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Chairside®<br />
A Publication of <strong>Glidewell</strong> Laboratories • Volume 5, Issue 2<br />
Periodontist Dr. Daniel Melker<br />
Success with Biologic Shaping<br />
Page 39<br />
One-on-One with Dr. Paul Homoly<br />
Maximize Your Profit<br />
Page 24<br />
The Deceptions of Rubber Gloves<br />
Page 54<br />
Dr. Frank Spear on<br />
Tooth Positioning for Anterior Esthetics<br />
Page 18<br />
Dr. Michael DiTolla’s<br />
Clinical Tips<br />
Page 9
Contents<br />
9 Dr. DiTolla’s Clinical Tips<br />
In this issue, I detail my favorite articulating paper,<br />
TrollFoil, which is a world apart from the cardboardthick<br />
articulating paper of the past. Also highlighted<br />
is the cordless NV MicroLaser; the Reduction Ring<br />
for perfect preps; and the SONICflex LUX 2000 L,<br />
which I now use to clean all my preparations prior<br />
to cementation.<br />
13 “Aesthetic & Restorative Dentistry:<br />
Material Selection & Technique” –<br />
A Book Review<br />
Most dentists, myself included, haven’t bought a<br />
dental textbook since dental school. However, when<br />
I heard that Dr. Douglas Terry was co-authoring a<br />
book with Dr. Karl Leinfelder and MDT Willi Geller,<br />
I couldn’t wait to get my hands on a copy of it. Did it<br />
live up to the hype? Find out in my review.<br />
18 Too Much Tooth, Not Enough Tooth:<br />
Making Decisions About Anterior<br />
Tooth Position<br />
Creating an esthetic smile requires thoughtful evaluation<br />
by the dentist. But perhaps the most critical<br />
point in this process is the starting point for tooth<br />
positions, which includes developing a functional<br />
treatment plan. How is this achieved? Dr. Frank<br />
Spear, using a sequence from his Spear Education<br />
program, explains.<br />
24 One-on-One with Dr. DiTolla<br />
Which is more profitable: 12 single units on 12 different<br />
patients or a 12-unit complex-care case on a<br />
single patient? The answer might surprise you, as<br />
Dr. Paul Homoly explains in our latest one-on-one<br />
discussion. Watch our in-person dialogue from our<br />
first sit-down interview at chairsidemagazine.com.<br />
39 Biologic Shaping<br />
In order to achieve success with biologic shaping,<br />
there are very specific steps and clinical prerequisites<br />
that must be followed. Dr. Daniel Melker, periodontist<br />
for Dr. Bill Strupp, outlines how we can avoid<br />
weakening the tooth when performing conventional<br />
crown lengthening.<br />
Contents 1
Contents<br />
45 Practice Management: Social Media and<br />
Marketing the Modern <strong>Dental</strong> Practice<br />
Twitter, Facebook, YouTube, MySpace, Google reviews<br />
and blogs are terms every dentist needs to<br />
know. Thanks to the Web and the simplistic beauty<br />
of social media, the ability to generate patient-to-patient<br />
promotion of your services has never been easier.<br />
Officite’s Glenn Lombardi talks about the power<br />
of this free marketing tool.<br />
54 The Deceptions of Rubber Gloves<br />
Do rubber gloves cause more harm than good?<br />
Dr. Ellis “Skip” Neiburger explains how illogical fear<br />
prompted obligatory glove use, a practice that was<br />
mandated for use in dental practices nationwide<br />
more than 20 years ago. Plus, why he believes we<br />
should be given the option to practice barehanded<br />
dentistry.<br />
63 Patient Product Review<br />
In our magazine’s first-ever Patient Product Review,<br />
I introduce a unique product that will grab your patients’<br />
attention: Breakfast dental floss. Get your patients<br />
excited about maintaining good dental hygiene<br />
with this bacon-pancake-coffee-flavored product.<br />
64 Chairside ® Caption Contest<br />
2<br />
www.chairsidemagazine.com
Publisher<br />
Jim <strong>Glidewell</strong>, CDT<br />
Editor-in-Chief<br />
Michael DiTolla, DDS, FAGD<br />
Managing Editors<br />
Jim Shuck<br />
Mike Cash, CDT<br />
Creative Director<br />
Rachel Pacillas<br />
Clinical Editor<br />
Michael DiTolla, DDS, FAGD<br />
Copy Editors<br />
Melissa Manna<br />
Kim Watkins<br />
Magazine Coordinators<br />
Sharon Dowd, Lindsey Lauria<br />
Graphic Designers<br />
Jamie Austin, Deb Evans, Joel Guerra,<br />
Phil Nguyen, Gary O’Connell, Rachel Pacillas<br />
Staff Photographers<br />
Sharon Dowd, Kevin Keithley<br />
Illustrators<br />
Wolfgang Friebauer, MDT, Phil Nguyen<br />
Ad Representative<br />
Lindsey Lauria<br />
(lindsey.lauria@glidewelldental.com)<br />
If you have questions, comments or complaints regarding<br />
this issue, we want to hear from you. Please e-mail us at<br />
chairside@glidewelldental.com. Your comments may be<br />
featured in an upcoming issue or on our Web site:<br />
www.chairsidemagazine.com.<br />
© 2010 <strong>Glidewell</strong> Laboratories<br />
Neither Chairside magazine nor any employees involved in its publication<br />
(“publisher”), Chairside makes Magazine any nor warranty, any employees express or involved implied, in or its assumes publica-<br />
Neither<br />
tion any liability (“publisher”), or responsibility makes any for warranty, the accuracy, express completeness, or implied, or or assumes usefulness<br />
liability of any or information, responsibility apparatus, for the accuracy, product, completeness, or process disclosed, or useful-<br />
or<br />
any<br />
ness represents of any that information, its use would apparatus, not infringe product, proprietary or process rights. disclosed, Reference or<br />
represents herein to any that specific its use would commercial not infringe products, proprietary process, rights. or services Reference by<br />
herein trade name, to any trademark, specific commercial manufacturer products, or otherwise process, does or not services necessarily<br />
constitute name, trademark, or imply its manufacturer endorsement, otherwise recommendation, does not or necessar-<br />
favoring<br />
by<br />
trade<br />
ily by constitute the publisher. or imply The its views endorsement, and opinions recommendation, of authors or expressed favoring<br />
by herein the do publisher. not necessarily The views state and or reflect opinions those of of authors the publisher expressed and<br />
herein shall not do be not used necessarily for advertising state or or reflect product those endorsement of the publisher purposes. and<br />
shall CAUTION: not be When used viewing for advertising the techniques, or product procedures, endorsement theories purposes. and materials<br />
that When are presented, viewing the you techniques, must make procedures, your own theories decisions and about ma-<br />
CAUTION:<br />
terials specific that treatment are presented, for patients you and must exercise make personal your own professional decisions about judgment<br />
regarding treatment the for need patients for further and exercise clinical personal testing professional or education judg-<br />
and<br />
specific<br />
ment your own regarding clinical the expertise need before further trying clinical to implement testing or new education procedures. and<br />
your own clinical expertise before trying to implement new procedures.<br />
Chairside is a registered trademark of <strong>Glidewell</strong> Laboratories.<br />
Chairside ® Magazine is a registered trademark of <strong>Glidewell</strong> Laboratories.<br />
Editor’s Letter<br />
Two years ago, the words social media and dentistry were<br />
rarely mentioned in the same sentence. Today, hardly a<br />
week goes by where I don’t get a flyer, e-mail or tweet<br />
about a new Social Media in Dentistry seminar. I have<br />
been involved with social media on a personal level for a<br />
couple of years, but it had nothing to do with dentistry.<br />
I use Yelp to make better decisions about which restaurant<br />
to try in a new city and to see what dishes people<br />
are raving about. One day while browsing Yelp, I noticed<br />
that somebody had written a glowing review for a local<br />
dentist, and for the first time I realized dentists were being<br />
dragged into the social media age, like it or not.<br />
It almost doesn’t matter how incredible a business is,<br />
someone is going to write a negative review. For example,<br />
Thomas Keller’s The French Laundry, often regarded as<br />
the best restaurant in the U.S., has 10 1-star reviews on<br />
Yelp! The point being, even the best of the best can have<br />
a subpar day. Perhaps the reviewer was having a bad day<br />
and it didn’t even have that much to do with the restaurant<br />
itself.<br />
The rest of the story is that The French Laundry has nearly<br />
600 5-star reviews. It is pretty clear to most people<br />
viewing the page for The French Laundry on Yelp that<br />
the majority of customers had the meal of a lifetime and<br />
a few disgruntled patrons hated the experience. People<br />
don’t stop going to The French Laundry because of those<br />
10 bad reviews, they continue to go based on the 600<br />
positive ones.<br />
Your dental office is bound to get a bad review. Maybe<br />
your front office quotes the incorrect insurance amount<br />
or your crown on tooth #9 doesn’t quite match. Invite<br />
your best patients to leave positive reviews for you and<br />
your office. Glenn Lombardi reviews how to do that in<br />
our interview on page 45. Make sure that the majority<br />
acknowledges your 5-star dentistry and 5-star service, just<br />
in case you have that inevitable bad day.<br />
Yours in quality dentistry,<br />
