog chasing a rabbit. I was on

a quest for quality. Yet our gross was incredibly high. I

think my practice at one time was in the top half-percent

of solo practitioners’ productions. But my net, hell, I was

embarrassed to talk about it. I was doing these big implant

cases, but to tell you the truth I was secretly praying

for a couple of simple 3-unit bridges to walk in so I could

pay my bills. And you know what? That’s another dirty

little secret – these big cases often don’t yield the profit

that they really need to.

300

200

100

Tooth

Dentistry

Figure 1

Centric Relation

Dentistry

Rehabilitative

Dentistry

one 12-unit case. You don’t need to think

about it that much. You know, ultimately

where this conversation is going to lead

is that when you’ve got six or more units

and you do the cases right, Mike – I’m talking

about preoperative photos, preoperative

study models, incisal edge matrixes, customized

provisional temporaries, using

temporaries as diagnostic tools, putting in

nightguards, corrected equilibrations and

follow-ups. When you do the case well, my

studies have shown that typically you’re

going to need to add 40 percent more

to the fee over your fee schedule. So, if

you’re $1,000 per unit and you’re doing 6

units, in order for those numbers to work

out well for you, you’re going to need to

add 40 percent to that fee. And if you’re

12 units or more, Mike, in order for those

units to work out well, you’re going to

need to add 70 percent to your fees

in order for that case to be profitable.

MD: Wow. And you’re talking about fees that

are already in place for 1-, 2- and 3-unit crown

Interview with Dr. Paul Homoly29


400

300

200

100

& bridge? This isn’t somebody who hasn’t raised

his or her fees for eight or nine years and has

an artificially low crown fee; this is somebody

who has their crown fee in place for the 1- and

2-unit cases. They still need to add more than

70 percent for a 12-unit or more case?

PH: Right, because dentists must consider

the time invested. It takes time to get study

models. It takes time to pour the models.

How much time is spent on a good Diagnostic

Wax-Up? You learn how to rehabilitate a

case while you do the wax-up, not as you’re

prepping the teeth. That’s where the wisdom

is manifested. You don’t need to do that with

simpler unit cases. How many dentists spend

hours and hours at their office after business

hours waxing-up cases, trimming dies, looking

through microscopes, and going through

trial equilibrations without charging the patient

for it? That’s unsustainable behavior.

And that’s not something you see or hear in

the journals – people don’t talk about it.

Tooth

Dentistry

Figure 2

Profit per Hour

275

2 crowns

177

1 crown

163

Composite

326

3 crowns

Centric Relation

Dentistry

Rehabilitative

Dentistry

PH: I can’t even address that situation because if you’re

doing big cases and you’re not doing the right wax-up,

you’re not doing the right temporaries, you’re just slamming

stuff in and hoping people will get used to it, then

you’re going to end up with skinny kids, number one.

The probability is going to come back to eat you. Number

two: You’re going to end up moving several times in your

career because people are going to come back mad and

you’re going to end up with a remake legacy that you’re

not going to be able to deal with.

MD: So plan on taking state boards in several different areas,

is what you’re saying. That’s a good plan.

PH: Let’s look at it from a standpoint of some illustrations.

Figure 1 (page 29) shows the complexity of care all the

way from the left, which is tooth dentistry, all the way to

the right, which is rehabilitative dentistry.

The vertical column represents that fee per hour and consists

of the patient fee minus the lab fee minus office

overhead, divided by time.

Typically when we’re in the tooth realm of 1, 2 or 3 units,

the level of profit is fairly modest, but it escalates. The

common belief in dentistry is, as I do 8, 10,

20 units, this profit yield should continue on a

straight line. That’s the belief.

Now, when you actually put the numbers to it,

it looks like this: Single posterior composite fee,

$163; posterior ceramo metal unit with a profit

of $177. If you do 2 units in the same quadrant,

as you were saying earlier, Mike, you can get

it done in not twice the time but probably 1.3

units of time. So the profit jumps from $177 to

$275. And if you do 3 units in this same quadrant,

the profit jumps up to about $326 (Fig. 2).

The three posterior units in the same quadrant

at the same vertical dimension, plane of occlusion,

condylar position, incisal edge position,

where you’re not changing those variables, 3

units in the same posterior quadrant represent

what I call “The Sweet Spot.” That is: the highest

net fee per hour most general dentists can

generate. It’s the sweet spot (Fig. 3, next page).

MD: Or what’s even scarier is, because they’re

not doing that, they’re not adding 70 percent

to those bigger cases. They’re not doing

any prep work, they’re just doing run and

gun: prepping all the teeth and putting the

temps in. That’s where the risk will come back

to bite you.

It’s like the spot on a golf club, Mike: You go on a golf

course, you pick up your 6-iron, you happen to swing

well and click! You can tell when that ball hits the sweet

spot on the club. It is the maximum flight of the ball.

It is the maximum performance of the ball with the minimum

exertion of energy. Three units in the posterior

quadrant provide maximum results, in terms of profit,

with minimal energy.

30 www.chairsidemagazine.com


MD: And I bet most dentists know that on a certain

level. They couldn’t give you numbers. They certainly

couldn’t quantify it. But you might say to them,

what’s your favorite thing to do? And they might say,

“I like a good 3-unit bridge.” And we have 3 units

here in the sweet spot, the profit per hour, but we’re

only prepping 2 units, so that might be the sweet spot.

You charge for the pontic, and life is good. Greatest

determination ever: that we can charge the same

for a pontic as an abutment. So I think most dentists

would probably know that on a certain level. They

couldn’t articulate it, but they would know on a certain

level, that’s my favorite thing to do. And that’s

probably why.

PH: When you take out the fee schedule and say,

“Well, my crown fee is $800. So, for 1 unit I’m going

to charge $800; for 2 units I’m going to charge

$1,600; for 3 units I’m going to charge $2,400,”

that progression makes sense. Why? Because it is

very low risk, very low remake and low planning

time.

MD: So, that actually works? To actually take

your crown fee and multiply it by two or three

actually works in these lower-risk cases?

PH: Absolutely, and for many dentists, that’s

where 80 to 90 percent or more of their

dentistry exists and where the fee schedule

makes sense. There’s all sorts of journal articles

about what to charge for a single-unit

crown in the Southwest versus the Northeast,

and how much time is taken. And all

those are valid if the dentist is doing 3 units

or less. Now, all of that breaks down when

the case gets complicated. All of it breaks

down when the dentist has to change vertical

plane of occlusion, condylar guidance or

incisal edge position – I sound a bit like a

broken record here. But those are the big

variables of a case. Those variables, in addition

to medical factors, especially when

you’re dealing with dental implants, where

host resistance is a huge component. Then

factor in aging components, risk factors that are

inherent to the dentistry, the intraoperative remake.

You made a statement earlier, before we

started about veneer cases – what percentage of

them need to be remade because of the contact.

MD: Or a single unit will need to be remade within

an 8- to 10-unit case.

PH: An 8- to 10-unit case of single unit would

need to be made, so that’s 10 percent right there.

400

300

200

100

I call that an intraoperative remake. Now,

your laboratory may not charge you for that

but there’s still the factor of time involved.

MD: The patient has to come back again, have

it put on. It’s another 45-minute appointment.

PH: Another 45-minte apointment. Remember:

profit per hour is that per hour. It’s divided

by time. So you have intraoperative

remake that is a factor when you do your 12-

unit case. You have complexity to the case

relative to the patient’s musculature and

neurophysiology. You have a change in the

patient’s medical history that can ultimately

make a case turn sour. Plus, all the time

and planning. All of the photographs and

models will oftentimes – if you take a 12-

unit case now and you take your unit fee at

$800 per unit and multiply it times 12, you’re

going to be 40 to 70 percent too low if you

base it off a fee schedule (Fig. 4, page 33).

Tooth

Dentistry

Profit per Hour

275

2 crowns

177

1 crown

163

Composite

Figure 3

326

3 crowns

Centric Relation

Dentistry

The Sweet Spot

Rehabilitative

Dentistry

MD: Wow. So, the crown fee is reliable if you’re

doing one crown, two crowns or three crowns.

But if you have a great case that walks in the

door that you’re excited about, if you take that

crown fee and multiply it times the 12 crowns,

you’re saying there’s almost no way on a case

as complex as that to make the same per hour

if you were doing two crowns.

Interview with Dr. Paul Homoly31


PH: That’s right. You’re better off doing 2

units at a time on six to eight different patients.

Or even on that patient!

MD: Even on that patient. Spend six years doing

two crowns at a time. Your kids will be fatter,

right?

PH: Absolutely right. And that is something

dentists miss all the time. I missed it early

in my career, Mike; I’m sure you missed it,

too. We were so in love with the process of

fixing teeth that we didn’t really see or feel

the bigger picture. When dentists hit their

40s, their backs begin to get sore, their eyes

begin to go. You can’t make up for lost ground

very easily. You are not the practitioner

from 40 to 50 or 50 to 60 that you were from

20 to 30 and 30 to 40. You won’t have the

same energy, you won’t have the same eyesight,

and you won’t have the same stamina.

The earlier dentists learn to set their

fees relative to complex care, the easier it

will be for them to accumulate wealth, to

be able to build a profitable practice and

to have what they really deserve. The practice

of dentistry takes a lot: We capitalize

our own businesses, we hire the people, we

manage the facilities, we do the dentistry,

we empty the plaster trap. We do a lot of

things. And improperly set fees can drag you

right down.

MD: That makes a lot of sense. So, to do that

12-unit case correctly, the 12 times the singleunit

crown fee is the baseline.

NET FEE:

Sum of (Patient Fee - Lab Fee - Office Overhead)

Dentist’s Time

PH: That’s right, that’s the baseline. You said

it earlier, Mike: That’s your base pay. Now you

look at, where should the fee be? When you

look at the sweet spot, I’ve got it set at about

$326 per hour. And that’s net fee per hour.

MD: Define net fee per hour for us.

PH: Net fee per hour is the patient fee minus the lab fee

minus the lab overhead divided by time.

That $326 represents my net fee per hour when I’m doing

3 units all in a posterior quadrant. That’s the safe sweet

spot right there. Now, when we cross the line and start

doing rehabilitative dentistry, where we’re doing those

four variables, now our net fee has to be greater than

that sweet spot. Here’s why: Because if it’s not greater,

we’re not profiting at the level that the risk demands. If

you were an investor and you were to invest in something

that is safe, like U.S. Treasuries, you would accept a

lower return on investment because you’re not making a

tremendous risk in the marketplace. But what if you were

invested in a very volatile, risky investment? What type of

return would you expect there based on risk?

MD: It’s got to be higher.

PH: It’s got to be a lot higher. When you start doing rehabilitative

dentistry, you’re making an investment in a risky

business. Therefore, your net fee per hour must be greater

than what you’re doing on a lower- or no-risk case.

MD: In one sense, these complex cases are sort of volatile.

There are just more things that can go wrong versus a singleunit

crown.

PH: Mike, they always go wrong!

MD: It’s just a matter of getting it right in the end!

PH: That’s right! Even in the end, it can’t be right all the

time. I did rehabilitative dentistry for 20 years, and I can

think of very few cases. You sit down and treatment-plan

a patient. Let’s say you’ve got 12 units of root canals and

implants and all sorts of moving parts in the mouth. You

treatment plan that case out, you get your treatment planning

form out and you color in all the teeth, color

in all the arrows, you get it all done and you

add it up. Now, what’s the probability that the

treatment plan is exactly what you’re going to

do at the end of the case? It’s about zero. There’s

always stuff that will change. We’re going to pursue

excellence. This is a great treatment plan

and I practice in a very excellent way and this

is the way it’s going to be. Dream on! There’s no

amount of excellence that’s going to compensate

for change of host resistance or act of God or anything

else that goes on.

MD: It reminds me of that old thing, how a plane flying from

Los Angeles to Hawaii is off course 99 percent of the time,

constantly correcting for the winds. But hopefully the pilots

get that plane down where it needs to be in the end. It’s a constant

matter of adapting to the environment. Build-ups you

32 www.chairsidemagazine.com


have to do that you didn’t foresee, that you didn’t plan on.

Composites falling out and you’ve got to do some filler, and

now that post is coming out.

PH: Or you laid a flap and what looked like good bone

now is mush and you have to graft the area and allow it

to heal. Or you have a post-operative complication. You

place three or four implants. I remember earlier in my

career, we weren’t as sophisticated about our flap management.

We’d place three to four implants. We’d come

back in about 10 days or so, pull the lip back and you

know what? Some of the cases, the flaps would open and

we would see the tops of the implants, and that’s when I

would feel the heat – the heat from my stomach come up,

like swamp gas settling on my face.

MD: That’s going to take a few minutes off of your life! And

you weren’t being compensated for it, were you?

