A Publication of Glidewell Laboratories • Volume 5, Issue 2
Periodontist Dr. Daniel Melker
Success with Biologic Shaping
One-on-One with Dr. Paul Homoly
Maximize Your Profit
The Deceptions of Rubber Gloves
Dr. Frank Spear on
Tooth Positioning for Anterior Esthetics
Dr. Michael DiTolla’s
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
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
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
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
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
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
Jim Glidewell, CDT
Michael DiTolla, DDS, FAGD
Mike Cash, CDT
Michael DiTolla, DDS, FAGD
Sharon Dowd, Lindsey Lauria
Jamie Austin, Deb Evans, Joel Guerra,
Phil Nguyen, Gary O’Connell, Rachel Pacillas
Sharon Dowd, Kevin Keithley
Wolfgang Friebauer, MDT, Phil Nguyen
If you have questions, comments or complaints regarding
this issue, we want to hear from you. Please e-mail us at
email@example.com. Your comments may be
featured in an upcoming issue or on our Web site:
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Chairside is a registered trademark of Glidewell Laboratories.
Chairside ® Magazine is a registered trademark of Glidewell Laboratories.
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
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
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
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
You have three Maryland bridge
choices, none of them great as a permanent
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.
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
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
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
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
Typically the wings on a Maryland
bridge are too thin to place retentive
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
- 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
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.
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Letters to the Editor 5
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
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 firstname.lastname@example.org.
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
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.
CATEGORY...... Articulating Paper
New Milford, Conn.
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
PRODUCT........ NV MicroLaser
CATEGORY...... Diode Laser
SOURCE.......... Discus Dental
Culver City, Calif.
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.
PRODUCT........ Reduction Ring
CATEGORY...... Prepping Guide
SOURCE.......... The Reduction Ring
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
PRODUCT........ SONICflex ® LUX 2000 L
CATEGORY...... Sonic Scaler
SOURCE.......... KaVo Dental
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.
– 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
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
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
Contact the author, Dr. Douglas Terry, at 281-481-3470, dentalinstitute.com or
Aesthetic & Restorative Dentistry: Material Selection & Technique. Douglas Terry,
Karl Leinfelder and Willi Geller. Everest Publishing Media, Stillwater, Minn., 2009.
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
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
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
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
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
with and use these
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.
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-
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.
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.
– 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,
Interview with Dr. Paul Homoly
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
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
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
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
MD: That’s pretty simple and straightforward. It’s not a
buccal pit amalgam; it’s more difficult than that. But in the
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
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
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
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
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
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
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.
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.
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
& 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.
Profit per Hour
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.
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
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
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.
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).
Profit per Hour
The Sweet Spot
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,
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
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.
Sum of (Patient Fee - Lab Fee - Office Overhead)
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
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
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
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
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
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.
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?
$1,000 $5,000 $10,000
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
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
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
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
– 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.
3. Acrylic provisionals should be placed with
Durelon (3M ESPE ; St. Paul, MN) temporary
cement. Durelon is antimicrobial and helps
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
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
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.
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
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
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.
■ 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
Figure 10: Tissue sutured just coronal to the bone with 5-0
chromic suture material.
Figure 12: Final restoration with margins placed into the
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?
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
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
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
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
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.
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
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
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
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
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.
of Rubber Gloves
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
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
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
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
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.
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.
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
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
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
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
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
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.
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.
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
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.
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.
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
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.
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.
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,
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
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-
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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-
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
Written by Ellis Neiburger, DDS, for Chairside magazine. Copyright ©2010 Ellis Neiburger. All rights reserved.
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
1st place winner of $500 lab credit
“eHarmony gets one wrong.”
David Lesansky, DMD
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
“It is guys like you who get on my last nerve!”
Michael T. Reynolds, DDS
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.
The Chairside ®
“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: email@example.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.