Dr. Michael DiTolla<br />
Editor-in-Chief, Clinical Editor<br />
mditolla@glidewelldental.com<br />
Editor’s Letter 3
Letters to the Editor<br />
“Dear Dr. DiTolla,<br />
I was planning to do a resin-retained<br />
(Maryland) bridge on a patient of mine<br />
to replace tooth #4. Tooth #3 has an<br />
occlusal amalgam and a weak MF cusp,<br />
for which I plan to do a MOF onlay preparation.<br />
Tooth #5 is virgin, so a distal<br />
rest and lingual wing are also planned.<br />
I would like to use Prismatik Clinical<br />
Zirconia or Cercon ® for this case, but<br />
I need your expertise on preparation design<br />
and material choice. I spoke to a lab<br />
technician already but want information<br />
from the head honcho. Mahalo.”<br />
- Todd R. Okazaki, DDS, Haleiwa, Hawaii<br />
Dear Todd,<br />
You have three Maryland bridge<br />
choices, none of them great as a permanent<br />
restoration.<br />
Your prep design ideas are excellent:<br />
Go with the MOF onlay prep on<br />
tooth #3 and the distal rest/lingual<br />
wing on tooth #5.<br />
Choice 1: PFM with metal wings and<br />
ceramic pontic tooth #4. The upside<br />
is you can bond to the metal with<br />
resin (alloy primer with Kuraray Panavia<br />
F); the downside is the MOF<br />
on tooth #3 is ugly if you can see it<br />
when the patient smiles.<br />
4<br />
www.chairsidemagazine.com<br />
Choice 2: Composite reinforced with<br />
fiber (Kerr Premise Indirect with<br />
Vectris ® ). The upside is that any resin<br />
cement will bond with it because it<br />
is resin; this will give you the best<br />
bond strength. The downside is that<br />
the bridge is weaker than the PFM<br />
Maryland.<br />
Choice 3: Zirconia bridge (3M <br />
ESPE Lava ). The upside is that the<br />
bridge is as strong as the PFM and<br />
better looking. The downside is you<br />
can’t bond to zirconia, even with Panavia<br />
F or Parkell C&B-Metabond ® . It<br />
might be tough to get the distal rest<br />
and the lingual wing to bond to the<br />
tooth.<br />
As you can see, there is really no right<br />
answer, per se. When my patient declines<br />
a single-tooth implant and we<br />
decide to use a Maryland bridge, I<br />
usually tell them that it is not a permanent<br />
restoration like a fixed bridge<br />
or an implant. When they agree to<br />
that concept, I will usually go with<br />
either Choice 1 or Choice 2, based<br />
on their esthetic needs and the size<br />
of their smile, thickness of their anterior<br />
teeth, so on and so forth.<br />
I have tried a zirconia Maryland<br />
bridge or two and have not had good<br />
luck. Bisco claims its new bonding<br />
agent for zirconia, Z-PRIME Plus,<br />
will bond resin to zirconia, but I<br />
haven’t seen any independent confirmation<br />
of this yet. We are currently<br />
testing it in our R&D Department at<br />
the lab to see if we can observe an<br />
increase in bond strengths.<br />
I hope that helps!<br />
- Dr. DiTolla<br />
“Dear Dr. DiTolla,<br />
Thanks for the input. I’ve decided to go<br />
with a resin-retained bridge for the following<br />
reasons:<br />
1) The patient cannot afford an implant.<br />
2) The patient is female with no evidence<br />
of parafunctional habits.<br />
3) The location of the bridge.<br />
4) Its conservative nature.<br />
I prepped the case today. Tooth #3<br />
ended up being an MOL inlay. The MF<br />
cusp appears to be strong. I was wondering,<br />
because the weak link appears<br />
to be the bond strength to zirconia, is<br />
it possible to incorporate female potholes<br />
(micro ones) into the internal surface<br />
of the zirconia so my cement (C&B-<br />
Metabond) can fill in the females and<br />
lock in the bridge mechanically? That<br />
is, use mechanical rather than adhesive<br />
retention to the zirconia. Why use Lava<br />
instead of Prismatik Clinical Zirconia or<br />
Cercon? Is it because it can be colored?<br />
My experience is that Lava is the most<br />
esthetic, but your lab tech recommended<br />
Prismatik CZ. Also, would you be<br />
able to send me a sample of Z-PRIME?<br />
By the way, it would be an honor if<br />
you used my name in your magazine<br />
– only if you send me an autographed<br />
copy, though. Thank you for sharing<br />
your great practical ideas. Mahalo.”<br />
- Todd R. Okazaki, DDS, Haleiwa, Hawaii<br />
Dear Todd,<br />
Typically the wings on a Maryland<br />
bridge are too thin to place retentive<br />
potholes.<br />
We only have one sample of Z-PRIME<br />
at the moment and it’s in the hands<br />
of R&D to test how well it works.<br />
Perhaps Bisco would be willing to<br />
send you one?<br />
I tend to use Lava as an example of a<br />
zirconia-based material because it is<br />
familiar to most dentists. Our Prismatik<br />
CZ is colored the same way.<br />
Thanks for letting us use the letter,<br />
and I promise you’ll be receiving a<br />
signed copy of the magazine! Take<br />
some great before-and-after pictures<br />
and they might find their way into<br />
Chairside, too.<br />
- Dr. DiTolla
“Dear Dr. DiTolla,<br />
I’ve been in practice since 1971. Recently,<br />
I’ve been having issues with missed<br />
mandibular blocks. At first I thought<br />
it was the anesthetic; then I started<br />
to think I was at fault. So I started researching<br />
my old anatomy books to see<br />
if my technique slipped, and I even got<br />
ahold of some CAT scans to study the<br />
anatomy again.<br />
But then the article by Dr. William Forbes<br />
showed up in Chairside and it was very<br />
enlightening! I was giving my blocks too<br />
low! The photos and diagrams were very<br />
helpful in regaining the proper technique<br />
for the mandibular block. Once I<br />
started to give them higher, I was back<br />
on track to good anesthesia. Thank you<br />
for a very educational article.”<br />
- Dennis J. Nowak, DDS, Orland Park, Ill.<br />
“Dear Dr. DiTolla,<br />
I just wanted to say thanks for the help<br />
your clinical videos have provided<br />
throughout the years. I just cemented<br />
my first BruxZir ® crown and it was<br />
sweet! The patient loved the combo of<br />
high strength and tooth-colored material.<br />
Keep up the great work!”<br />
- Ray A. Morse, DMD, Panama City, Fla.<br />
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Letters to the Editor 5
Contributors<br />
Michael C. DiTolla, DDS, FAGD<br />
Dr. Michael DiTolla is Director of Clinical Education & Research at <strong>Glidewell</strong> Laboratories in Newport<br />
Beach, Calif. Here, he performs clinical testing on new products in conjunction with the company’s R&D<br />
Department. <strong>Glidewell</strong> dental technicians have the privilege of rotating through Dr. DiTolla’s operatory<br />
and experience his commitment to excellence through his prepping and placement of their restorations.<br />
He is a CR evaluator and lectures nationwide on both restorative and cosmetic dentistry. Dr. DiTolla has<br />
several clinical programs available on DVD through <strong>Glidewell</strong> Laboratories. For more information on<br />
his articles or to receive a free copy of Dr. DiTolla’s clinical presentations, call 888-303-4221 or e-mail<br />
mditolla@glidewelldental.com.<br />
Paul Homoly, DDS, CSP<br />
Dr. Paul Homoly is a world-class leader in dental education. As a comprehensive restorative dentist<br />
and educator, Dr. Homoly has helped dentists build prosperous practices for more than 20 years.<br />
Dr. Homoly’s focus is to coach high-performance dental teams and the full spectrum of dental professionals<br />
and to advance leadership and communication in dentistry worldwide. He recently released<br />
“YES! On-Line,” an in-office DVD/online case acceptance training program for the entire dental team.<br />
For more information regarding “YES! On-Line” or specific practice questions, call 800-294-9370, visit<br />
paulhomoly.com or e-mail paul@paulhomoly.com.<br />
Glenn Lombardi<br />
Glenn Lombardi is president of Officite LLC, a leading national provider of customized Web sites, search<br />
engine marketing and social networking solutions for the dental community. Since 2002, Officite has<br />
built more than 4,200 Web sites for dentists worldwide and has delivered more than 210,000 appointment<br />
requests. Glenn is a frequent speaker at National <strong>Dental</strong> Association and state association meetings,<br />
including the Academy of General Dentistry and DC <strong>Dental</strong>. His presentations focus on professional<br />
Web site development, optimization of a Web site for search engines and how to seamlessly<br />
integrate the Internet into your practice to attract new patients and increase case acceptance. For more<br />
information about the services offered by Officite, visit officite.com or call 888-282-9751. E-mail Glenn<br />
at GLombardi@officite.com.<br />
6<br />
www.chairsidemagazine.com
Daniel J. Melker, DDS<br />
Dr. Daniel Melker graduated from Boston University School of Dentistry in 1975 with specialty training<br />
in periodontics. Since then, he has maintained a private practice in periodontics in Clearwater, Fla.<br />
Presently, Dr. Melker lectures at the University of Florida Periodontic and Prosthodontic graduate programs<br />
on the periodontic-restorative relationship and presents at UAB, UH, Baylor University and LSU.<br />
He has published several articles in national dental magazines as well as The International Journal of<br />