PH: I wasn’t being compensated for it. So how do you fix

a case like that? You don’t. You let it granulate in. You see

the patient for 15-minute increments every two weeks and

it’s like watching a death march. And the longer you look

at the patient like a little thermometer, your profitability is

going down. Now you’re just hoping to break even.

And specialists wonder why more dentists don’t

refer dental implants or complex-care patients. Because

oftentimes the general dentist is much more

profitable from the sweet spot on down, from 3

units on down, than they are with these big godalmighty

cases that sometimes can take years to

complete. The dentist that refers a lot, Mike, is the

dentist that has abundance in his or her practice.

The dentist who’s doing a lot of bread and butter

dentistry, their bills are paid, they’re making

their profit goals, their staff is happy, they have

a good facility, they feel good about the dentistry

they’re doing. Abundance drives referrals. That’s a

different topic we can touch on another time – the

specialist-generalist relationship.

400

300

200

100

consider adding 5 to 10 percent to my fee

for consultations. Second thing I would

look at is occlusal analysis. What does that

mean? Well, it means that you’re at home or

you’re at the office, you’ve got nobody else

there, the study models in your hand, you’re

on your articulator thinking. This is where

you’re manifesting your wisdom. You get

compensated for that. And occlusal analysis,

with the accompanying Diagnostic Wax-Up

and creation of templates, that’s got to be

worth at least 20 to 25 percent of a premium

fee. Another thing we miss is equilibration.

Mike, I believe that equilibration is one of

the finest arts in dentistry: knowing when

to stop; knowing where to grind. Knowing

when to grind, when not to grind. Knowing

when enough is enough. How much

do we need to adjust bites long-term on

these rehabs? We’re always kind of touching

things up. And equilibration is another

10 to 15 percent on these cases. So, if you

look at the different areas that we typically

don’t charge for, those can add up to 40, 60,

70 percent over those fees that one would

Profit per Hour

275

2 crowns

177

1 crown

163

Composite

326

3 crowns

162

12 crowns

125

12 crowns with 5% remake

MD: Right, but the point being that they need to be

well versed and confident in their sweet spot dentistry

to be able to think about referring out the comprehensive

dentistry.

Tooth

Dentistry

Figure 4

Centric Relation

Dentistry

Rehabilitative

Dentistry

PH: That’s right. And when you sit down and you

treatment-plan your big case, you’re going to add fees to

different areas of the case where we normally don’t add

fees. Number one is going to be in consultation. Consultation

with physician, consultation with specialists, consultation

with laboratory, consultation with other dentists,

consultations with pharmacists – whomever is going to

be involved in the case, consultations take time. I would

charge based on their fee schedule. You

want to end up with your fee for the rehab

case now. You want to end up where your

profit – when you fee a case, plan on a 5

to 10 percent intraoperative remake. Mike,

you work here with Glidewell. You see

20,000 units a month go out the door. Give

Interview with Dr. Paul Homoly33


me a sense: What is the average remake rate

of the dentists you work with?

MD: If you combine everything – removable,

fixed, all the different things we do – it’s around

6.5 percent. And that includes me being in the

lab. My personal remake rate here at the laboratory

is about 6.5 percent – and that’s healthy.

We see dentists whose remake rates are 30 to

35 percent, and there’s something wrong there.

We see dentists whose remake rates are, I was

looking at an account the other day because we

got a goofy impression, the most insane impression

ever. It was literally about 8 cm and it was

an impression of just one tooth for a crown on

that tooth. There was no tray. It was an impression

of the prep and about the occlusal third of

the opposing tooth, nothing else. It was crazy.

And the department said this dentist sends that

in all the time; that’s his standard impression.

And when I looked up his remake rate, it was

less than 1 percent!

PH: Well, that may not be good either.

MD: That’s my point! He’ll cement anything.

In fact, we have records. We’re relatively sure

he once cemented a crown intended for one patient

on another patient. I suppose he looked at

the inside of it and prepped the tooth to match

it; we call him “Dr. CEREC” now. It’s just as

bad to have a really low remake number because

it shows you don’t have quality control.

You know, there are 63 steps between when the

impression is taken and the crown is delivered.

A lot of it has to do with the provisional. When

the temporary is on for two weeks, nothing good

happens. Nothing good happens during those

two weeks except the patient’s pterygoid muscles

heal from the lower block that you gave them,

if you’re still giving lower blocks (which I hate

to do). But nothing good happens. Things shift,

things move around. Bacteria gets under the

temporaries and teeth get hypersensitive. They

erupt. So there’s a number of reasons why there

would be a remake rate around 6.5 percent.

CAD/CAM has the opportunity to lower that a

little bit. But that’s what it is and that’s what

it should be. It should not be 35 percent and

it should not be 1 percent. So, 6.5 percent is

right about where it should be, if you’re honest

about evaluating dentistry intraorally and

giving people quality restorations.

PH: So the smart thing to do as a practitioner

is, when you put your final treatment plan together, factor

in additional cost for consultation, occlusal analysis, diagnostic

provisional, equilibrations, nightguard, post-operative

adjustments – then it makes perfect sense to factor

in another 8 to 10 percent for intraoperative remake. And

the patient accepts that fee.

Now, Mike, the patient has paid your premium fee. You’ve

got your premium fee and now you get into the case.

What’s your attitude now about an intraoperative remake?

How much stress does it cause you now?

MD: Just one? Is that all I have? We planned for three!

PH: Right, if you’re planning for 10 percent and you have

5 percent, you don’t have the stress and the anxiety of

the case hanging over you. If you’ve underfeed the case,

everything extra you do is just another straw on your

back, in terms of your profitability. If your case is feed

with the adjustments made to risk intraoperative remakes

and these aspects that I’ve been talking about, now when

the remakes or the failures or the breakdowns or the

changes in the patient’s medical history occur, it doesn’t

become a stressful event for you, not nearly as much.

You might feel bad that you need to redo something, but

economically it isn’t hurting you and the team and your

ability to sustain the practice. Lack of profitability is not

sustainable behavior. And we see it all the time with these

doctors who come back from the institutes – and I’ve got

nothing against the institutes, I teach at most of them –

but they come back with this idealistic attitude that as

long as you pursue excellence and you trim your own

dies and you use microscopes and you have these special

gizmos they told you to buy that you’re not going to have

problems with your cases. You are going to have problems

with your cases. And that’s normal. My point here in

this discussion is to charge for them.

MD: You’re right, because losing profitability is not a longterm

strategy. The lack of profitability would absolutely get

in the way of quality dentistry, unless you’re independently

wealthy from an outside source and you’re doing dentistry

as a hobby.

PH: If a dentist is not profitable and then reaches his or

her 50s or 60s and they begin to think about bringing

in an associate, now this tendency to suffer from lack of

profitability brings an associate to transition into the practice,

to buy the practice. If the practice is not profitable

and the dentist is buying into it, that ushers in a whole

other layer of complexity relative to: 1) the failure of the

buy-in; 2) the dentist is not modeling good profitable behavior.

So we have this lack of profitability culture, this

legacy that is passed on from dentist to dentist to dentist,

which is a shame.

34 www.chairsidemagazine.com


Several years ago, Reader’s Digest magazine had a phantom

patient that went from office to office. And I forget

the situation, but apparently the fees that came back

ranged anywhere between $2,000 and $25,000. One of

the journals had the patient’s X-rays and all that. And I

looked at that case and thought: The only dentist who

got it right was the dentist who charged $20,000. Because

he was the guy that took the models, was putting

them in the splint, who did the equilibrations, who did

the case well. And the dentists who cried about it

were the ones losing money because they didn’t know

how to set fees, and they thought this guy was a bandit.

He’s not a bandit; he just knew what he was doing.

Big difference there.

MD: You mentioned to me a study that you have in which

more than 100 dentists participated, doing the same type

of thing as the Reader’s Digest article. This is probably long

overdue in dentistry, because dentists had a knee-jerk reaction

to it: Oh my gosh! It’s not like in dentistry we take an

FMX into a machine and then out comes a treatment plan

with the fees already on there. It kind of would be nice in

a sense: “Your case is going to be $20,000.” And the patient

gasps and we just say, “It’s the machine! We all use the same

one. Go to the dentist down the street and he’ll tell you the

same thing.” Because now you’re taking the emotion out of

the dentist and the guilt about telling somebody they need

$20,000 worth of dentistry. So, it was a study that was done

by some friends of yours, where they had 126 dentists treatment

plan an 8-unit case, with some other things that needed

to be done. There, you also saw fees all across the board. Tell

our readers about that study.

PH: Ken Mathys and I teamed up years ago, and taking

what I’ve described as this right-fee solution, that’s the

brand we use for this. And that’s taking your fee schedule

and proportioning it so that the fees of different procedures

you do make sense to each other. For example, the

care and skill and judgment of doing a simple posterior

crown may be less than the skill needed to do a Locator ®

Bar Overdenture. So there’s going to be a difference of

skill between those two.

Ken is a CPA, and he runs a company called Dental Practice

Advisors (dentalpracticeadvisors.com). I asked Ken to

use his CPA stamp-of-approval on the spreadsheet that I

gave him. That is, take it up to the CPA level of accountability.

Well, he and his team did a wonderful job. What

they did in 2006 is take 126 of their best clients, dentists

who are working under a financial plan and who care,

and they gave each of these dentists the same 8-unit case.

And this 8-unit case involved changes in vertical dimension

and anterior guidance and those sorts of things.

Ken worked it out; he worked with another dentist to put

this case together, all the different appointments,

what they would need to do. Then

he gave this sample case to 126 dentists and

asked them: How much time would you

spend doing it and what would you charge?

The numbers these dentists came back with

were all over the place. Fewer than 15 percent

of the dentists made any change in fee

relative to changing those four variables –

anterior guidance, vertical dimension, condylar

position or incisal edge position.

MD: So, essentially, they just took their crown

fees and multiplied it times eight?

PH: Exactly. Eighty five percent of the dentists

did that. When you look at the profitability

aspect of it, close to 20 percent of the

dentists were netting out less than if they

were doing single-unit posterior units.

MD: Wow, talk about a kick in the groin.

PH: It’s amazing. When you see the math

you just want to shake your head. The big

culprit is time. The biggest mistake a dentist

can make is to look at his profit and say, I

need to find a cheaper lab. A cheaper lab is

not the answer. What you want is a lab that

can get the job done right the first time. The

answer to many of our profitability issues

has to do with time and leadership. Time

is the divisor. That is, if you use two hours

instead of three hours, that’s a huge difference

in profitability. Time is a big culprit.

Ultimately, Mike, you arrive at a fee that

might be 40 to 70 percent more than you

would normally charge.

MD: What does the average dentist say when

it’s suggested to them that they need to do that?

Do they say, “I can’t do that”?

PH: Exactly. They look at it and say: “I have

a hard enough time selling a $10,000 case.

Now you’re saying that it’s a $17,000 case?”

Well, it is based on the amount of time and

risk that you have to do. And they say, “Well,

I can’t sell that.” That’s where it goes into

leadership. That’s when the dentist needs to

look in the mirror and say to him or herself,

“What do I need to do in how I present care

to patients? How do I train my team? How

do I run my facility? How do I earn the right

Interview with Dr. Paul Homoly35


to charge $17,000? How do I, as a practitioner

and as a leader, signal to the marketplace

– my patients, my team – that we’re

worth it?” Because the difference between

the $10,000 and the $17,000 reconstruction,

when it’s done well, is huge. You can’t be

doing reconstructions half-assed, because it

will come back to haunt you. So the higher-fee

cases are more difficult to sell. Case

acceptance for the high-fee case is something

that I have focused on for the last 20

years of my life.

MD: Now, in those 20 years that you’ve been

focusing on high-fee case acceptance, is there

a huge difference between case acceptance for

a $10,000 case and a $17,000 case? Don’t they

both sound relatively expensive to the patient?

100%

Case

Acceptance

0%

$1,000 $5,000 $10,000

Figure 5

PH: Absolutely, yes. You know there’s a case

acceptance curve, where case acceptance is

real high when the case is real low (Fig. 5).

But as you cross that $5,000 to $6,000 mark,

that’s where I see case acceptance drop

down. Is case acceptance that different between

the $10,000 and $17,000 level? Not

really, but enough psychologically for the

dentist. Not so much in the patient’s mind,

but it is in the dentist’s mind. So factoring

in proper case acceptance dialogues and essential

conversations that you have, those

conversations need to be entirely different

at the $10,000 level up than at the $5,000 level down. And

that’s been the topic of some of our other articles.

MD: Yes, we’ve talked about that before. So a dentist who’s

reading this or listening to this and realizes, wow, I bought

this practice 13 years ago and I just took over at whatever

Delta-approved fees the previous dentists had and we’ve tried

to make increases every year based on our ZIP code as time

went on. Maybe I should take a closer look at my fee schedule

before I get too much farther into this to see if my fees are

in the right place and make sure that when I’m operating

at the sweet spot, I am making the net profit per hour that I

deserve.