Periodontics & Restorative Dentistry and has twice been honored with the Florida Academy of Cosmetic<br />
Dentistry Gold Medal. Contact Dr. Melker at 727-725-0100.<br />
Ellis Neiburger, DDS<br />
Dr. Ellis “Skip” Neiburger graduated from the University of Illinois College of Dentistry in 1968. After<br />
postgraduate research in Oral Pathology and Forensic Dentistry at the U.S. Armed Forces Institute of<br />
Pathology, Dr. Neiburger pursued a career as a paleopathologist. He was curator of anthropology at<br />
the Lake County Museum for 17 years. Dr. Neiburger’s research on ancient anatomy and occlusion has<br />
taken him throughout the world, and his studies in the areas of prehistoric pathology, dental computing<br />
and clinical dentistry have been widely published. He is editor and vice president of the American<br />
Association of Forensic Dentists and has written five books on dentistry. Dr. Neiburger is a general practitioner<br />
in Waukegan, Ill., and can be contacted at 847-244-0292 or drneiburger.com.<br />
Frank Spear, DDS, MSD<br />
Dr. Frank Spear is one of the premier educators in esthetic and restorative dentistry in the world today.<br />
He earned his dental degree and an MSD in Periodontal Prosthodontics from the University of Washington.<br />
Dr. Spear is an affiliate professor in Graduate Prosthodontics at the University of Washington and<br />
maintains a private practice in Seattle limited to esthetics and fixed prosthodontics. He is also founder<br />
and director of Spear Education. Dr. Spear has received the Christensen Award for Excellence in Restorative<br />
Education, the American Academy of Cosmetic Dentistry Achievement Award, the Saul Schluger<br />
Memorial Award for Excellence in Diagnosis and Treatment Planning and the American Academy of<br />
Esthetic Dentistry President’s Award for Excellence in <strong>Dental</strong> Education. To learn more about Dr. Spear<br />
or Spear Education, visit speareducation.com or call 866-781-0072.<br />
Contributors 7
PRODUCT........ TrollFoil<br />
Dr. DiTolla’s<br />
CLINICAL TIPS<br />
CATEGORY...... Articulating Paper<br />
SOURCE.......... Troll<strong>Dental</strong><br />
New Milford, Conn.<br />
800-537-8765<br />
trolldental.com<br />
I am unsure when the last significant innovation in articulating<br />
paper took place, but I know we have come<br />
a long way since the days of typewriter ribbon and<br />
cardboard-thick paper. Troll<strong>Dental</strong> hasn’t reinvented<br />
the articulating wheel with this product, but minor<br />
improvements make TrollFoil my favorite articulating<br />
paper. First of all, it comes mounted in its own plastic<br />
frame, and one less instrument on the bracket table is<br />
fine with me. The double-sided foil is only 8 microns<br />
thick, and it has no problem marking wet surfaces,<br />
dry surfaces or highly polished surfaces, such as cast<br />
gold or BruxZir ® .<br />
Dr. DiTolla’s Clinical Tips 9
Dr. DiTolla’s<br />
CLINICAL TIPS<br />
PRODUCT........ NV MicroLaser <br />
CATEGORY...... Diode Laser<br />
SOURCE.......... Discus <strong>Dental</strong><br />
Culver City, Calif.<br />
800-422-9448<br />
discusdental.com<br />
I am happy to report that yet another one of my favorite<br />
products has gone cordless. To me, cordless is<br />
about more than convenience; many times it determines<br />
whether a dentist uses the technology or lets<br />
it collect dust, especially when it comes to using it in<br />
multiple operatories. The NV MicroLaser , manufactured<br />
by Zap Lasers and distributed by Discus <strong>Dental</strong>,<br />
is miraculously small when compared to the size of<br />
my old diode laser, which is the size of a shoebox.<br />
The NV MicroLaser weighs only 1.9 ounces and measures<br />
just 0.6 inches in the section where you hold it.<br />
Even better, the NV MicroLaser has done away with<br />
the need for a fiber-management system with the introduction<br />
of disposable cutting fibers that snap onto<br />
the laser body. With presets for all common laser procedures<br />
and a look and feel that would make Steve<br />
Jobs jealous, the NV MicroLaser would seem to be the<br />
prototype for all diodes to come.<br />
10 www.chairsidemagazine.com
Dr. DiTolla’s<br />
CLINICAL TIPS<br />
PRODUCT........ Reduction Ring<br />
CATEGORY...... Prepping Guide<br />
SOURCE.......... The Reduction Ring<br />
Englewood, Colo.<br />
888-228-8088<br />
reductionring.com<br />
As many of you probably know, I am a big fan of<br />
depth cut-based preparation techniques. In my opinion,<br />
they are a foolproof way of ensuring you get adequate<br />
reduction and thus a functional and esthetic<br />
restoration. Some dentists are too set in their ways to<br />
consider trying a new prep technique, but the fact remains<br />
that the majority of the posterior crown preps<br />
we receive at the lab are under-reduced. Enter the Reduction<br />
Ring. Unless your patients have translucent<br />
cheeks, checking occlusal reduction on a molar visually<br />
is substandard. With a 1.5 mm or 2 mm Reduction<br />
Ring, you are able to watch the ring slide between<br />
teeth to indicate if you have enough reduction on the<br />
lingual cusp of that upper first molar. The best news?<br />
No more calls from our technical advisors asking you<br />
to re-prep and re-impress!<br />
Dr. DiTolla’s Clinical Tips11
Dr. DiTolla’s<br />
CLINICAL TIPS<br />
PRODUCT........ SONICflex ® LUX 2000 L<br />
CATEGORY...... Sonic Scaler<br />
SOURCE.......... KaVo <strong>Dental</strong><br />
Charlotte, N.C.<br />
888-275-5286<br />
kavousa.com<br />
If you have been to a course by Dr. Bill Strupp you<br />
are probably quite familiar with this sonic scaler from<br />
KaVo. Bill uses 3M ESPE Durelon to cement all his<br />
temps for a number of important reasons. The two<br />
main reasons are: 1) the temps will never fall off, and<br />
2) since there is no leakage at the margin, the tissue<br />
always looks pristine two weeks later. That said, when<br />
you go to remove the temp it comes off easily, but all<br />
the Durelon is stuck to the tooth. If you try to clean<br />
it with a hand instrument, it will take approximately<br />
30 minutes to clean the prep. With the SONICflex you<br />
are finished cleaning the prep in about 15 seconds.<br />
I now use the SONICflex to clean all my preps prior<br />
to cementation. And with some of the new diamond<br />
tips available for sonic scalers, I can actually refine<br />
the margins of my crown preps and make them satin<br />
smooth with the SONICflex, as well.<br />
Waterlase YSGG is a registered trademark of BIOLASE Technology, Inc.<br />
12 www.chairsidemagazine.com
Book Review<br />
“Aesthetic &<br />
Restorative Dentistry:<br />
Material Selection<br />
& Technique”<br />
– BOOK by Douglas A. Terry, DDS; Karl F. Leinfelder, DDS, MS;<br />
Willi Geller, MDT<br />
– REVIEW by Michael DiTolla, DDS, FAGD<br />
– CLINICAL PHOTOGRAPHY by Douglas A. Terry, DDS<br />
Most of us purchased our last dental textbooks in dental school and probably rarely refer to them. I still pull out<br />
my color atlas of human anatomy and local anesthesia book from time to time, but that’s about it. For the most<br />
part, the books we studied from were boring but served their purpose: to educate. However, I have found that I’m a<br />
visual learner. I learn better through pictures, and the better the photography is, the more drawn in to the subject matter<br />
I am.<br />
Toward the end of last year, I received an e-mail about a new book being completed by Dr. Douglas Terry, Dr. Karl<br />
Leinfelder and Master <strong>Dental</strong> Technician Willi Geller. I was only familiar with Dr. Terry at the time and had actively followed<br />
his numerous published articles. Many of these articles focused on direct composites, and you could clearly see<br />
his skill and artistry. As a dentist who has focused exclusively on indirect restorations for the past 10 years, I told myself<br />
I would reprint the next article on indirect restorations that Dr. Terry wrote.<br />
Since the book arrived in mid-January, it has had its own reserved parking spot on my desk. It is 700-plus pages of<br />
some of the most accomplished photography in dentistry, and more importantly, it is downright useful. “Aesthetic &<br />
Restorative Dentistry: Material Selection & Technique” is an exhaustive work, but an absolute joy to read.<br />
Dr. Terry covers composite resins as expected, but I was surprised and delighted to see him cover such diverse topics as:<br />
principles of tooth preparation, ceramic materials, elastomeric impression materials, contemporary adhesive cements,<br />
provisionalization and periodontal plastic surgery. It is exactly the table of contents I would have come up with, because<br />
it contains all the topics that I love.<br />
A number of dental journals publish articles in which amazing dentistry is accomplished with, for example, multilayered<br />
direct composites. A patient with a fracture of an anterior tooth needs a large Class IV composite with an incisal<br />
edge involved. The dentist takes an impression, pours a study model, repairs the defect, makes a putty matrix, and then<br />
begins rebuilding the tooth. The result is absolutely gorgeous, but I don’t know a single dentist who routinely practices<br />
like this. That is why it is so refreshing to see the practical knowledge Dr. Terry has included in this book.<br />
I wanted to give you a sneak peek of the stunning visuals I am referring to, and Dr. Terry was kind enough to give<br />