PH: I’d contact Ken at Dental Practice Advisors. For

years I did the fees and analysis, but they are far quicker

at it and more complete. What they’ll have you do

is submit two or three of the large cases you’ve done,

your fee schedule and your profit and loss

statement. And they’ll look at it comprehensively.

They’ll look at how much money

you need to live; that’s where they’ll start. How

many days do you want to work? How much

money do you need to live? This will create the

profit per hour that you need to make. Then

they’ll look at your practice overhead and your

fee schedule. They’ll adjust your individual fee

schedule such that the fees are balanced up

to that 3-unit level. Then they’ll look at your

complex-care cases to help you look at and

see, what is the profit you have? And what’s

amazing, when you come back from a profitability

analysis or a fee analysis like that, you

come back with some hard data on a piece of

paper. Now you can sit down with your team

and say: Listen, when we did Mrs. Smith, that

case where we all pulled our hair out, we made

less on a per-hour basis than when we’re just

fixing individual teeth. When you can see it in

black and white, Mike, that becomes a great

leadership tool. It becomes more real to everyone.

And now, I can sit down with my dental assistants

and say: You know, you’ve been asking for a raise the last

several months. See this profit point that we have right

here? In order for me to give you a raise, we’re going to

need to move that profit point up. A lot of that has to

do with time. So let’s think together: How can we shave

an hour or two off of these longer procedures without

reducing quality. How can we do that? When the team is

engaged – engagement means they’re thinking on their

own without my direct influence – they’ll help create the

solution, they’ll support the solution.

MD: Sure. And now she is responsible for her own raise. The

doctor says, I want to give you a raise. I think you deserve

36 www.chairsidemagazine.com


one; you’re a fantastic employee, and here’s what we need

to do in order to get to the point where we can do that. Or,

if the staff is on some sort of bonus plan, certainly adding

that extra fee on there – especially if the doctor is a financial

arrangements person who doesn’t want to quote the $17,000

versus the $10,000. The doctor has got to feel a lot better about

making bonus payments to the staff when they’re charging

the right fee for these complex cases.

PH: And when you see it in black and white and you

know it’s the right fee, now your leadership can take over.

Establishing a fee for complex-care cases is a process. It’s

not an emotional thing; it’s a process. When you have a

process, you have the ability to lead because you can always

go back to the tool. You can always go back to the

fee analysis and say, OK, we’re doing better – now we

just need to do a little bit better. You’re not just constantly

raising the bar for the sake of raising the bar … because

people get burned out on that. You cannot constantly

ask people to perform better if they don’t have the right

intrinsic reasons to do so. And the fee analysis provides

that. It’s in black and white.

I would suggest visiting the Dental Practice Advisors Web

site to get started. For the skills related to case acceptance,

visit my Web site: paulhomoly.com. I can teach you

and your team the essential philosophies and conversations

that make it easy for your patients to say yes.

MD: That sounds like some great advice. I don’t know what

the hardest job in the world is, but I can say that if every job

in the world paid exactly the same, I’m not sure I’d still be a

dentist. It is a difficult job. We’re working in a very sensitive

area of people’s mouths and they tend to be afraid of us. It’s

difficult and therefore we need to be compensated for it.

PH: Highly compensated!

MD: The only way to make sure that’s going to happen is

to make sure your fees are in place. Whether it’s the 1-, 2-,

3-unit sweet spot crown fee that’s in place or the 12-unit case

that you think is going to make you financially independent,

in reality you’re going to make less money on that than on

the 3-unit case unless you get your fees in order. So it’s something

I would definitely encourage dentists to take seriously.

Contact Ken for guidance on fees and to see if they are in

fact in the right place. You don’t want to practice for 30 to

40 years and then find out you did everything right, except

charge the right amount for procedures.

hope the audience hears what I’m going to

say right now. I’m not advocating that you

go and raise your fees 40 to 70 percent. I’m

not saying that. What I’m saying is, when the

case is complex we need to think about taking

our fees up. To make it easy for you:

don’t take them up all at once. Maybe take

that 6-unit case up 20 percent, just to build

your confidence in quoting a higher fee, and

keep bumping it. Don’t make the jump; don’t

go cold turkey on this thing. Build your confidence

with it. That way, when you begin to

slowly escalate your fees for complex care,

you will become more and more accustomed

to quoting a higher fee.

MD: That’s one part of it, but the other part

is making sure that the base single-unit crown

fee for the 1-, 2-, 3-unit case is in the right place

as well. And it might be! Or it might need to

go up only $40 or $100. Or maybe it is in the

right place, and then you just need to worry

about more complex cases. But why not find

out? Isn’t it kind of like getting blood work

done? The good news is that you find out everything

is fine and you don’t need anything. You

don’t say: Well, that was a waste of time and

money. Instead you say: Oh good, everything’s

all right. Why not find out that your fees are in

the right place now so you don’t have to worry

about it 20 years from now, when things didn’t

turn out the way you thought they would.

PH: And now you can pursue quality and be

compensated at a level that will help perpetuate

your practice and makes the pursuit

of quality a sustainable event.

MD: Excellent. Well, thank you for stopping by

today. I loved the opportunity to finally discuss

fees with you, and I know that the readers and

listeners of Chairside will love it as well. CM

For questions related to this interview or learn more about

Dr. Paul Homoly, call 800-294-9370, visit paulhomoly.com or

e-mail paul@paulhomoly.com.

PH: Remember, Mike, you and I were going to have this

fee conversation last year, at the beginning of 2009. And

we both agreed: I don’t know if we should be talking

about raising fees when the economy is tanking. So now,

a lot of indicators say we’re coming out of that, and I

Interview with Dr. Paul Homoly37


Biologic

Shaping

– ARTICLE and CLINICAL PHOTOS

by Daniel J. Melker, DDS

When performing conventional crown lengthening, the previous margin of the old restoration is used to determine

the necessary amount of bone to be removed so there will be adequate space for the biologic width.

By adequately creating a space for the biologic width, the new margin will not infringe upon it.

A potential problem of this procedure is that a significant amount of bone will be removed, weakening the tooth or creating

a weakened furcation area. The more bone removed in the furcation, the greater the likelihood of future problems

with maintenance. It is critical to try to preserve as much bone as possible in order to support the tooth, especially in

the furcation area. The clinical prerequisites and steps for success with biologic shaping are as follows:

1. All previous restorative materials and decay should be removed.

2. A core build-up should be placed where necessary to add volume to the teeth. The material should be a

composite-bonded resin. The core helps the periodontist determine where the final margin placement of the

new restoration will be.

Biologic Shaping39


3. Acrylic provisionals should be placed with

Durelon (3M ESPE ; St. Paul, MN) temporary

cement. Durelon is antimicrobial and helps

decrease sensitivity.

4. Remove provisional at time of surgery for

access. Ideally, a mosquito forcep is used with

a gentle rock at the incisal third of the occlusal

surface of the provisional.

5. Shape the tooth surface and remove old

margin, as well as 360 degrees of CEJs. A

flat-ended bur with a 4-degree taper is best for

biologic shaping. A diamond grit is best.

6. Correct any reverse architecture and remove

any necessary bone where biologic width

issues are still present. The goal is to create an

osseous contour identical to the soft tissue

contours that take place when forming a new

biologic width.

Figure 2: With the provisional removed, the surgeon now has

the ability to treat the tooth vertically.

7. Add sufficient connective to protect the bone

from bacterial infiltration. The co-nnective also

protects underlying periodon-tal tissues from

impression material and cementation irritation.

8. Once the flaps are adapted using 5-0 chromic

gut suture just coronal to the osseous support,

potassium oxalate should be used to help

decrease sensitivity. The liquid is applied to the

root surface for 45 to 60 seconds and then

lightly air-dried. Repeat two to three times.

Figure 3: The depth of the margins can be seen with inflammation

noted on the distal of tooth #19.

Figure 1: Biologic width violation along with a severe inflammatory

response.

Figure 4: A split thickness flap is retracted to see the underlying

defects and location of the existing margin. Note the

reverse architecture present and close location of the existing

margin to the bone.

40 www.chairsidemagazine.com


9. Cement provisional with polycarboxylate

cement (i.e., Durelon or Dentsply Tylok ® ; York,

PA). Tylok may be more ideal for cementation

during surgery, as it is water-soluble.

10. Homecare consists of chlorhexidine used twice

daily, in both the morning and evening. Previ-

Dent ® (Colgate; NY, NY) should be used at bedtime

to help decrease sensitivity. After meals,

the patient should rinse with water or Listerine

to remove excess food particles.

Figure 5: The use of a coarse diamond bur on the tooth

surface to remove the old margin. By doing this procedure

first, there may be less osseous removal after completion of

shaping.

11. At four weeks, the provisionals are either remade

or relined leaving 1 mm of space to allow

for continued biologic width growth in a coronal

direction. No margination of the tooth surface

should take place at this time.

12. At 14 weeks, chamfer margins are placed just

coronal to the gingival collar and impressions

are taken. A recommendation of one #7

SilTrax ® (Pascal Company; Bellevue, WA) cord be

placed in the sulcus for retraction of tissue.

When endodontics is present the new margin

may be placed within the sulcus. In these

cases, a ferrule effect is recommended.

Figure 6: The tooth is grossly smoothed. With the old margin

removed, space for the biologic width is created without

excessive bone removal.

Figure 7: A superfine diamond bur is used to further smooth

the tooth surface. This allows for long-term maintenance of

the tooth.

Figure 8: A diamond round bur #8 is used to create a parabolic

architecture. A parabolic architecture is created to mimic

the soft tissue contours, which are created after the new formation

of the biologic width. The highest point of bone should

be interproximally, as is the soft tissue. The buccal and lingual

bone should be in a more apical position.

Biologic Shaping41


■ Reasons for Biologic Shaping

1. Replace or supplement the current indications for clinical crown lengthening.

2. Minimize removal of supporting osseous structure.

3. Facilitate supragingival or intrasulcular margins to preserve the biologic width.

4. Eliminate developmental grooves.

5. Eliminate previous subgingival restorative margins.

6. Reduce or eliminate furcation anatomy and thus facilitate margin placement.

7. Allow supragingival or intracrevicular impression techniques.

8. Facilitate hygiene and maintenance procedures.

9. Reduce or eliminate cervical enamel projections.

10. Facilitate ideal restorative emergence profile. Flat is better than fat contours. CM

Daniel J. Melker, DDS, is in private practice and can be reached at 727-725-0100.

Figure 9: Parabolic architecture created for ideal architecture

for placement of tissue over the bone.

Figure 11: Occlusal view showing 360 degrees of perfect

tooth surface to place a margin at the gingival collar once it

has healed.

Figure 10: Tissue sutured just coronal to the bone with 5-0

chromic suture material.

Figure 12: Final restoration with margins placed into the

sulcus.

42 www.chairsidemagazine.com


Social Media and

Marketing the Modern Dental Practice

– INTERVIEW of Glenn Lombardi

by Michael DiTolla, DDS, FAGD

Dr. Michael DiTolla: Glenn, I’d like to welcome you back to the pages of Chairside to discuss the topic of social media. Each time

I speak with you, we’re talking about Web site design or Google AdWords and optimizing search engines.

Today, however, we’re focusing our talk on social media and how this new form of communication is impacting dentists. I

don’t really know how this works for dental offices, even though I can tell you that social media does impact my life. For example,

I follow United Airlines on Twitter (@UnitedAirlines). I fly 100,000 miles with them every year so I’m interested in what’s

going on, and just today I got a tweet about a couple of snowstorms in various locations. They said if you’re flying there, go

online to rebook your tickets. They also do special “Twitter fares,” where for a two- or three-hour period they’ll have an airfare

sale to somewhere I might be traveling (or all of a sudden I’m planning on going). It’s neat. Similarly, when I go to book a

hotel, I typically go on TripAdvisor before doing so to check it out. Also, I find myself looking up things on Yelp, whether it is a

restaurant or my girlfriend looking up hair salons. So, I have begun to realize that I rely on social media a lot in my personal

life, but I’ve wondered how it applies to a dental office. If you want to start taking us through how a dentist can use social

media to promote their practice and get in touch with their patients, I would love to hear about it.

Social Media and Marketing the Modern Dental Practice45


Glenn Lombardi: Well, let me start by differentiating social media and traditional marketing: While traditional marketing

involves the dentist marketing to patients, social media involves patients marketing to patients. It’s interactive, it’s

exponential, and the reach is phenomenal. It’s a very cost-effective medium, and it’s a great way to share information

and engage with patients while enhancing your brand and improving your reputation.