us permission to reprint one such case from the book. Following is a short photo essay on utilization of the total etch<br />
technique for rebonding a fractured porcelain veneer. There have been other articles on the same topic, but none have<br />
been done with the same style and simplicity of this case. Like our dental school textbooks, this book will certainly<br />
educate you, but with a passion, clarity and detail rarely seen in dental publishing today.<br />
Book Review – Aesthetic & Restorative Dentistry: Material Selection & Technique13
Figure 1: Preoperative facial view of fractured porcelain on a maxillary left central incisor.<br />
Figure 2: The internal surface of the fractured<br />
porcelain restoration was micro-etched with<br />
silica coated aluminum oxide particles (Rocatec<br />
/CoJet System, 3M ESPE ).<br />
Figure 3: The fractured fragment was etched for two minutes with<br />
a 9 percent buffered hydrofluoric acid gel (Porcelain Etch, Ultradent<br />
Products ® , Inc.).<br />
Figure 4: Application of an MDP-containing bonding/silane coupling<br />
agent mixture (Porcelain Bond Activator mixed with Clearfil SE Bond<br />
Primer, Kuraray).<br />
14 www.chairsidemagazine.com
Figure 5: The fractured ceramic surface of<br />
the intact veneer was etched with 9 percent<br />
buffered hydrofluoric acid gel (Porcelain Etch,<br />
Ultradent Products ® , Inc.).<br />
Figure 6: The exposed tooth preparation was<br />
etched for 15 seconds with a 37.5 percent<br />
phosphoric acid (Gel Etchant, Kerr/Sybron).<br />
Figure 7: Silane was applied to the etched<br />
ceramic surface of the intact veneer and<br />
lightly air dried.<br />
Figure 8: An adhesive (All-Bond 3 , Bisco) was applied to the tooth structure and ceramic<br />
surface and lightly air dried.<br />
Figure 9: A dual-cured resin cement (Illusion<br />
, Bisco) is placed onto the internal<br />
surface of the fragment.<br />
Book Review – Aesthetic & Restorative Dentistry: Material Selection & Technique15
Figure 10: The fragment was seated and<br />
the excess resin cement was removed with<br />
a #000 sable brush. It was then polymerized<br />
from all aspects, facial, lingual, incisal and<br />
proximal, for 60 seconds, respectively.<br />
Figure 11: The final post-operative result reflects harmonious integration of form, color and<br />
texture that can be achived from the reattachment of a fractured porcelain veneer restoration.<br />
Purchase “Aesthetic & Restorative Dentistry: Material<br />
Selection & Technique” at quintpub.com or amazon<br />
.com. For an autographed copy of the book, log on to<br />
everestpublishingmedia.net. CM<br />
Contact the author, Dr. Douglas Terry, at 281-481-3470, dentalinstitute.com or<br />
dterry@dentalinsititue.com.<br />
Reference<br />
Aesthetic & Restorative Dentistry: Material Selection & Technique. Douglas Terry,<br />
Karl Leinfelder and Willi Geller. Everest Publishing Media, Stillwater, Minn., 2009.<br />
16 www.chairsidemagazine.com
Too<br />
Much<br />
Tooth,<br />
Not<br />
Enough<br />
Tooth<br />
Making Decisions About<br />
Anterior Tooth Position<br />
– ARTICLE and CLINICAL PHOTOS by Frank Spear, DDS, MSD<br />
The restoration or creation of an esthetic smile is always the result of focused observation, thoughtful<br />
evaluation, and a systematic approach to planning and sequencing treatment. Restorative and<br />
esthetic dentistry approached through this process will incorporate the five critical elements that contribute<br />
to the beauty of a natural smile and result in a successful outcome for both patient and dentist.<br />
These five essential considerations are tooth position, gingival levels, arrangement, contour and color.<br />
Although each of these is important in the final result, the first step is the most important – and in<br />
the esthetic process, the starting point for tooth position always is the incisal edge of the maxillary<br />
central incisor. 1,2 As in denture prosthetics, this step is critical not only in the esthetic plan, but also in<br />
developing the functional treatment plan – because it determines the appropriate positions of all the<br />
maxillary teeth and subsequently, beginning with the lower incisors, determines the positions of the<br />
mandibular teeth.<br />
18 www.chairsidemagazine.com
Lip mobility as a factor in tooth display<br />
Figure 1a: Average amount of<br />
central incisor display in a 30- to<br />
40-year-old woman with correctly<br />
erupted central incisors.<br />
Figure 1b: High lip mobility of more<br />
than 10 mm combined with a resting<br />
display of 3 mm.<br />
In this article, I review the elements used in determining the correct position of the incisal edge of<br />
the maxillary central incisor, step No. 1 in the diagnostic and treatment planning sequence called<br />
Esthetics—Function—Structure—Biology, used in the Spear Education program. The practitioner must<br />
evaluate three aspects to ensure correct placement of that edge, and I will describe them here.<br />
■ The Elements Of Determining Incisal Edge Placement<br />
The three factors the dentist must evaluate for correct placement of the maxillary<br />
central incisor’s incisal edge are tooth display and lip mobility; the position of the<br />
incisal edge relative to the position of the other teeth in the maxillary arch; and<br />
phonetic considerations.<br />
Tooth display and lip mobility. The first consideration is a combination of two<br />
elements: the amount of tooth displayed at rest and lip mobility. Lip mobility is the<br />
amount of lip movement that occurs as the patient smiles. 3 The majority of observers<br />
will select as an ideal esthetic smile one that displays the full central incisor<br />
and includes a slight amount of gingiva apical to the tooth. 4 The amount of tooth<br />
that shows at rest will vary depending on the amount of lip movement during the<br />
smile. As an example, if the patient’s central incisor is 10.5 mm long (an average<br />
length) and the lip moves 6 mm from rest to full smile, assuming a display of the<br />
gingival margin during full smile, 4.5 mm of tooth will be displayed at rest. If the<br />
same patient’s lip is less mobile, moving only 4 mm from rest to full smile, 6.5 mm<br />
of tooth will be displayed at rest to achieve the same esthetics. Conversely, if the<br />
patient has a highly mobile lip, with 10 mm of movement, only 0.5 mm of tooth<br />
will display at rest to meet the esthetic requirements of an ideal smile.<br />
“As a general rule in<br />
my practice, with the<br />
patient’s lip at rest,<br />
I always ensure that<br />
at least the edges<br />
of both central<br />
incisors are visible<br />
so that the patient<br />
does not appear<br />
to be edentulous.”<br />
The preceding example illustrates clearly that placement of the incisal edge will be influenced dramatically<br />
by the patient’s level of lip mobility and the desired appearance of the smile regarding tooth<br />
exposure and gingival display (Fig. 1a,1b). As a general rule, the more mobile the lip, the less tooth that<br />
can be displayed with the lip at rest to create a pleasing smile; the less mobile the lip, the more tooth<br />
Too Much Tooth, Not Enough Tooth: Making Decisions About Anterior Tooth Position 19
Creating suitable incisal edge position in a patient with extreme wear<br />
Figure 2a: Patient’s upper lip at<br />
rest. No tooth is visible. This patient<br />
is 50 years old and would typically<br />
display 1 mm of tooth at rest.<br />
Figure 2b: Measurement is aimed at<br />
determining how many millimeters<br />
to add to the patient’s central incisors<br />
to achieve a normal amount of<br />
tooth display for his age.<br />
Figure 2c: Provisional restorations<br />
are placed to give the patient 0.5 to<br />
1 mm of tooth display.<br />
display at rest that will be necessary to create a pleasing, full smile. In 1978, Vig and Brundo 5 examined<br />
a sample of women and determined the following averages for tooth display at rest according to age:<br />
• Age 30, 3 mm to 3.5 mm<br />
• Age 50, 1 mm to 1.5 mm<br />
• Age 70, 0 mm to 0.5 mm.<br />
According to Vig and Brundo’s study, this change in display is less the result of tooth position than of<br />
changes in the facial tissues relative to the skeletal base. I find this information especially useful with<br />
patients who believe their teeth are too short. To begin, I evaluate how much tooth they display with<br />
the upper lip at rest. I then ask the patient to smile, and I note the amount of lip movement. If I know<br />
the amount of tooth display desired with the patient’s full smile, the patient’s lip mobility combined<br />
with the average length of a central incisor helps me determine where to begin in testing placement of<br />
the incisal edge. This is an especially useful technique with patients who exhibit extreme dental wear.<br />
Often, these patients display no tooth with the lip at rest (Fig. 2a). Using Vig and Brundo’s 5 averages, I<br />
can approximate display at rest on the basis of the patient’s age and know how much to lengthen the<br />
central incisors to create an average tooth display with the lip at rest (Fig. 2b). I then can try this incisal<br />
edge position as either a composite mock-up or a provisional restoration (Fig. 2c). By asking the patient<br />
to smile fully, I can evaluate the smile and use this observation to refine the edge position. Whenever<br />
the practitioner is lengthening the incisal edge, he or she must evaluate “f” and “v” sounds and modify<br />
tooth shape and position for acceptability (see section on phonetics below).<br />
The ultimate position of the incisal edge for patients with extreme tooth wear is a combination of tooth<br />
display at rest, lip mobility, age and functional consideration based on what the occlusion will tolerate.<br />
Vig and Brundo’s 5 averages of tooth display at rest are simply useful starting points from which to make<br />
refinements to arrive at the most appropriate position for each patient. As a general rule in my practice,<br />
with the patient’s lip at rest, I always ensure that at least the edges of both central incisors are visible<br />
so that the patient does not appear to be edentulous.<br />
Position relative to other maxillary teeth. The second consideration in establishing the correct maxillary<br />
incisor position is evaluation of the incisal edge relative to the other teeth in the maxillary arch. 6,7<br />
20 www.chairsidemagazine.com
Figure 3: Note the pleasing symmetry<br />
of the central incisors, canines<br />
and posterior teeth when they all<br />
are on the same plane.<br />
Figure 4: The classic reverse smile<br />
line caused by the central incisors<br />
being apical to the plane of the<br />
posterior teeth.<br />
In a normal Class I occlusion, the incisal edge of the central incisor will be on approximately the same<br />
plane as the tips of the canines and the buccal cusp tips of the premolars and molars. When this arrangement<br />
exists, the maxillary central incisal edge position is esthetically pleasing, and the smile line<br />
exhibits symmetry with the lower lip (Fig. 3). 9<br />
When the maxillary central incisal edge is coronal to the plane of the posterior<br />
teeth, it is caused most commonly by overeruption of the teeth as a result of<br />
Class II malocclusion or of restorative dentistry completed without consideration<br />
of edge position. The teeth appear too prominent in the face, and the smile line<br />
exhibits an exaggerated curvature. Bringing the edges apically to the plane level<br />
with the posterior teeth is an excellent starting point when correcting front teeth<br />
that appear too long. After the anterior teeth are placed on the same plane as the<br />
posterior teeth, either through orthodontics or provisional restorations, the practitioner<br />
then can refine the position for the most pleasing appearance. 7,8<br />
When the maxillary central incisal edge is apical to the plane of the posterior<br />
teeth, it creates a reverse smile line (Fig. 4). Common causes of this are undereruption<br />
resulting from a Class III malocclusion, ankylosis caused by trauma or a<br />
patient’s habit (such as tongue thrusting and thumb sucking). Perhaps the most<br />
common cause of this tooth position, however, is wear of the anterior teeth resulting<br />
from a protrusive bruxing habit or chemical erosion while the posterior teeth<br />
sustain minimal wear.<br />
Placing the maxillary central incisor’s incisal edge visually on the plane of the posterior<br />
teeth, either orthodontically or restoratively, will resolve most of the esthetic<br />
problems and create a position from which the dentist then can make refinements.<br />
Although this is a useful method of starting to position central incisal edges, it cannot<br />
always be used. When posterior teeth are missing, worn away, overerupted or<br />
improperly restored, one must use the first and third considerations alone.<br />
Phonetics. The third consideration in appropriately positioning the maxillary<br />
incisal edge is phonetics, specifically the “f” and “v” sounds, as described<br />
in classic prosthodontic texts. 9-11 Most technique discussions men-<br />
“Given the importance<br />
of esthetic success<br />
in practice today,<br />
and the fact that every<br />
facet of treatment<br />
is affected when a<br />
dentist decides to<br />
change a patient’s<br />
incisal edge position,<br />
it is critical that<br />
dentists learn, become<br />
comfortable<br />
with and use these<br />
techniques when<br />
evaluating patients.”<br />
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<br />
“s” sound is the result of the interaction between the maxillary and mandibular incisors. 12 In the<br />
Esthetics—Function—Structure—Biology treatment planning protocol, we first position the maxillary<br />
incisors to the ideal esthetic position and then modify the mandibular incisors and the lingual aspect<br />
of the maxillary incisors to correct the “s” sound, the final position and shape being determined<br />
by the movement of the mandible during speech. Enunciation of “f” and “v” sounds creates light<br />
contact of the central incisors with the “wet-dry” line of the lower lip. Dimpling or trapping of the<br />
lower lip signals that the contact impingement by the teeth is too great and indicates teeth that are too<br />
long and must be shortened. One difficulty in using “f” and “v” sounds to evaluate length and position<br />
is that they can tell the dentist reliably whether the teeth are too long, but they do not offer much<br />
insight into whether the teeth are too short. Even when the maxillary central incisors are severely worn,<br />
formation of “f” and “v” sounds will look correct because speech is so adaptable to shortening of the<br />
maxillary incisors. Because restorative dentistry usually is involved in lengthening maxillary<br />
central incisors, using phonetics is an excellent consideration in determining whether teeth have been<br />
lengthened too much.<br />
■ Conclusion<br />
The focus of this article is the esthetic considerations of the maxillary central incisal edge as part of<br />
the Esthetics—Function—Structure—Biology process of diagnosis. Clinicians should recognize that all<br />
changes made to the position of the maxillary central incisor must address the functional etiology that<br />
placed the central incisor in a position other than one that creates the ideal smile. They also must understand<br />
clearly how the functional component, the occlusion, must be altered to produce a predictable<br />
result with the new incisal edge position.<br />
In this article, I have presented three considerations in evaluation and positioning of the maxillary central<br />
incisal edge. Given the importance of esthetic success in practice today, and the fact that every facet<br />
of treatment is affected when a dentist decides to change a patient’s incisal edge position, it is critical<br />
that dentists learn, become comfortable with and use these techniques when evaluating patients. CM<br />
Dr. Frank Spear is founder and director of Spear Education. To learn about Dr. Spear or Spear Education, visit speareducation.com or call 866-<br />
781-0072.<br />
DISCLOSURE: Dr. Spear did not report any disclosures. The views expressed are those of the author and do not necessarily reflect the opinions<br />
or official policies of the American <strong>Dental</strong> Association.<br />
■ References<br />
1. Boucher CO, Hickey JC, Zarb GA, eds. Prosthodontic Treatment for Edentulous Patients. 7th ed. St. Louis: Mosby; 1975:224.<br />
2. Sharry JJ. Complete Denture Prosthodontics. 3rd ed. New York City: McGraw-Hill;1974:234.<br />
3. Martore AL. Anatomy of facial expression and its prosthodontic significance. J Prosthet Dent 1962;12(6):1020-1042.<br />
4. Tjan Ah, Miller GD, The JG. Some esthetic factors in a smile. J Prosthet Dent 1984;51(1):24-28.<br />
5. Vig RG, Brundo GC. The kinetics of anterior tooth display. J Prosthet Dent 1978;39(5):502-504.<br />
6. Frush JP, Fisher RD. The dynesthetic interpretation of the dentogenic concept. J Prosthet Dent 1958;8(4):558-581.<br />
7. Lombardi RE. The principles of visual perception and their clinical application to denture esthetics. J Prosthet Dent 1973;29(4):358-382.<br />
8. Lombardi RE. A method for the classification of errors in dental esthetics. J Prosthet Dent 1974;32(5):501-513.<br />
9. Pound E. Esthetic dentures and their phonetic values. J Prosthet Dent 1951;1(1-2):98-111.<br />
10. Watt DM. Tooth positions on complete dentures. J Dent 1978;6(2):147-160.<br />
11. Pound E. Recapturing esthetic tooth position in the edentulous patient. JADA 1957;55(2):181-191.<br />
12. Rothman R. Phonetic considerations in denture prosthetics. J Prosthet Dent 1961;11(2):215-223.<br />
Reprinted with permission from the American <strong>Dental</strong> Association (ADA): Spear FS. Too much tooth, not enough tooth: making decisions about<br />
anterior tooth position. JADA 2010;141(1):93-96. Copyright ©2010 American <strong>Dental</strong> Association. All rights reserved. The American <strong>Dental</strong> Association<br />
makes no representation and accepts no responsibility for the accuracy, timeliness or comprehensiveness of the cover image.<br />
22 www.chairsidemagazine.com
– INTERVIEW of Paul Homoly, DDS, CSP<br />
by Michael DiTolla, DDS, FAGD<br />
I finally had the opportunity to sit down and<br />
talk with Dr. Paul Homoly about a topic that<br />
should be of interest to most dentists: profitability<br />
on typical crown & bridge cases.<br />
Most dentists have spent a fair amount of<br />
time thinking about their single-unit crown<br />
fee, and almost by default. It is probably<br />
one of the more productive procedures<br />
in our offices. But have you always assumed<br />
that productivity is linear for larger<br />
crown & bridge cases? If so, read on<br />
for some eye-opening perspectives. To<br />