MD: And that really is profound, isn’t it? I’ve never heard the definition of social media be stated in such basic terms: patients

marketing to patients. So instead of the typical advertising relationship that we’re all familiar with, it’s almost like third-party

endorsement, where it’s a patient telling another patient about your services. It’s like me telling another dentist how much I

like my Officite Web site versus you guys sending a mailer to them. Of course you think you’re great. But if I tell another dentist

that I think you’re great, it takes on another meaning. That’s really very profound, isn’t it?

GL: It is testimonial driven. Social media is connection. It’s building relationships

online. For example: Suppose a woman comes into the office for a

whitening treatment. She’s so pleased with her new smile that she goes home,

visits her Facebook page and posts a picture of her new whitened smile to

show all of her friends. She’s excited, right? That’s part of the connection, that’s

part of sharing. All of her friends are going to see her newly whitened teeth

and then comment or write on her wall about how great her teeth look. What’s

the next question going to be? “Where’d you get the new smile?” That’s where

the connection begins, that’s where the referral begins. And that’s the power

of a patient testimonial.

MD: Wow, funny you mention that because last year, I was in a weight loss contest

with somebody here at work. I lost 50 pounds and he lost 15 pounds. And I took

his money, and that was great, but even more fun – and I didn’t even think about

it until just now – was, I went to my Facebook page and immediately deleted every

profile picture of me with a double chin or where I appeared to be pregnant at

certain angles from the side. I got rid of all those and replaced them with the pictures of the new me. I ordered new business

cards. And I changed the photograph that I send out in my seminar packets. So, you’re right: As soon as that monumental event

occurred, I made all of those changes. I didn’t have a dentist to thank, but I did have a 99-cent “Lose It” iPhone application to

thank. I don’t know how many copies of that application I’ve sold, but I’ve told everybody about it because it was at the heart

of my weight loss.

GL: Referral marketing. Great application.

MD: You’ve told me before that dentists are actually leading the way in the health profession for having Web sites. And I think

everyone will agree that it’s necessary for established practices to have a Web site. Today we’re talking about how social media

can enhance that even more. Explain to me how dentists can utilize the power of social media, and what kind of content they

can provide to make this happen.

GL: First, you want to set up a social media network with profiles on Facebook and Twitter. Facebook is a great place

to start. It’s the No. 1 social media Web site out there, with more than 400 million users. So it’s growing quickly, with

the fastest growing age group being 35- to 55-year-old females. It’s a great targeted market for dentists.

MD: Boy, that’s exactly who we’re going after in the dental practice, isn’t it?

Social media

is connection.

It’s building

relationships

online. ”

GL: Exactly. You’ll want to set up your Facebook page as Fan-based, meaning without friends – strictly a business profile

site. There are a number of things you can put on your Facebook site, including logos and photos of your office that

are cohesive with the look and feel of your Web site. You’ll also want to add any videos you might have from vendors

like Invisalign or Glidewell or any videos you’ve taken of patient testimonials. Third, you’ll want to include content,

such as tips for healthy smiles or articles about practicing good oral hygiene. And finally, you should announce any new

services or products your practice is offering, such as mouthguards and why this new product is beneficial.

MD: Or anti-snoring appliances would be a great example. It’s the No. 1 way new dentists come to us at the laboratory. And

what we typically see is: A dentist makes one (and you assume it’s either for the dentist or their spouse) and finds out, wow, this


46 www.chairsidemagazine.com


eally does work. But it never goes anywhere from there and they never send another in because dentists, in the past, didn’t feel

comfortable telling other patients about it. But you’re saying this Facebook page is a great way to let everyone know, “Hey, we

now offer these anti-snoring appliances.”

GL: That’s a great example. Now the dentist can post on Facebook his or her own personal experience that testifies how

the appliance helped reduce or eliminate their own snoring. It’s a great way to relate with a patient on a personal level.

It’s a way to build loyalty and trust from your current patients.

MD: And that’s a great idea, because I remember when Web sites first came out, one of the things I would see in terms of video

from doctors was the dreaded tour of the office, where it would be the doctor walking around showing the patient the surgical

suites and sterilization areas and lab areas. You can just imagine the patient watching the video and saying, “Oh, gross,” as

they see scalpels lying on a surgical tray. And you got the feeling that this was probably not the best way to do it, but patient

testimonials would be. How great would it be to have the doctor or the doctor’s wife talk about how he made an anti-snoring

appliance for himself and now he doesn’t snore anymore. It would make the dentist seem more human and at the same time

let a group of fans know about this new service you provide, which you tested on yourself before releasing to them.

GL: Right. And as those fans read and hear and understand what your practice has to offer, they’ll talk to their friends

who may have similar issues. For instance, if Mary knows about Sue’s husband and his snoring problems, she may say,

“Check out this Facebook post from my dentist about how to prevent snoring with a new device.” Then the simple

content shared on Facebook has reached its true viral potential. You’ve done nothing but post a message to Facebook,

which is free, and in turn you are generating a new patient to your practice.

MD: Free: There’s a word that dentists love! So we’re talking about a different kind of Facebook page. It sounds as though this

fan page is different from a personal page.

GL: Yeah, and you might want to have both – one for personal use and one strictly business related. But either way,

you definitely want to have a business profile with fans for your practice because this is how you really start to grow

your practice and see patients take an interest in what you have to say. These fans could be existing patients, potential

patients or even friends of patients, and they’ll have the ability to post, comment and interact on your social media

pages.

MD: Now it seems pretty simple to pick a local example: Sprinkles Cupcakes in Newport Beach has a ton of fans because people

are pretty passionate about their cupcakes. They are fantastic. And every day Sprinkles tweets a secret phrase that, if you go to

their store and say it before noon, they give you a free cupcake. But I can see that on their Facebook page it’d be very easy for

them to get a lot of fans because of the wide appeal of cupcakes. Now, if you have a dental office with a Facebook profile and

a fan page, how do you go about getting fans? That seems like it may be slightly more difficult.

GL: When you first set up your Facebook and Twitter accounts, you’ll want to add these social media icons to your Web

site homepage with a direct link back to your social media pages. Then, when patients visit your Web site, they can click

on them and be directed to your Facebook page or follow you on Twitter.

Another way to generate fans is in your office. Whether you post a sign that says you are now on Facebook and Twitter,

or you ask your staff to inform patients of your social media presence, simply communicating the message will help

attract new people to your pages. And, if you’re doing marketing in the neighborhood, whether it is direct mail or ads,

put your Facebook and Twitter icons on all of your marketing materials with URLs to your social media pages. People

will see these images and know that they can connect with your practice that way.

MD: Now let’s assume that after going through dental school I’ve been beaten down by my dental instructors, I’ve got low selfesteem.

If I have almost no self-esteem, why would anyone want to follow me on Twitter? For a dentist who is sitting in their

practice right now saying, “I’m boring. My dental practice is nothing exciting. I’m not doing dentistry to the stars, why would

anybody want to follow me on Twitter?” What would you say to a dentist like that?

GL: I would say to the dentist, you have three options: First, if you are comfortable integrating social media into your

practice, you should move forward with it and try managing it on your own. Set up your profiles, share information and

begin building your fan base and interacting with patients.

Social Media and Marketing the Modern Dental Practice47


Second, if you’re not comfortable with social media or don’t have time to manage it effectively on your own, you can

have someone else manage it for you. Officite can write your content and post it for you – once, twice or even four times

a month. It’s a great way to outsource that service to a professional who can become your social networking partner

and build a strong presence for your practice on Facebook and Twitter. One of the things that Officite offers when we

set up your Web site is to include a blog page, which is an integral part of social networking. This blog feeds your social

networks, so all you have to do is post to your blog and then your Twitter account and Facebook page are automatically

updated with that same content. This really streamlines the entire management process.

A third way to jumpstart your social networking is to empower someone on your staff to take the lead. There’s probably

an assistant or office manager who’s already interacting on Facebook and Twitter who can create the content and

manage the social media sites for you.

It’s important for dentists to understand that those who wait to get Web sites have a much tougher time coming up in

the search results than the dentists who have been doing it the past three to five years. The early adopters are now the

ones listed high in the search engines. So, as it relates to social media, you don’t want to wait five years and be left

behind when competitors in your neighborhood are generating new fans to their Facebook pages and attracting new

patients.

MD: That’s a great point. As you listed off those three options, you squashed every possible objection a dentist could have. Because

anytime you go up to a dentist with a new idea, whether it be a new restoration or a new concept like social media, there

are going to be objections to change. And you tend to hear the same four or five objections, and I think you just answered all of

them. For myself, I was thinking that I don’t mind blogging. Then I think about my dad, who’s a retired dentist, and he would

have said, “Why do I need this? I can’t do this. I have nothing to say. I don’t like to type.” There would have been all kinds of

objections. But if you would have said to him, “Look, you can pay and have a professional do it or you can delegate someone

on your staff do it,” there are enough options so that he could have no further objections. So I don’t see any reason why dentists

shouldn’t be willing to try it.

It’s funny you mentioned the blogs because I follow probably seven or eight blogs, only one of them being dental related, and I

can see dentists being a little bit nervous about writing a blog or not really wanting to sit down and do it. It is interesting that

the blog can update these other forms of social media. So is the blog kind of the centerpiece in this strategy?

GL: Sure, it’s the nucleus; it’s where it all happens. By writing and feeding all of your messages through a blog, it automatically

sets up your Facebook and Twitter page with content. Not to mention that a blog is a great way to reveal

your credibility, engage with patients and boost your search ranking. In fact, Google now spiders Twitter and Facebook,

and the information on these social networking sites can actually appear in the search results when a relevant search

is performed.

In addition to the Facebook and Twitter feeds, you’ll notice that reviews about your practice are also visible to people

searching for you in the local maps results of Google. For instance, if you type “Dentist, Park Ridge, Ill.” into Google, the

new local Google Maps results will display what’s known as the Google 10-pack: 10 dentists in Park Ridge with phone

numbers, Web addresses and reviews for each listing. These reviews have become an extremely important factor for

dentists in terms of managing their online reputation and earning high rankings in the search results. So it’s imperative

for dentists to manage their reputation online as it relates to how their practice is portrayed on the Internet.

MD: Interesting. So, the online reputation is something that I look at in regards to, as I mentioned before, restaurants on Yelp.

And you’ll look to see what other people have written about a restaurant. If something has 200 reviews and has a 4.5-star rating,

you can be pretty well assured that it’s a quality establishment. And if you look through all of those reviews, there’d be

plenty of 5-star reviews and a couple of 3-star reviews that brought that down just a little bit, so they didn’t have a perfect rating.

But I know dentists who have told me, because of a couple random lawsuits that are going on – specifically with Yelp – that

they’re afraid to be reviewed online. However, it sounds like to stand on the sidelines and to stay away from it doesn’t shield

you from somebody who didn’t have a positive experience. And that one bad review will never be replaced with a good review

if you don’t encourage it. Explain to our readers a little bit about managing this online reputation.

GL: What you want to do is manage and audit your online reputation. There are a couple ways to do that. The first thing

you want to do is simply perform a Google search for your name and practice and see what comes up in the results.

48 www.chairsidemagazine.com


Take a look at any reviews posted to find out what patients are saying about the quality of your practice. This can give

you basic insight into your current online image.

Second: Sign-up for Google Alerts using your name, your practice and other words or electives specific to you. Then,

anytime anything is written about you on the Internet, you will get notified by Google via e-mail, telling you where the

online source came from and what was written about you.

Third: Manage your online reputation by encouraging positive patient reviews. We recommend that you collect e-mails

as patients come through the office. And people who have a Yahoo or Google e-mail are the ones to ask, “Hey, you had

a positive experience. Would you mind giving us a review?” Why is it important to use a Yahoo or Google user? Because

they already have logins for these accounts. All they have to do is Google your name, click on your profile in the local

business center, click on “Add a Review,” type it in – and BAM! You have a review. Even if you get one positive review

per week, you will attain 52 positive reviews in just one year’s time. If you happen to get one or two negatives, the 50

positive ones will outweigh the one or two bad ones. Not only will a favorable review be influential for prospects deciding

whether to visit your practice, but reviews also effect where Google ranks you in the local maps results. The more

positive reviews you have, the better the ranking.

MD: Yeah, it’d still be a 99 percent positive review. You know, it’s always been

recommended that you ask patients for referrals, to refer other patients. And

a lot of dentists struggle with this. Personally, I had to almost become robotic

and memorize a line to be able to say to patients: “Hey, John. We’re just about

done with your appointment today, but I just want to tell you that we love

having you here. Whenever you come in, everybody gets excited. You show up

on time. You pay your bills on time. You are actually our ideal patient. And I

know that birds of a feather flock together, so if you’ve got any friends or family

who need dentistry, we would love to see them.” And then you would hand the

patient a couple of business cards. You pay the patient a compliment and tell

them, you’re our dream patient and you’re fantastic, we love having you here.