watch video footage of this interview,<br />
visit chairsidemagazine.com.<br />
24 www.chairsidemagazine.com
Interview with Dr. Paul Homoly<br />
25<br />
Interview with Dr. Paul Homoly
Dr. Michael DiTolla: Paul, it’s nice to have<br />
you back at <strong>Glidewell</strong>. This is the first inperson<br />
Chairside ® interview that we’ve had<br />
the opportunity to do together. Usually for the<br />
magazine, we interview people over the phone.<br />
It’s really nice to have you live in the studio,<br />
to be here together and to look at charts<br />
and information together. We’ve had fantastic<br />
response from your previous Chairside<br />
articles, and I’m really excited about what<br />
we’re going to talk about today. I know this<br />
is something that I struggled with when I<br />
was in private practice, and it’s a topic that<br />
dentists don’t spend enough time thinking<br />
about – it’s almost like a dirty word. And that<br />
dirty word is “fees.” This has to do with profitability<br />
and whether we’re ethical and whether<br />
we should be giving our services away. It’s<br />
scary for me to think that there are dentists who<br />
go through all this college, all this dental<br />
school and then take a big risk – $750,000<br />
on a practice and staff it and practice for<br />
30 years with the best intention to practice<br />
the best dentistry – but then never really<br />
give much thought to the fees, just kind of inherit<br />
the fee schedule from the dentist whom he or<br />
she bought the practice. Thirty years later this<br />
dentist discovers that because his or her fees<br />
were set at the wrong place, after dedicating<br />
his or her entire life to helping patients, there’s<br />
nothing to show for it. Is this a scenario you<br />
commonly see?<br />
Dr. Paul Homoly: Yes, absolutely. Or the dentist<br />
reads a magazine that says, you should<br />
be charging $830 for a crown, so that’s where<br />
he or she sets the crown fee. Talking about<br />
money in dentistry is always dangerous because<br />
money isn’t really part of our culture.<br />
When you think about it, how much did<br />
we study money when we were in dental<br />
school? And how often is money discussed<br />
from the main podiums in front of large audiences?<br />
Typically the biggest groups and<br />
the biggest draws in dentistry have to do<br />
with pursuing clinical excellence. And the<br />
money is kind of like the dirty little secret<br />
behind it. But ask yourself this, Mike: How<br />
much excellence can a dentist produce if<br />
he or she is not profitable? How long can<br />
this dentist retain great staff members if he<br />
or she’s not able to pay competitive wages?<br />
What quality of dental laboratory must a<br />
dentist use if he or she can’t afford premium<br />
lab fees?<br />
Money and profitability are almost an antecedent to clinical<br />
quality because the dentists who are most profitable<br />
are the same dentists who can afford good equipment,<br />
take time off for rejuvenation, use the best labs and pay<br />
the best salaries. So, for us to talk about fees – that’s really<br />
the first domino that must fall. Every dentist needs to be<br />
really smart about setting his or her fees. And without that<br />
wisdom, dentists won’t prosper.<br />
Hufford Financial Advisors (huffordfinancial.com) partnered<br />
with Indiana University and the AGD in 2007, and<br />
together they surveyed 1,630 AGD dentists. When the surveys<br />
came back, Mike, 70 percent of AGD dentists were<br />
unable to retire and less than 10 percent expressed confidence<br />
in their investment decisions. Money isn’t a part of<br />
our culture. I encourage you to contact Hufford Financial<br />
Advisors to request a copy of the Financial Preparedness<br />
Study for Dentists.<br />
MD: And the AGD is a totally voluntary organization, you<br />
don’t have to join. You get AGD credits, which count for, in a<br />
real sense, nothing. It’s kind of a bonus above and beyond,<br />
it goes toward your state credits. But to pursue fellowship in<br />
that academy, like I did, is really just about trying to do the<br />
right thing and being a constant student of dentistry.<br />
PH: Becoming a better dentist.<br />
MD: Wow, and AGD dentists are very focused on clinical<br />
quality. I think organized dentistry plays a small role in this;<br />
granted, we didn’t learn much about money in dental school,<br />
nor were we ready – we needed to learn how to control a<br />
handpiece and not kill someone. But even after graduation,<br />
I noticed that I received continuing education credit every<br />
time it was a clinical course. But God forbid I go to a practice<br />
management course where zero hours were offered. What<br />
message does that send to the dentist, when you literally don’t<br />
get any credit for learning how to run your practice?<br />
PH: The message is that it’s not important or it’s wrong<br />
to learn.<br />
MD: It’s wrong to learn.<br />
PH: So let’s talk about fees. A typical dentist goes into practice,<br />
reads a practice management article and looks at a fee<br />
schedule. So you’ve got a whole list of numbers. You’ve got<br />
the ADA code, you’ve got the procedure itself and you’ve<br />
got a fee. And that fee schedule makes a lot of sense when<br />
you’re only doing one tooth at a time. So let’s say your<br />
crown fee is $800. You’re doing one crown. How much<br />
time, judgment, risk and skill go into doing one posterior<br />
unit, Mike?<br />
MD: That’s pretty simple and straightforward. It’s not a<br />
buccal pit amalgam; it’s more difficult than that. But in the<br />
26 www.chairsidemagazine.com
grand scheme of things, that single-unit crown is pretty basic.<br />
That’s something we do every day.<br />
PH: It’s pretty basic. And if you look at the most common<br />
procedures a dentist performs, typically there are 10<br />
to 12 procedures they’ll do 80 to 90 percent of the time.<br />
Most of the time, those procedures are done one tooth<br />
at a time. In these instances, working off a fee schedule<br />
makes sense. Now, Mike, tell me this: If you were to do<br />
two crowns, let’s say in the same quadrant, one right next<br />
to the other – does doing two crowns take you twice as<br />
long as doing that one crown?<br />
MD: No, because I can anesthetize them both at the same<br />
time, I can break contacts on both of them at the same time<br />
with a bigger bur. Making the temporaries, they’re going to be<br />
connected, so there’s just a little bit of bisacryl material.<br />
PH: Take the impression at the same time. Take the bite<br />
at the same time.<br />
MD: That’s all going to be at the same time, as well, as opposed<br />
to if they were in two separate quadrants. So, it’s not<br />
twice as difficult – maybe 1.3 times more difficult.<br />
PH: What if there were three crowns in the same quadrant?<br />
Does the same apply?<br />
MD: Yes, it would not take three times as much time to do<br />
three crowns, but it would be slightly more difficult.<br />
PH: It would be slightly more difficult. I think the fee<br />
schedule, Mike, makes sense up to those 3 units per quadrant.<br />
If my fee for a crown is $800 and I do two crowns,<br />
it’s $800 times two. If I do three crowns, it’s $800 times<br />
three. That makes perfect sense.<br />
Now, let’s jump to complex-care dentistry, Mike. Let’s say<br />
you’re doing 12 crowns. If you’re doing 12 crowns, chances<br />
are real strong that you’re going to change the plane<br />
of occlusion. If you’re doing 12 crowns, chances are really<br />
good that you’re going to change the anterior guidance,<br />
there may be vertical dimension involved, certainly changing<br />
condylar position. Of the anterior guidance, vertical<br />
dimension, plane of occlusion, condylar position, you’re<br />
changing three or maybe even four of those variables.<br />
MD: Whether you want to or not!<br />
PH: Whether you intend to or not (laughter). Now,<br />
let’s say you’re charging $800 per unit and you look at<br />
your 12 units. How much sense does it make to take<br />
your $800 per unit fee and multiply it by 12 for this kind<br />
of complex-care case? How much more complexity is<br />
there in the 12-unit case as opposed to 12 crowns done<br />
one at a time?<br />
MD: It’s huge! It’s a much bigger difference.<br />
There is a much higher degree of difficulty in<br />
pulling off that 12-unit case, not to have the<br />
patient lisp afterward, be able to function<br />
well with those teeth without breaking them<br />
off in the anterior. There are a lot of factors<br />
involved. But as a dentist, you would tend to<br />
think: Well, if I did 12 single-unit crowns on<br />
12 different people, that’s a lot of work! This<br />
12-unit case is going to be great, I can do<br />
it all on one person at one time. But it fails<br />
to take into account all the systems that<br />
you’re changing and the degree of difficulty<br />
with successfully completing a big restorative<br />
case like this.<br />
PH: Sure, it’s not only the degree of difficulty<br />
in terms of what you know to be true about<br />
occlusion, but it’s also the degree of difficulty<br />
relative to your planning. How much<br />
planning, preoperative planning, are you to<br />
do, Mike, for 2 units in the same quadrant?<br />
How much planning do you do for a case<br />
like this?<br />
MD: None. You get them in the hygiene room<br />