If you’ve got any friends or family who are in need of a dentist, have them stop

by and tell us that you sent them and we’ll take great care of them.

It’s a way to build

loyalty and trust

from your

current patients. ”

Most dentists you talk to would say, “Ah, I just can’t do that! I just can’t walk

in and have that conversation with a patient. It sounds desperate, it sounds

like I’m begging. Maybe someone on my staff could do it.” And they probably

could, but it’s not as powerful. It is a difficult thing to do, but nobody argued

that it’s a bad idea to pay a compliment to a patient. It’s not easy to be a dental

patient, but then to ask them for a referral? Otherwise, the patient comes in for

his or her appointment and see the front office receptionist sitting there with 5,000 charts behind the desk. They see four other

people in the waiting room, but the patient doesn’t know those patients are waiting for the hygienist and not the dentist. To the

patient it looks busy in there and it probably never occurs to them, I should make them busier.

It seems like social media is more about the younger patients, so it might be easier to say to them, “Hey, we love having you

here and I know you said you like coming. We would love if you could write a positive review for us,” or something like that. It

seems like that would be a painless thing to ask for in the office versus saying, “Hey, send us more patients.”

GL: Exactly. At Officite we actually provide our clients with review cards, where the front office staff can actually hand

a card to the patient that describes how to complete a review on Google or Yahoo. It has a simple process laid out. So,

when the patient leaves with that card, he or she has a direct roadmap on how to do a review and is more apt to go

and make that review happen.

Start with patients you know or that you are confident have been satisfied with your services time and time again. Again,

if you can get 10 or 20 reviews, you are ahead of the game. Just start the process and don’t worry about setting an unrealistic

goal. Get comfortable with the review process, let it work itself out, and your patients will take care of the rest.

MD: You can even tell your patient, “We’re having a contest to see how many positive Google reviews we can get.”


Social Media and Marketing the Modern Dental Practice49


GL: Exactly. And the names of those who give you a positive review on Google or Yahoo will be put in a drawing for

a chance to win some sort of prize or even a special offer for a dental service.


When you first set

up your Facebook

and Twitter accounts,

you’ll want to add

these social media

icons to your Web

site homepage with a

direct link back to your

social media pages. ”

MD: I mentioned earlier that I’m sitting here with my iPhone in my pocket,

and it’s buzzed a few times. And I don’t know whether it’s tweets from Lance

Armstrong telling me where he’s cycling today, but I spend a lot of time getting

information – whether it’s from Twitter, Yelp, Urbanspoon, Facebook even – on

my iPhone. It’s become an important device in my life for managing what’s

going on and how I interact with the world.

When Apple released its 2009 fourth fiscal quarter financial results, it set more

records and sold more iPhones then ever before. Just when I think that everyone

has an iPhone, Apple goes and makes a record profit. What should dentists

be doing to take advantage of the fact that everybody carries a smartphone

and stays so closely connected to the world of social media?

GL: Number one, their practice Web site should be iPhone compatible.

This was one of the first things Officite did about a year ago when the

iPhone grew in popularity. We made it possible for all of our dentists to

have an iPhone-compatible Web site with easy navigation and quick links

to phone numbers, appointment requests and social media sites so that

patients on the go would always be able to access their dentist’s site. Remember,

patients are busy and they want to make one click to get where

they’re going.

The iPhone is where more than 50 percent of your information is going

to be gathered, reviewed and read, and this includes social media sites.

Today you see kids, my 15-year-old included, who are on their iPhones

more than the computer because that’s how they access their Facebook.

And this is a great way to expand your reach to potential patients who may never see your direct mail, ads or even

Google searches. As this generation grows up with social media and advanced technology like the iPhone, it’s necessary

to adapt your strategy to reach out to an entire new patient base that is growing very quickly.

MD: That’s a good point, because it’s the same way with my daughters – very attached to their devices. In fact, one of the only

effective punishments we have left is to turn off the texting and take away the laptops. It is their connection to friends and to

the world. And you’re right: This is the generation of patients who are coming next.

In general, most of the discretionary choices I make are somehow reviewed on social media before I go out and interact with

any given business. It makes total sense to optimize things for the iPhone – it is unique and it has broad appeal. As an information

portal, it makes a lot of sense.

GL: Four or five years ago we all started booking travel, buying books and other consumer products online – and that

drove companies’ behavior to sell online. And the same goes today with the growing popularity of the iPhone.

When you go to check an alert for a flight, you’re doing it on your iPhone at the airport. You’re not pulling out your

computer anymore. When you search for a restaurant, you’re pulling out your iPhone. When I drove over here from my

hotel, I got the directions on my iPhone. That’s the way I’m interacting with the world, that’s what’s changing. So when

people look for a dentist, they want to be able to look on their iPhone as well. It’s all about taking control of who you

are and how people gather information about your practice.

MD: Another area I’m interested in hearing about is YouTube. You briefly mentioned it earlier and I guess it’s something that

would be considered a social media site, but we’ve produced many clinical education programs here at the lab and we’ve

put them out on iTunes. We notice they are immediately downloaded, but we’ve also found out they’ve ended up on YouTube,

not by our doing! So we’ve started to put them on YouTube ourselves to see how many views we are getting on these clinical

education programs. Not just here in the U.S., but worldwide – I’m huge in Moldova. I don’t even know where that is, but if I

50 www.chairsidemagazine.com


went there I’d be given a key to the country because a lot of dentists there have watched these videos. So it’s gotten easier. We

use HD cameras in the operatory for filming; we’ve also got some cheaper handheld cameras. And then you get down to the flip

cameras, or even the iPhone having a video camera, but I wonder: Do you have many of your dental clients doing videos and

posting these? Whether it’s before-and-after shots or something else, is that considered social media, too?

GL: Yes, and what that does is increase your case acceptance and expand your reach to patients searching for specific

patient education videos. You can post your video to your YouTube account, and then link it to your Facebook and Twitter

accounts. This is a great way to tie all of your networks together while providing a visual interpretation of a service,

product or even a patient testimonial.

MD: Even something as simple as bleaching before-and-after pictures, which I think many dentists take for granted now. It

works so well and it works so often that patients aren’t even offered it anymore. I don’t agree with that thinking because it

seems like almost every Google search that I do, when the results pop up, there is always an ad that says, “Slaughter your yellow

teeth! Murder your yellow teeth!” It’s an obviously Photoshopped before-and-after: someone with teeth the color of cheddar

cheese now has bone white teeth in the after. And any dentist looking at the before-and-after would say it looks fake or glow

in the dark. These companies don’t have unlimited funds and they wouldn’t advertise if it wasn’t selling. Every time I see one

of these ads, it reiterates to me that bleaching is still something that’s very important to the patient. It’s possibly the most basic,

most conservative, certainly the most affordable esthetic procedure that we have, and I think dentists sometimes go out and get

fixated on the “almighty” veneers or the crown and they forget about lowly bleaching – which, for the average American, is the

esthetic change that they’re looking for. So I know that a before-and-after shot of bleaching and a little slide show on YouTube

would be very effective, as it would be on a Facebook fan page, with a little testimonial. This seems like a very effective way to

communicate with your patients and show them something that really 80 percent of them could benefit from.

GL: Yes, exactly. So whether you produce that video yourself in the office using a patient – which always has a positive

effect – or you get a video from a dental manufacturer like Glidewell that provides free patient education, putting a video

on your Web site and social media pages is only going to enhance awareness about the services you offer. So, you’re

right – a high percentage of your patients would probably benefit from a certain treatment and continually educating

and informing patients about these procedures via your social media channels could eventually convince them to come

in for the bleaching treatment. You could even tweet to your followers that you’re offering a special on tooth whitening,

but it has to be Thursday afternoon. That might be a way to enhance and grow your revenue while filling chairtime.

MD: That’s obviously what United Airlines is doing when they decide to tweet that they’re having a fare sale between L.A. and

Hawaii for the next three hours. They’ve noticed inventories are low. And after three hours, they’ll tweet back and say, OK, it’s

over. So they must have filled that inventory. Do you have some dentists doing that, filling some excess inventory that way?

GL: We do, because dentists always know when their slow period is going to be. Whether it’s around the holidays or at

the beginning of summer, dentists can plan their social media strategy in advance for the months business will be slow

in order to increase the chances of filling chairtime. This might involve preparing blog posts, tweets or Facebook posts

to inform patients that they’re having a special offer on cleanings or that a new procedure is available.

MD: When we talk about blogging for the practice, part of it certainly could be video blogging, correct?

GL: Yes, and I definitely recommend supporting text in your blog with a video.

MD: From a patient perspective, it seems like a video blog would be very compelling. It’s almost like a behind-the-scenes look

at what happens or what’s available or what could happen in a dental office. I don’t think “Extreme Makeover” or “The Swan”

would have been as successful as they were if they didn’t include some kind of glimpse behind the scenes of what happens. So

I think it’s one thing to blog and write about it but another thing if there’s a 60-second video showing some before-and-after

pictures of the past week or the past month or something like that. I can see patients really taking an interest and wanting to

watch that and learn about it.

GL: Sure, a monthly blog with some video is always going to be a hit. I mean, when you go to ESPN.com, the Greatest

Sports Item is a video now. As consumers, we are drawn to visuals. So the same should be true of dentists. Whether you

build the video yourself or obtain a video from a vendor, posting it on your blog can generate a lot of interest. It grabs

a patient’s attention and says, “Look, we have a new video of a patient receiving whitening or a new animation about

Social Media and Marketing the Modern Dental Practice51


anti-snoring devices.” That is going to create interest as long as it’s kept brief and compelling, and hopefully increase

your number of appointment requests.

MD: That’s a good idea. We, even as a laboratory, have products that dentists probably aren’t even aware of. There are products

that I didn’t pay attention to until I needed them in my personal life. For example, my son plays ice hockey now, and you’ve got

to wear a custom-made mouthguard. We made him one recently that looks nicer than the one that the players for the Anaheim

Ducks wear, and it’s their colors and their logo. Now, every kid on the team wants one. Dentists always ask me, “Well how

much money do you really make on this?” It’s not so much getting the child in for the two alginates for the $200 mouthguard;

it’s more about getting Mom, the 35- to 50-year-old mom, into the practice to meet everyone. She sees that you treat the child

well. And then, “By the way, Mom, I don’t know if you’re interested, but we’re doing a bleaching special through the end of this

month.” It’s products like this that dentists traditionally don’t think of as restorative dentistry, a short little blurb about this

custom-made athletic mouthguard for kids playing basketball or baseball or hockey. I mean, what a great way to get some new

families into your office that you may not have met. And now they’re able to become ambassadors for the practice. They tell

everyone, “We got a great new custom mouthguard. Now my kid’s the envy of everybody on the team.”

GL: Absolutely. Not only do you get one more family in the door with a new innovative marketing tool, but you may

also get the whole sports team in your office. Again, that’s another way to market your practice. It’s always important to

consider marketing services to your community, such as a local sports teams, to help bring in new patients.

MD: As always, Glenn, after speaking with you today I walk away with a greater appreciation for the power of the Internet

and what marketing the modern dental practice is really all about. One of the things that really impresses me is, unlike the

days of full-page Yellow Page ads at $1,400 per month (and you weren’t sure exactly how effective it was), most of this is free.

You mentioned the word “free” once or twice during this interview and talked about how the updates you’re able to do via

the social media sites, which are free once they’re set up. That’s pretty impressive. Marketing the modern dental practice looks

clean, and a lot less embarrassing at times, because we can use video and photographs in a more authentic way to market the

dental practice. The Internet, which some dentists may view as a necessary evil, really seems to be becoming more classy. You’ve

opened my eyes once again today to what social media can do for a dental practice, as well.

GL: Dentists should not be intimidated by social networking. In fact, they should embrace it as an integral part of their

online marketing strategy. A simple blog on your Web site synced to your Facebook, Twitter and YouTube accounts can

significantly increase your Web site traffic, improve your search ranking, enhance your online reputation and, ultimately,

attract new patients to your office. With anything related to social media, it’s patients marketing to patients, a powerful

thing called referral marketing. So make sure you don’t overtly try to sell or market. Just be personal and learn to

actively engage with your patients.

MD: Well, I’m relatively lazy, so I gave you all my words and images and had you put my Web site together, which I love and

others love. For the other lazy dentists reading this, what’s the best way for them to get in touch with you and get started with

Officite?

GL: They can go to officite.com. Or dentists can call 888-282-9751 to talk to one of our social media experts, who can

walk them through the process of setting up a social network and blog. If they choose, we can manage the entire process

for them, as well as monitor their online reputation. Plus, we can even help with the online review process by providing

our reputation marketing kit, which gives them everything they need in the office to generate positive reviews

and manage their online reputation.