before they go home that day and prep it.<br />
PH: You put them in the chair, you can see<br />
the end result and you prep the case. Now,<br />
let’s say you were going to prep me for 12<br />
units and you were going to change those<br />
four variables. How much planning would<br />
you have to do? How much time would you<br />
have to put into that case?<br />
MD: Hopefully I’m going to put in a couple of<br />
hours ahead of time and get some lab-fabricated<br />
provisionals, which will add some expense, a<br />
Diagnostic Wax-Up. The patient’s expectations<br />
are going to be higher.<br />
PH: You’ll be shooting photographs. You’re<br />
going to be taking models. Your team’s going<br />
to be pouring and mounting those models.<br />
You’ll be talking to the lab. What if the<br />
patient has gum issues or bone issues or<br />
missing teeth and needs implants? Now you<br />
have to get on the phone and call your specialist.<br />
How much time does that take, you<br />
playing phone tag back and forth? Sending<br />
the models back and forth? So there’s a<br />
huge additional component of time involved<br />
in these cases that doesn’t appear on your<br />
fee schedule. Know what’s not on our fee<br />
schedule, Mike? We get all these ADA codes,<br />
Interview with Dr. Paul Homoly27
ut you know what there’s not an ADA code<br />
for? Wisdom. We don’t charge patients for<br />
our wisdom.<br />
On the flight from Charlotte to Orange<br />
County, I was reading the recent AACD<br />
journal accreditation cases. What magnificent<br />
dentistry is being done within that<br />
organization. I just love looking at those<br />
cases. But what I’d be really curious to find<br />
out is, how much profit are they generating?<br />
I wonder how much profit there is<br />
considering the amount of time they’re<br />
spending on incisal edge matrixes and reduction<br />
guides and customized incisal guide<br />
tables and custom shading.<br />
MD: And that’s one of my pet peeves in journals,<br />
as well. They will show a direct composite,<br />
where they’re rebuilding a mesial incisal<br />
angle and a lot of the facial on an anterior<br />
tooth, and they’ll do a model, a Diagnostic<br />
Wax-Up and then a putty matrix of it to help<br />
build up the lingual of the composite. And<br />
I’m looking at all this stuff going, “This is<br />
insane! You’ve got to charge $1,000 for this<br />
composite to be able to do it like this,” which is<br />
fine if you can get it. But you’re right. I think<br />
the average dentist who looks at it and tries<br />
it would lose a lot of money, because we’re<br />
just charging this straightforward fee without<br />
any wisdom built into it.<br />
PH: At the heart of advanced restorative<br />
dentistry is wisdom. What have we learned<br />
from the previous cases? For example, take<br />
the profession of law. You walk into a law<br />
firm and there are 50 attorneys. You’ve got<br />
the old ones and the young ones. Now,<br />
whose hourly fee is going to be the highest<br />
and why?<br />
MD: You would think that those who have<br />
been there the longest would be the highest<br />
paid because they have seen the most cases.<br />
Especially if your case is a little bit more<br />
difficult, they might go, “You know, I tried<br />
something like this 14 years ago and read<br />
about it. Here’s what we need to do.” A young<br />
attorney might not have that experience<br />
or wisdom.<br />
PH: Yes, so you’re paying lawyers a premium<br />
fee for their wisdom. Patient comes<br />
to you with a severe overbite, jaws clicking,<br />
periodontal problems, muscular problems and phonetic<br />
problems. That’s a difficult case. There’s a lot of risk<br />
there. A case like that requires a lot of wisdom. And really,<br />
I think the point of this article is or where I’d like<br />
to go is, how does a dentist take what they’re doing now<br />
and begin to assess: What’s the risk? How much wisdom<br />
do I need to apply? But do it in a practical way so<br />
you’re not guessing what your fees need to be. There’s<br />
a more objective way of looking at what the fee needs<br />
to be when you really understand your fee based on<br />
time, skill, risk, remake or change in patient medical<br />
history. Patient medical history is a real big one, Mike.<br />
Most rehabs are going to occur in a patient’s fifth or<br />
sixth decade of life. They’re going to be in their 50s or<br />
60s. How many of these folks are still employed? So let’s<br />
say you’re going to do a big case, a $12,000 to $15,000<br />
case. Even by today’s fees, sometimes it costs as much<br />
as $10,000 per quadrant depending on if you’re doing<br />
sinus elevations, bone grafts, implants, progressive loading,<br />
multiple units. If you take a high-fee case, a $20,000<br />
case, on a person who’s in their late 50s or early 60s,<br />
that person is typically still in their income-producing<br />
years. And they’re kind of at the peak of their earning<br />
power. Now, you have a case that’s supported by posterior<br />
implants and fixed bridgework. The anterior teeth are<br />
all porcelain in the anterior guidance. What’s the probability<br />
that you’re going to have a problem somewhere in<br />
that case 10 to 15 years down the line, Mike? What’s the<br />
probability?<br />
MD: Off the top of my head ... maybe 85 percent?<br />
PH: I’d say 100 percent (laughter).<br />
MD: Well, I was putting a few weak-muscled patients in<br />
there, patients who won’t be able to chew anymore.<br />
PH: The patient’s medical history changes. So, one thing<br />
we don’t recognize as we read the journal articles is what<br />
the case will look like 20 years from now. Show me that<br />
case when the patient’s sugar level is 250 and spinning<br />
out of control. Show me that case when the patient loses<br />
partial control of their hand or their eyesight starts to go<br />
and they aren’t able to clean their mouth.<br />
MD: Or Sjogren syndrome patients, who run out of saliva<br />
and the teeth just deteriorate from underneath it.<br />
PH: Or from all the medication they take. The difference<br />
now is that the patient is retired and they’re living<br />
off their retirement income. Now the case has a problem.<br />
Now you’re going to have to assign a fee. The fee<br />
to the patient now feels much greater than it did during<br />
their income-producing years. The point I’m making<br />
here is, when you initially do the case you cannot take<br />
shortcuts. If there’s a question between doing 2 units or<br />
28 www.chairsidemagazine.com
3 units of implant to support a bridge, use three. Will it<br />
be more difficult to sell the case with three implants?<br />
Yes, it will. But if you do not engineer the case for the<br />
lifetime of the patient, when they do have failures and<br />
remakes in their retirement years, you are going to have a<br />
huge management headache. Second point about fees is<br />
that, if you’re not doing many complex-care cases<br />
– let’s say you’re doing one or two or three a year,<br />
Mike – that’s what I call a hobby. It’s like the old guy<br />
that sits with the beret at the state fair building<br />
with the ship in a bottle. He loves it because he<br />
loves doing it, not finishing it.<br />
400<br />
MD: But dentists want to chase the big cases, right? They<br />
go, they take courses: “If I get just one big case per<br />
month, it will pay the bills.” Really, in terms of profit,<br />
what you’re saying is, for a 12-unit case, where you’re<br />
almost doing that full maxillary arch, the dentist would actually<br />
be better off doing four 3-unit bridges on four different<br />
patients in terms of profit than one 12-unit<br />
case on a single patient?<br />
PH: Absolutely. Because you can do four<br />
3-unit bridges without having to spend<br />
the time and planning that you do with<br />
Profit per Hour<br />
MD: Isn’t that like somebody who goes golfing just<br />
three times a year? They go out there but they’re terrible<br />
at it. Can you be good at something you do three<br />
times a year?<br />
PH: You can’t be good, you can’t be fast, but you<br />
can still enjoy it. So, it doesn’t make any difference<br />
what you charge for a case like that. Enjoy it, have<br />
fun with it. But I think for the majority of us doing<br />
complex-care dentistry and trying to make a living<br />
at it, if we’re doing one or two cases a month<br />
or one or two cases a week, the importance of<br />
setting the right fee becomes especially important.<br />
Without the right fee, what will happen with<br />
complex-care cases? Your gross will go incredibly<br />
high but your net will begin to dip. You’ll feel like<br />
hell, you’ll feel more stressed, and the overall quality<br />
of your practice and other cases will begin to suffer, too.<br />
The big cases will pull the rest of the practice down.<br />
MD: How confusing must that be for a dentist to see the gross<br />
go up, be high-fiving people: “We had a great production day!<br />
Woo hoo!” And then the net goes down so far it becomes depressing.<br />
PH: That was me. My first 10 years in practice, I pursued<br />
quality. I was like a sled dog chasing a rabbit. I was on<br />
a quest for quality. Yet our gross was incredibly high. I<br />
think my practice at one time was in the top half-percent<br />
of solo practitioners’ productions. But my net, hell, I was<br />
embarrassed to talk about it. I was doing these big implant<br />