MD: I always tell people that this is an exciting time to be a dentist. And you’ve got me convinced that this is an exciting time

to be marketing a dental practice, as well. Thank you for your time, Glenn. I really appreciate it. CM

Download this interview for on-the-go listening at chairsidemagazine.com. For more information about the services offered by Officite, call 888-282-9751 or

visit officite.com. To contact Glenn Lombardi, e-mail GLombardi@officite.com.

52 www.chairsidemagazine.com


The Deceptions

of Rubber Gloves

I

t has been more than 25 years since the

public panic over AIDS, Hepatitis B and

infection control prompted government agencies

to mandate the use of examination gloves

in dental the practice. In response to public

outcry, the American Dental Association,

the Centers for Disease Control, and the

Occupational Safety and Health Administration

established guidelines for infectious

disease control that include the routine

use of eyeware, face masks and gloves by

dentists and their staff as a way of preventing

the spread of disease in dentistry. For the most

part, these guidelines have been significantly

ineffective and, in many cases, harmful. It is

time for a change.

– Article and Clinical Photos by Ellis Neiburger, DDS

To many clinicians and public health scientists, using gloves, masks and eyeware when treating patients seems reasonable

and rational. Although these devices are generally assumed and touted to protect both the patient and the dental

staff, many dental scientists and clinicians seriously doubt the effectiveness of masks and gloves, citing the rarity of

any disease transmission and numerous hazards associated with their use. 1-45 In this article, I will focus on examination

gloves and document evidence-based facts that support the notion that glove use has been recommended on an

unscientific basis and can increase the risk of infection rather than prevent it. Now that the AIDS scare of the 1990s has

passed, and the disease is better understood, dependable scientific data is available to back this claim. It is time for a

non-emotional re-evaluation of “protection.”

Government regulations, expanding the recommendations of the CDC, now require dentists to wear gloves with all patients.

This may not be in the best interest of either the public or the dental professional. It has been proposed that the

original recommendations of the CDC be re-applied. Those recommendations state that “gloves and protective ware be

recommended, not mandated, for dental care and the use of these tools be determined by the clinician on a case-by-case

basis where the benefits to the patient and safety of the dental staff be the prime focus.”

The Use of Gloves

Since 1985, concerns about AIDS and Hepatitis B have renewed emphasis on infection control and the use of barrierprotection

devices in dental offices. From the original CDC recommendations, a variety of preventative extrapolations

have been made by numerous self-proclaimed experts, organizations and manufacturers in an attempt to one-up each

54 www.chairsidemagazine.com


other while seeking wealth, attention and power. These recommendations have a great emotional appeal and range

from the use of thicker glove materials and longer lengths to double- or triple-gloving. The ADA, CDC, OSHA and

many state dental boards have recommended or mandated the use of gloves for all patient contacts. 1,2 Most dentists

and their ancillary staffs wear gloves, most often composed of latex, which gives the best control and dexterity of all

available glove materials. 3 These elaborate exposure-prevention guidelines are based on a minimal amount of scientific

data concerning the efficacy of barrier protection against viruses in a dental setting. 4,5 Almost all of the scientific data

concerning safety and glove use in dentistry are extrapolations from the medical field. The use of gloves by health care

personnel has been accompanied by a heightened incidence of glove-related problems. 36, 38 Knowledge of these serious

problems have been ignored or suppressed by many dental institutions in an effort to create a false sense of security

among dental workers and patients who are led to believe that practicing Universal/Standard Precautions will protect

them from all infections and dangers inherent in dental practice, and that not using Universal Precautions will doom

them to certain death.

Barrier Protection and AIDS

Unlike glove materials, there are no known bacterial, viral or fungal life forms that are capable of penetrating intact

skin. 5 Intact skin is the best protection against infection. Nonsterile (contaminated) latex exam gloves are the choice

of most dentists not only because of their lower cost but also because they interfere with dexterity considerably less

than poorly fitting vinyl/nitrile gloves. Due to economics, few dentists use the more expensive sterile latex gloves for

non-surgical treatment. Before the 1990 AIDS panic, only about 20 percent of America’s dentists wore gloves, and this

reflected concern mostly about HBV. 7,8

Before 1986, preventing HBV by wearing gloves was only occasionally mentioned

in the literature. 9 At that time, most dentists chose to operate barehanded

because they favored superior dexterity over questionable barrier

protection. 7,8 Occupational infection of dentists or staff members was rare

and even more rarely reported. In those relatively few HBV cases, the virus

was transmitted by accidental needle sticks for which gloves would not offer

protection. 1,9 The rarity of dental-related infections (HBV, herpes), low

mortality rate and the recent development of HBV vaccines has made HBV

a relatively preventable disease and therefore of less concern than in the

past. 10

AIDS, more than any other disease, prompted interest in barrier protection. 1,2,3

This poorly understood, fatal (now chronic) disease originally inspired fear

and panic among the health care, government and public communities. 11 In

the 1990s, fueled by media attention, civil rights of gay people, and governmental

and scientific politics, AIDS took on the undeserved reputation as

the nation’s “number one” disease. In reality, cardiovascular disease, cancer

and diabetes killed millions more people each year.

“Unlike glove materials,

there are no known

bacterial, viral or fungal

life forms that are

capable of penetrating

intact skin. Intact skin is

the best protection

against infection.”

The U.S. mortality rate for AIDS (2007) is 14,561 persons per year. 12 This is a statistically insignificant number (0.0005

percent) compared with the total population of the U.S. (305 million), yet it was once the highest funded and publicized

disease.

Fear of contracting occupational-derived AIDS caused many professionals to quit their jobs or deny HIV/AIDS patients

humane care. This irrational fear – fed by unsubstantiated anecdotal stories of infection from media, politicians, activists

and “safety” merchants-required extreme action from the government and the surgeon general at the time, Dr. Charles

Everett Koop. The CDC responded to the call with the concept of Universal Precautions. This was a form of cover-up

ritual with enough emotional and quasi-scientific appeal to placate the professional and non-professional populace.

Patients relaxed and those with HIV received treatment.

The technique of “protecting” oneself has been used throughout history. Although ineffective, it calms widespread

panic. During the 14th century plague in Europe, physicians “covered up” in special cloaks to confuse the disease devils

(Fig. 1). In the 1918 swine flu epidemic, useless cloth masks covered many faces in an attempt to protect from the flu,

which killed 60 million people. (Some people were shot for failing to wear a mask.) In the 1950s, in preparation for

a nuclear war, schoolchildren were taught to duck and cover under their desks (and not to run to the nearest bomb

The Deceptions of Rubber Gloves55


shelter). In the 1990s it was gloves, mask and eyeware to “cover” the skin and

stop the spread of AIDS, which can only be transmitted from unprotected sex

and IV drug use.

The first case of AIDS was reported in 1959, and since there have been no

documented cases of occupational HIV infection in any dental health care

worker. 1,13 There have been billions of dental patient visits worldwide with no

disease transmission. There is one botched CDC investigation involving Dr.

David Acer, an openly gay Florida dentist with HIV, who was alleged to have

infected some patients (with secret high-risk behaviors). But even Dr. Acer

wore gloves during all patient contact. In 1992, the U.S. General Accounting

Office investigated and reported that this case was so bizarre, and the CDC

did such a poor job in its investigation, that no reliable public policy should

be drawn from the matter. 14,15 The GAO report did state that “gloves do not

prevent most injuries caused by sharp objects, however, and so do not necessarily

reduce contact rates.” 14 The CDC also published six to seven “possible”

HIV transmissions in dentistry, but these, in the words of CDC officials, “were

short on science.” 17

Primarily because of HIV-AIDS concerns, universal barrier protection, including

the wearing of gloves, has been recommended and/or mandated for all

dental staff when in direct contact with a patient. 1,2,3,7 This recommendation is

still in effect. This has increased the use of gloves, along with problems associated

with their use, for both staff and patient. Knowledge of these problems

and hazards and the option of wearing gloves in appropriate situations are

important for the health of the dentist, the dental staff and the patient.

Figure 1: “Cover-up” garb, worn by the 14th

century physician, was believed to shield the

practitioner from the plague.

Mechanical Hazards of Gloves

Gloves pose a number of mechanical problems for the wearer:

Gloves do not offer protection against needle punctures, the leading cause

of HBV and HIV infections in health care workers. 1,2,13,14,16 Eighteen of the

25 healthcare workers in North America and Europe who reported HIV occupational

seroconversion during the years when AIDS first became a concern

developed their infections from large-gauge needle puncture wounds. 1,13

This percentage has increased substantially over the years as the few new

contamination cases reported needle stick-sharps injuries as the prime cause of

seroconversion among medical staff. There have been no documented cases of

dental staff occupationally seroconverting. Sharp punctures are not prevented

by gloves. 1 In fact they have been shown to increase penetrating injuries. 17,18

The hazards of reduced touch sensation caused by gloves tends to contribute

to clumsiness, which often results in increased skin penetrations due to

the insulation of proprioceptive nerve endings in the skin of a dentist’s

hands. 17,18 Solovan, et al. reported 2.3 times as many tissue lacerations in dental

prophylaxis patients treated with gloves compared with work done barehanded.

8

1. In the largest clinical dexterity study to date, 50 dentists who practice in

Lake County, Ill., were tested for the average threshold for perception of light

touch using a dynanometer. 18 Results were 4.4 grams without gloves and 6.7

grams with their favorite gloves, which represents a 52 percent reduction in

light-touch proprioception. There was a 16-fold increase in percutanious injuries

while manipulating endo files (gloved) in a manual dexterity exercise as

compared to the same dentists working bare-handed. 18

2. Dental burs, especially those designed to cut acrylic, tend to snag the latex

Figure 2: A dental bur snags a latex glove

and drives into the flesh of the dentist’s hand.

Figure 3: These gloves were burned while a

dental assistant was using a Bunsen burner in

a dental laboratory.

56 www.chairsidemagazine.com


ubber and drive the bur into the flesh of the operator’s hand, creating a deep

penetrating wound 19 (Fig. 2). There is considerable danger in wearing gloves

around rotating machinery.

3. Dental lathes and rotary devices can snag gloved fingers and have caused

bone fractures among dental personnel. 20

4. Both latex and vinyl gloves are flammable and pose a danger with the use

of open flame (e.g., wax in prosthodontics) 21 (Fig. 3).

5. Gloves increase the difficulty of handling small instruments such as pins,

burs and endodontic files. 18,21 This impairment increases the time required to

perform normal dental procedures and increases the opportunity for drop

and aspiration accidents. 22

6. Gloves are also poor barriers to many solvents used in dentistry, such as

alcohol, eugenol and methacrylates, as well as composite bonding agents and

some impression silicones. 36, 37 This allows contaminates to enter the gloves.

Figure 4: A pantograph tracing of a free

fractured cross section of latex glove demonstrates

0.005 micron channels. 24

Problems with Barrier Protection

The primary purpose of the gloves is to provide a barrier to the transfer of

microorganisms and other agents. They are fairly effective against organisms

that are 10 microns or larger (e.g., bacteria), but there is little evidence that

they effectively protect the wearer from viruses encountered in practice. 9,23

There have been numerous studies done that show minimal benefits for those

9, 15,24

who wear gloves.

New latex gloves have numerous porosities that are three to 15 microns in

diameter. 24 These porosities increase in size and number when the gloves are

stretched and used. Ten micron voids are the smallest imperfections that can

be detected by usual testing methods. 24,26,27 The capsid of HIV is 0.1 to 0.12

microns in diameter. 27 A hundred of these viruses could pass side by side

through one of the “natural” 10-micron openings in latex gloves. The HBV virus

of Hepatitis B is even smaller, 0.042 microns, which may partially explain

why it is more infectious than HIV 29 (Fig. 4). Vinyl and nitrile gloves have

significantly more rips and openings.

Figure 5: A pantograph of 0.01 micron holes

(dark) in latex gloves after a six-day exposure

to atmosphere ozone. 28

Besides their natural porosity, latex gloves frequently have manufacturing

defects in the form of visible holes 50 microns or larger in diameter. 27,30 From

2 percent to 36 percent of unused latex gloves and 23 percent of unused vinyl

gloves examined had tears or holes that could allow fluids in a patient’s

mouth to leak into the glove, causing “wet finger syndrome. ”26,27 These voids

increase in size and number as the latex is worn or just exposed to atmospheric

ozone 28,31 (Fig. 5). This was corroborated in a report by Brough et

al., which revealed holes in 37 percent to 70 percent of used postoperative

surgical gloves. 32

In separate hallmark studies, both Reignold 9 and Gonzalez 33 presented data

showing that the use of gloves provides dentists little protection against HBV.

Reingold studied 434 oral and maxillofacial surgeons and found that only the

number of years in practice correlated with the number of infections these

surgeons had incurred. The use of gloves showed no increase in protection.

Gonzalez reported only a


than glove-wearing nonreactors, which explained the greater number of HBV

cases. 9

Most reports on the effectiveness of gloves against viruses involve assumptions

only. Hadler’s report, 34 which is unique because it was distributed by

the CDC, is a typical example in which HBV was supposedly transmitted to

patients by an oral and maxillofacial surgeon carrier. Prior to this discovery,

the surgeon did not routinely wear gloves. No other HBV transmissions were

noted after he began wearing gloves. The conclusion was that the gloves

prevented further transmissions. Omitted from consideration was the later

discovered shorter incubation period for HBV infection, the probability that

the surgeon’s carrier status changed and that newly infected patients did not

immediately test positive after the test surgeon began wearing gloves. This

and three other similar studies were extrapolated by the CDC to apply to HIV

infections and became the prime “scientific” rationale for the recommendation

that gloves be worn as an element of Universal Precautions. 1 At that time, the

AIDS epidemic was peaking and any rationale, scientific or not, would suffice

for CDC action.

Figure 7: Persistent dermatitis on the hand of

a dental assistant after the routine wearing of

latex gloves.

Eventually, the errors in this study forced the CDC to recant and recommend that vaccination be the only effective preventative

measure for HBV. Retracting Universal Precautions would be embarrassing and spark the AIDS panic again

and thus was not implemented. This constituted an official deception that had serious future consequences.

Gloves: An Expensive Contamination Hazard

Most dentists use nonsterile latex gloves instead of sterile gloves because of their lower cost. 6 A 100-pair box of nonsterile

exam gloves costs between $5 and $11 at most supply firms. Sterile gloves usually cost 10 times as much ($50-

$95). The average dentist and staff uses $4,000 worth of nonsterile gloves per year (36 patients a day). 11 Extrapolating

to the 150,000 dentists in America, the nation’s annual cost for dental gloves comes to at least $600 million. This is a

tremendous expense for minimal to no benefit, because the wearing of gloves in dentistry has shown no significant

improvement in reducing HBV (now addressed by vaccination) or AIDS (no documented cases of occupational transmission

in dentistry before or after 1985). To invest this level of resources for a useless exercise defrauds the dentist,

who pays the supply bill, and the patient, who pays the dentist.

Because the CDC and OSHA are primarily interested in protecting the dental staff member rather than the patient, the

contamination potential (for patients) of nonsterile exam is placed secondary to the costs of glove supply. Both organizations,

however, sensibly recommend sterile gloves for some surgical procedures. It is ironic that the nation’s health

organizations insist on stringent infection control measures and advertise the fact as a safety promotion to the public,

yet what they are advocating is that dental staff use contaminated (infected) exam gloves, rather than freshly washed

and disinfected hands as was done before 1985.

Of course, using sterile gloves for all procedures would increase the cost of providing dentistry to such an extent (more

than $5 billion annually) that no one would be able to afford dentistry. It is estimated that using sterile gloves as we

do examination gloves would cost each dentist $40,000 more in supplies each year. 11 In spite of this, infections from

bare-handed and gloved (sterile/nonsterile) dentists have been historically very rare and insignificant. Evidence-based

science shows it doesn’t matter whether you wear gloves, and it never did. Yet dentists continue to believe that placing

contaminated gloves on a compromised patient’s oral mucosa is safe and beneficial.

This is with the consideration that most latex glove products are manufactured and hand-packed in Third World countries,

where facilities are hygiene-primitive and the bathroom hygiene of many latex workers consists of using the

left hand as toilet paper. Soap and clean water is a rarity (Fig. 6). Because exam gloves are considered already contaminated

(nonsterile), they are seldom checked for pathogens. It is assumed that contaminated gloves are not clean.

The hope is that they will be “kitchen clean,” which the CDC, dental organizations and dental boards assume is good

enough for the population.

Microbe contamination is not the only problem. Gloves often are coated with talc or cornstarch, which act as lubricants

and absorbents. There are problems with this, most notably that talc and starch are physical irritants. 36,37 They can cause

58 www.chairsidemagazine.com


inflammation in lesions on the wearer’s hands and can irritate wounds in the patient. Latex rubber ingredients have

been identified as contributing to various degrees of dermatitis, as well as local and systemic allergic reactions. 39 Both

talc and starch are irritants when inhaled and can cause asthmatic exacerbations in susceptible individuals. 28,36,40 The

talc and starch will absorb latex proteins, become airborne and get inhaled by susceptible individuals. This can cause

life-threatening conditions to breathing-compromised people (e.g., asthmatics). The incidence of latex sensitivity has

increased from 3 percent to 6 percent in the general population since 1985 concurrent with widespread latex glove use.

Some researchers consider this to be an epidemic in itself. The incidence of latex sensitivity in the dental community

has soared from 3 percent to more than 22 percent. 47 This appears to be the direct result of wearing latex gloves and exposing

skin and mucosa to the allergenic protein, as this problem did not

arise until gloves became mandated. This is a dangerous change of events:

Many deaths and thousands of serious reactions have been reported due

to the increased latex exposure. 47 Another deception dentists and patients

face is that gloves not only won’t be of much help in preventing disease,

but they can cause considerable morbidity and mortality for which our

patients and staff are seldom warned. This situation wastes money, endangers

lives and discredits the dental profession.

Starch is easily broken down into simple sugars that provide an ideal

growth medium for microbes and contribute to bacterial and fungal

growth on the warm hands of a glove wearer. This increase in resident

and “leaked” microbial growth presents a danger to both the patient and

the operator. 28,32 The components of latex (and other) gloves have been

implicated as contamination hazards that may contribute to urticaria, nonhealing

wounds, asthma, facial edema and toxic shock in health care

workers. 30,38,41 Forty of the 50 dentists (80 percent) in a Lake County, Ill.,

study wore gloves at least 85 percent of the time. 21 Twenty-five (50 percent)

of these dentists reported hand lesions concurrent with the wearing

of gloves. Three of the remaining 10 dentists, who intermittently wore

gloves, also reported hand lesions. All but one of these dentists attributed

the lesions to the wearing of gloves. 18 Tightly fitting gloves keep

contamination close to the wearer’s skin surface. This increased contact

encourages growth and spread of pathogens and increases the likelihood

of allergies and/or reactions.

Nonsterile gloves are not only contaminated during manufacture but are also quickly contaminated by the natural

flora of the hands. To illustrate, this author did an experiment. Thirty-one unused, multibrand, nonsterile gloves were

swabbed with sterile saline/cotton swabs and individually plated on typto-soy media. Cultures were incubated for 24

hours. Six (19 percent) of these gloves were contaminated with gram-positive cocci, spore formers and fungi. There are

numerous other studies that repeat these findings. 16,23,24,26,29

Considering that these microorganisms are augmented with a starch growth media, warmth and moisture from the

wearer’s hands, the potential for increased contamination and skin breakdown of both the wearer and the patient is

greatly increased. This is why the CDC recommends that dental health care workers who have exudative lesions or

weeping dermatitis, particularly on the hands, should refrain from all direct patient care and from handling dental patient

care equipment. 1 Because most dentists and their staff have microbreaks and other skin lesions as described above,

obeying this order would essentially furlough 20 percent of the nation’s dental staff at any one time.

Allergy Hazards of Latex Gloves

“This is with the

consideration that most

latex glove products are

manufactured

and hand-packed in

Third World countries,

where facilities are hygieneprimitive

and the bathroom

hygiene of many latex

workers consists of using

the left hand as toilet paper.”

Urticaria is a common complaint associated with the use of gloves. 36,39 In a Lake County, Ill., study, half of the glove

wearers experienced dermatitis. 18 Increased IgE reactivity of wearers and patients has resulted in thousands of lifethreatening

allergic reactions, such as anaphylaxis and asthma, to latex glove materials. 39,40,41 Additional allergic problems

have resulted from the starch or talc used inside the gloves. 36 Contact with latex gloves by sensitized individuals

has been life-threatening, as mentioned above. 39,40,41

Between 1988 and 1992, the FDA received reports of more than 1,100 life-threatening systemic and 15 fatal reactions to

latex. In recent years, as the population continues to be sensitized to latex (e.g., rubbing a gloved finger along the oral

The Deceptions of Rubber Gloves59


mucosa), this rate of anaphylaxis cases continues to increase. Both dentist and patient are at risk, and the deception

that everything is safe cannot ethically be maintained.

Miscellaneous Hazards

Gloves also produce other problems not previously mentioned.

1. Latex has a negative taste and “sour rubber” odor to many people. 42 Multi-flavored gimmick gloves are a poor

attempt to correct this problem.

2. Hands are compressed by the elasticity of latex gloves. This restricts the flow of blood, which increases tension

and muscle fatigue. 43 Although proper fit is important, the recommended snug fit is a disadvantage of glove use due

to the elastic nature of latex and the wearer’s nerve pathology caused by the constant compression. 35

3. Gloves impede productivity by restricting movement, limiting manual dexterity and consuming time while gloving

and degloving. 22,37,45 Assuming it takes 30 seconds to put on or take off gloves for each patient, a dentist who

treats 100 patients a week for 50 weeks of the year loses 83 hours of productivity annually. This makes dentistry

less efficient, more costly and deprives the relative poor of needed care.

4. Many patients, especially small children, are offended by the use of gloves. 35 They interpret gloves as a threat

or as an insult that they are dirty or diseased. This level of mistrust interferes with positive doctor/patient relationships.

35

5. The use of gloves has become an issue among the media, patients and dentists. 4,35 Many patients insist on being

treated with or without gloves based on information gleaned from magazine articles, news reports and word of

mouth. Most patients believe gloves are being worn for their protection, but OSHA recommends barrier protection

for the expressed benefit of the dentist and other members of the dental staff, not the patient. 2 There will be serious

consequences when the media learns that most dentists are treating their patients with contaminated exam

gloves.

6. There are additional problems associated with wearing gloves. The use of adhesives, impression materials and

electric pulp testers, which require direct skin contact, are all compromised. 45

7. Gloves are made of latex and plastic, which deplete natural resources, divert crop land (in the starving Third

World) from food production and engorge our limited waste landfills with useless, unrecyclable garbage. If not

buried, most gloves, being considered medical waste, are incinerated, producing hydrocarbon air pollution, CO2,

and increasing the effects of global warming. Therefore, gloves are not green.

Politics

The most serious deceptions are in the political arena. The directives on Universal Precautions came from the Centers

for Disease Control, a branch of the U.S. Department of Health and Human Services. This decision was made by a closed

committee of public health bureaucrats, most of whom had never been in dental practice. It was an attempt to silence

the AIDS panic, not to find the most efficient form of disease prevention.

Surgeon General Koop devised and promoted his UP concept for medical and dental personnel without any consideration

of cost or effectiveness or outside input. On October 29, 1999, The New York Times printed an expose reporting

Koop was financially tied to a prominent glove firm, Allegiance Healthcare Corp. The article stated that he had received

options to purchase 500,000 stock shares of the firm for a 1994 (low) price in exchange for four lectures per year and

advertising rights to his name. This involved millions of dollars. Koop was accused of also trying to downplay the allergy

danger issue in Congress because, as he told CDC representatives, “It would cause more harm than good and

frighten hospital workers out of using gloves.” Eventually Koop ended up with a failed health care Web site, worthless

stock, angry investors and a TV ad contract to sell “first alert” medical warning devices to the elderly. It seems that science

was not a part of this formula.

It is amazing that dentists, their organizations, OSHA, dental boards and America as a whole accepted the pronouncements

from the CDC, an organization of questionable authority and candor, without debate. The CDC has flubbed many

health initiatives, the latest being the severity and criticalness of the H1N1 flu outbreak and botched vaccine supply.

60 www.chairsidemagazine.com


In 1976 it also went out on a limb, declaring the swine flu of that year

was the 1918 variety. It was not, though useless vaccines were distributed

to the nation with hundreds of deaths and thousands of hospitalizations

from adverse reactions. The anti-HIV cream Noroxnol-9, promoted by the

CDC, was found to enhance the spread of AIDS, not hinder it. Former Surgeon

General David Satcher called the CDC labs a national disgrace. Congress

criticized the CDC for changing the definition of AIDS, thus doubling

case numbers in an effort to garner more funding. 17 This sad episode was

termed by the CDC as “the distortion.”

A long series of crises, scandals, reorganizations, mistakes, policy flipflops,

infighting and political interference has left the CDC with a legacy

of questionable competence. Since most infection control procedures are

based on this flawed organization’s recommendations, dentists would be

best served to be more critical than accepting of such government edicts.

“Strange schemes appeared

in the journals, such as

ads stating, ‘Patients love

headbags’ or ‘$20

precision, plastic individual

handpieces.’”

The second area of political deception lies in dental publishing. Originally, a few articles on gloves and other PPEs

appeared in 1980s journals rebutted by other papers opposing their routine use. As time went on, increasingly more

journals printed unsubstantiated horror stories of dentists getting AIDS from patients and other rumors. They published

increasingly bizarre recommendations from so-called infection control gurus increasing the panic. This brought attention

and sold issues. Advertising for disposable (e.g., glove) manufacturers went from 3 percent to 25 percent of most

dental publications’ ad space with the accompanying (financial) pressure on editors to avoid infection control criticisms,

which would hurt business. Strange schemes appeared in the journals, such as ads stating, “Patients love headbags (a

paper isolation bag with a hole for the mouth)” or “$20 precision, plastic individual handpieces (to ensure sterility and

cracked enamel).” Some major dental organizations, profiting from the increased attention, adverted in their journals

and took on the lead to perpetuate the deception that dentists were in danger of AIDS. They accepted whatever the CDC

handed them, because protesting or questioning had some degree of political risk. Instead, they embellished the recommendations

of extremes (e.g., heat sterilization of handpieces) to the detriment of the practitioners and their patients.

Few journals protested and fearful dental staff embraced the deceptions with lemming enthusiasm.

Conclusion

Gloves are imperfect. They often contribute to the breakdown of the natural skin barriers. They are poor barriers to the

transmission of viruses because of numerous voids derived from manufacturing and use. Gloves are cumbersome for

the dentist to wear. Gloves are costly, allergenic, contain irritants and breed microorganisms. The wearing of gloves is

beneficial at times (e.g., deep surgery) but can be hazardous at others. The wearing of gloves should not be mandated

by government edict but left to the discretion of the dentist in situations where the wearing of gloves provides more

benefit than liability. As costs and glove-related illnesses increase, there is no rational scientific reason to continue routine

glove use. It is time for dentists to decide what is best for their patients, not bureaucrats and hucksters. It is time

for re-evaluation of glove use on a case-by-case basis.

What can be done? If the contaminated/sterile glove issue becomes public, there will be extreme pressure to replace

exam gloves with expensive sterile gloves. Each practice will be required to spend at least 10 times more money on

glove supplies. How much will this cost you? In this time of financial difficulty, in which many practices are in economic

trouble and the excesses and window dressings of the wealthier past no longer can be comfortably funded, such

costs would be ruinous. Many dentists will lose their jobs. Many practices will fold. The glove problem must be tackled

sooner or later.

The problem with latex gloves is simple to solve. Dentists must pressure the CDC to declare that gloves are potentially

hazardous and that its recommendations on mandatory UPs (including glove wear) are optional in those cases where

UPs use is more detrimental than beneficial based on the dentist’s evaluation on a case-by-case basis. In this way, glove

use will be determined by the doctor, not the bureaucrat. The blood-borne pathogen concerns of a medical heart surgeon

need not be extrapolated to the dentist doing a prophy on a healthy 3-year-old. OSHA’s blood borne regulations

already have this glove option, to a limited degree, in place (Federal Register 12-6-91. 56:235 p.64129d3ii). Once the

CDC publicizes this change, dentists can once again take command of their practices. It’s your future and your patients’

health, and now is the time to act. CM

The Deceptions of Rubber Gloves61


Dr. Ellis Neiburger is a general practitioner in Waukegan, Ill. Contact him at 847-244-0292 or drneiburger.com.

References

1. Centers for Disease Control: Guidelines for prevention of HIV and HBV to heath care and public safety workers. MMWR. 38(56)1-33,1989.

2. OSHA joint advisory notice: Protection against occupational exposure to HBV and HIV. October 19,1987.

3. Editorial: Practitioners surveyed report dramatic increase in glove usage. Dental Products Report. 12:1.1987.

4. HolubW. et al.: AIDS, A new disease? American Clinical Products Review, 5:28-37,1988.

5. Fein S: A bad case of one upmanship. Dental Economics, 5:23,1988.

6. Most dentists wear gloves, survey says: ADA News, 20(3)1-5:23,1988.

7. Coburn S: AIDS Update, Illinois Dental Journal 3:1280129,1988.

8. Solovan D, Uldricks J, Caccamo P, Beck F.: Evaluation of oral procedures performed with gloves: a pilot study. Dental Hygiene, 3:122-124,1984.

9. Reingold A, Kane= M, Hightwer A.: Failure of gloves and other protective devices to prevent transmission of HBV to oral surgeons. JAMA 259(17):2558-2559,1988.

10. Dentists guard patients, selves against HB virus, ADA News, 20(3):3,1989.

11. Badner V: Dentists and the risk of HIV, New England Journal of Medicine, 319(2):113,1988.

12. CDC. HIV/AIDS Surveillance Report 2007 V19 p.20.

13. CDC Update: AIDS and HIV infection among heath care workers, MMWR, 37: 15-233,1988.

14. GAO, CDC’s Investigation of HIV Transmission by a Dentist. Sept. 1992. p.2-47.

15. Klein R, Phelan J, Freeman K.: Low occupational risk of HIV infection among dental professionals. New England Journal of Medicine, 318(2):86-90,1988.

16. Wormser GP, Rabkin C, Juline C: Frequency of nosocomial Transmission of HIV infection among heath care workers. New England Journal of Medicine,

319(5):307,1988.

17. Neiburger EJ:Dentists do not get occupational AIDS. J. Am. Assoc. Forensic Dentists 26:1-3; 2004 http://www.dentaleditors.org/Article%20Library/Neiburger%20

art1.htm.

18. Neiburger EJ: Gloves and manual dexterity, Journal of American Association of Forensic Dentists, 13:1-4,1990.

19. Shapter D: AIDS, what dentists are doing about it, Dental Management, 3:32-36, 988.

20. Bonner P: Report D.D.S. alert, 7:19:2-3,1987.

21. Tanchyk AP: Precautions in protection, JADA, 115:2:824, 1988.

22. Hardison J: Gloved and ungloved performance time for two dental procedures, JADA, 116:5:691,1988.

23. Klein R, Party E, Gershey E: Safety in the laboratory. Nature, 34:288,1989.

24. Arnold S, Whitmand J, Fox C, Fox M.: Latex gloves not enough to exclude viruses. Nature, 335:19,1988.

25. Young F (FDA Commissioner) Report: Dental Economics, 1:9,1989.

26. Editorial, AIDS found to pass through latex glove undetected, Dentistry Today, 12:12,1988.

27. Katz J, et al.: Fluorescein dye evaluation of glove integrity, JADA, 118:3:327-330,1989.

28. Otis L, and Cttone J: Prevalence of perforations in disposable latex gloves during routine dental treatment, JADA, 118:3:321-325,1989.

29. Tortora G,; Funke B, Case C: Microbiology, An Introduction, 3rd Ed. Benjamin/Cummings Publishing Co., New York, N.Y., 1989, p 327.

30. Boguszewski D: Third national forum on AIDS and HBV. Dental Products Report, 1:6,1989.

31. Baker R, Sherwin R, Bernstein G, =Nakasmura R: Precautions when lighting strikes during monsoon: the effect of ozone on condoms, JAMA,260:10:140: 4-5,1989.

32. Brough S, Hunt T, Barrie W: Surgical glove perforations. British Journal of Surgery, 76:317,1988.

33. Gonzalez E, Naleway C: Assessment of the effectiveness of glove use as a barrier technique in the dental operatory. JADA, 117:9:467-469,1988.

34. Hadler S, Sorley D, Acree K: An outbreak of hepatitis B in dental practice. Annals of International Medicine, 95:2:133-138,1981.

35. Neiburger EJ: Are we spreading AIDS by wearing gloves, New York State Dental Journal, 3:6-7,1988.

36. Fisher A: Contact Dermatitis, 3rd Ed. Lea & Febiger, Philadelphia, PA, 1986, pp 224-279 and pp 630-631.

37. Reitz C, Clark N: The setting vinyl polysiloxane and condensation silicon putties when mixed with gloved hands, JADA 116:3:371-375,1988.

38. Anto JM, Sunyer J, Rodriguez R: Community outbreaks of asthma associated with the inhalation of soybean dust. New England Journal of Medicine, 320: 1097-

1102,1989.

39. Van Der Meeren HL: Life threatening contact urticaria due to glove powder. Ned. Tijdschr Geneeskd, 132(21):968-970,1988.

40. Slater J: Rubber anaphylaxis, New England Journal of Medicine, 320:17:1126-1130,1989.

41. Dooms-Groossens A: Contact urticaria caused by rubber gloves. Journal of American Academy of Dermatology, 18:6:1360-31361,1988.

42. Yoder K: Patients attitudes toward the routine use of surgical gloves in a dental office. Journal of Indiana Dental Association. 64:6:25-27,1985.

43. Brantley C: The effect of gloves on psychomotor skills. Journal of Dental Education, 50:10:611-613,1986.

44. U.S. Revenue Forecast of Disposable Glove Market: Dentist, 4:9,1989.

45. Bender I, Landau M, Finsecca S, Trowbridge H: The optimum placement site of the electrode in electric pulp testing of the twelve anterior teeth. JADA, 118:3:305-

310,1989

46. Christensen Gordon: Operating Gloves. JADA 132;10:1455-1457,2001.

47. Assennato N, et al: Type I allergy to natural rubber latex and type IV allergy to rubber chemicals in healthcare workers with glove related symptoms. Clin Exp Allergy

Mar;32(3):441-7,2002.

Written by Ellis Neiburger, DDS, for Chairside magazine. Copyright ©2010 Ellis Neiburger. All rights reserved.

62 www.chairsidemagazine.com


Dr. DiTolla’s

Patient Product Review

ou don’t have to be in dental practice too long

to realize that men and floss don’t mix. I always

laugh as I walk by and hear my dental assistant

say, “Alright, Mark, let me show you how to use

the floss threader for cleaning under your new

bridge.” Those might be the most wasted words

in the English language. If an assistant talks and the patient

doesn’t hear it, did she really make a sound? Why is

it we can give the patient three floss threaders, and a year

later when we ask him if he needs any more he says he

still has them. Really? After a year? Are you putting them

in the dishwasher? Having them dry-cleaned? Or perhaps

you never used them in the first place!

Getting any male to floss is a tricky deal. You really need

to catch males while they are young, say around 13, and

let them know that chicks dig guys who floss. Drop some

floss in the pocket distal to tooth #2 or tooth #15, and

then hold it under his nose and let him smell some anaerobes.

Inform him that if a girl ever were to smell that, the

entire school would know about it in about 90 seconds.

Floss every day, and it goes away.

But for men who are out of adolescence, there is a need to

make floss a little more exciting. With every baby boomer

being told to eat steel-cut oatmeal with fresh fruit for

breakfast, here’s a way to kill two birds with one stone:

delicious breakfast dental floss. Bacon, waffles and coffee?

Either I’m watching an episode of “Mad Men” or I’m

using that great new floss my dentist recommended! Go

to accoutrements.com and let the people who brought

you Inflatable Turkey improve the periodontal health of

your male patients. CM

Breakfast Floss from Accoutrements ® , LLC. For more information, call 800-886-

2221 or visit accoutrements.com.

Patient Product Review63


“Uh oh. Looks like I’m gonna

need a rubber ... dam!”

PJ Wells, DDS

Canton, Ohio

1st place winner of $500 lab credit

“eHarmony gets one wrong.”

David Lesansky, DMD

Naples, Fla.

2nd place winner of $100 lab credit

“The tears of a crown.”

John S. Brizendine, DDS

Lake Forest, Calif.

3rd place winner of $100 lab credit

Honorable Mention

“It is guys like you who get on my last nerve!”

Michael T. Reynolds, DDS

Minneapolis, Minn.

The Chairside ®

Caption Contest Winners!

Congratulations to winners of the Vol. 5, Issue 1 Chairside Caption Contest. The winning captions were chosen from hundreds of entries

both e-mailed and submitted online to Chairside magazine when asked to add a caption to the illustration above. Winning entries were

judged on humor and ingenuity.

64 www.chairsidemagazine.com


The Chairside ®

Caption Contest

INTRAoral 2000

“Looks like somebody has a severe case of potty mouth.”

Send your caption for the above illustration along with your name and city of practice to: chairside@glidewelldental.com. By

submitting a caption, you authorize Chairside magazine to print your name in a future issue or on our Web site. You may also

submit your entry online at chairsidemagazine.com.

The winner of this issue’s Caption Contest will receive $500 in Glidewell credit or $500 credit toward their account. The

2nd and 3rd place winners will each receive $100 in Glidewell credit or $100 credit toward their account. Entries must be

received by May 21, 2010. The winners will be announced in the summer issue of Chairside.

More magazines by this user
Similar magazines