cases, but to tell you the truth I was secretly praying<br />
for a couple of simple 3-unit bridges to walk in so I could<br />
pay my bills. And you know what? That’s another dirty<br />
little secret – these big cases often don’t yield the profit<br />
that they really need to.<br />
300<br />
200<br />
100<br />
Tooth<br />
Dentistry<br />
Figure 1<br />
Centric Relation<br />
Dentistry<br />
Rehabilitative<br />
Dentistry<br />
one 12-unit case. You don’t need to think<br />
about it that much. You know, ultimately<br />
where this conversation is going to lead<br />
is that when you’ve got six or more units<br />
and you do the cases right, Mike – I’m talking<br />
about preoperative photos, preoperative<br />
study models, incisal edge matrixes, customized<br />
provisional temporaries, using<br />
temporaries as diagnostic tools, putting in<br />
nightguards, corrected equilibrations and<br />
follow-ups. When you do the case well, my<br />
studies have shown that typically you’re<br />
going to need to add 40 percent more<br />
to the fee over your fee schedule. So, if<br />
you’re $1,000 per unit and you’re doing 6<br />
units, in order for those numbers to work<br />
out well for you, you’re going to need to<br />
add 40 percent to that fee. And if you’re<br />
12 units or more, Mike, in order for those<br />
units to work out well, you’re going to<br />
need to add 70 percent to your fees<br />
in order for that case to be profitable.<br />
MD: Wow. And you’re talking about fees that<br />
are already in place for 1-, 2- and 3-unit crown<br />
Interview with Dr. Paul Homoly29
400<br />
300<br />
200<br />
100<br />
& bridge? This isn’t somebody who hasn’t raised<br />
his or her fees for eight or nine years and has<br />
an artificially low crown fee; this is somebody<br />
who has their crown fee in place for the 1- and<br />
2-unit cases. They still need to add more than<br />
70 percent for a 12-unit or more case?<br />
PH: Right, because dentists must consider<br />
the time invested. It takes time to get study<br />
models. It takes time to pour the models.<br />
How much time is spent on a good Diagnostic<br />
Wax-Up? You learn how to rehabilitate a<br />
case while you do the wax-up, not as you’re<br />
prepping the teeth. That’s where the wisdom<br />
is manifested. You don’t need to do that with<br />
simpler unit cases. How many dentists spend<br />
hours and hours at their office after business<br />
hours waxing-up cases, trimming dies, looking<br />
through microscopes, and going through<br />
trial equilibrations without charging the patient<br />
for it? That’s unsustainable behavior.<br />
And that’s not something you see or hear in<br />
the journals – people don’t talk about it.<br />
Tooth<br />
Dentistry<br />
Figure 2<br />
Profit per Hour<br />
275<br />
2 crowns<br />
177<br />
1 crown<br />
163<br />
Composite<br />
326<br />
3 crowns<br />
Centric Relation<br />
Dentistry<br />
Rehabilitative<br />
Dentistry<br />
PH: I can’t even address that situation because if you’re<br />
doing big cases and you’re not doing the right wax-up,<br />
you’re not doing the right temporaries, you’re just slamming<br />
stuff in and hoping people will get used to it, then<br />
you’re going to end up with skinny kids, number one.<br />
The probability is going to come back to eat you. Number<br />
two: You’re going to end up moving several times in your<br />
career because people are going to come back mad and<br />
you’re going to end up with a remake legacy that you’re<br />
not going to be able to deal with.<br />
MD: So plan on taking state boards in several different areas,<br />
is what you’re saying. That’s a good plan.<br />
PH: Let’s look at it from a standpoint of some illustrations.<br />
Figure 1 (page 29) shows the complexity of care all the<br />
way from the left, which is tooth dentistry, all the way to<br />
the right, which is rehabilitative dentistry.<br />
The vertical column represents that fee per hour and consists<br />
of the patient fee minus the lab fee minus office<br />
overhead, divided by time.<br />
Typically when we’re in the tooth realm of 1, 2 or 3 units,<br />
the level of profit is fairly modest, but it escalates. The<br />
common belief in dentistry is, as I do 8, 10,<br />
20 units, this profit yield should continue on a<br />
straight line. That’s the belief.<br />
Now, when you actually put the numbers to it,<br />
it looks like this: Single posterior composite fee,<br />
$163; posterior ceramo metal unit with a profit<br />
of $177. If you do 2 units in the same quadrant,<br />
as you were saying earlier, Mike, you can get<br />
it done in not twice the time but probably 1.3<br />
units of time. So the profit jumps from $177 to<br />
$275. And if you do 3 units in this same quadrant,<br />
the profit jumps up to about $326 (Fig. 2).<br />
The three posterior units in the same quadrant<br />
at the same vertical dimension, plane of occlusion,<br />
condylar position, incisal edge position,<br />
where you’re not changing those variables, 3<br />
units in the same posterior quadrant represent<br />
what I call “The Sweet Spot.” That is: the highest<br />
net fee per hour most general dentists can<br />
generate. It’s the sweet spot (Fig. 3, next page).<br />
MD: Or what’s even scarier is, because they’re<br />
not doing that, they’re not adding 70 percent<br />
to those bigger cases. They’re not doing<br />
any prep work, they’re just doing run and<br />
gun: prepping all the teeth and putting the<br />
temps in. That’s where the risk will come back<br />
to bite you.<br />
It’s like the spot on a golf club, Mike: You go on a golf<br />
course, you pick up your 6-iron, you happen to swing<br />
well and click! You can tell when that ball hits the sweet<br />
spot on the club. It is the maximum flight of the ball.<br />
It is the maximum performance of the ball with the minimum<br />
exertion of energy. Three units in the posterior<br />
quadrant provide maximum results, in terms of profit,<br />
with minimal energy.<br />
30 www.chairsidemagazine.com
MD: And I bet most dentists know that on a certain<br />
level. They couldn’t give you numbers. They certainly<br />
couldn’t quantify it. But you might say to them,<br />
what’s your favorite thing to do? And they might say,<br />
“I like a good 3-unit bridge.” And we have 3 units<br />
here in the sweet spot, the profit per hour, but we’re<br />
only prepping 2 units, so that might be the sweet spot.<br />
You charge for the pontic, and life is good. Greatest<br />
determination ever: that we can charge the same<br />
for a pontic as an abutment. So I think most dentists<br />
would probably know that on a certain level. They<br />
couldn’t articulate it, but they would know on a certain<br />
level, that’s my favorite thing to do. And that’s<br />
probably why.<br />
PH: When you take out the fee schedule and say,<br />
“Well, my crown fee is $800. So, for 1 unit I’m going<br />
to charge $800; for 2 units I’m going to charge<br />
$1,600; for 3 units I’m going to charge $2,400,”<br />
that progression makes sense. Why? Because it is<br />
very low risk, very low remake and low planning<br />
time.<br />
MD: So, that actually works? To actually take<br />
your crown fee and multiply it by two or three<br />
actually works in these lower-risk cases?<br />
PH: Absolutely, and for many dentists, that’s<br />
where 80 to 90 percent or more of their<br />
dentistry exists and where the fee schedule<br />
makes sense. There’s all sorts of journal articles<br />
about what to charge for a single-unit<br />
crown in the Southwest versus the Northeast,<br />
and how much time is taken. And all<br />
those are valid if the dentist is doing 3 units<br />
or less. Now, all of that breaks down when<br />
the case gets complicated. All of it breaks<br />
down when the dentist has to change vertical<br />
plane of occlusion, condylar guidance or<br />
incisal edge position – I sound a bit like a<br />
broken record here. But those are the big<br />
variables of a case. Those variables, in addition<br />
to medical factors, especially when<br />
you’re dealing with dental implants, where<br />
host resistance is a huge component. Then<br />
factor in aging components, risk factors that are<br />
inherent to the dentistry, the intraoperative remake.<br />
You made a statement earlier, before we<br />
started about veneer cases – what percentage of<br />
them need to be remade because of the contact.<br />
MD: Or a single unit will need to be remade within<br />
an 8- to 10-unit case.<br />
PH: An 8- to 10-unit case of single unit would<br />
need to be made, so that’s 10 percent right there.<br />
400<br />
300<br />
200<br />
100<br />
I call that an intraoperative remake. Now,<br />
your laboratory may not charge you for that<br />
but there’s still the factor of time involved.<br />
MD: The patient has to come back again, have<br />
it put on. It’s another 45-minute appointment.<br />
PH: Another 45-minte apointment. Remember:<br />
profit per hour is that per hour. It’s divided<br />
by time. So you have intraoperative<br />
remake that is a factor when you do your 12-<br />
unit case. You have complexity to the case<br />
relative to the patient’s musculature and<br />
neurophysiology. You have a change in the<br />
patient’s medical history that can ultimately<br />
make a case turn sour. Plus, all the time<br />
and planning. All of the photographs and<br />
models will oftentimes – if you take a 12-<br />
unit case now and you take your unit fee at<br />
$800 per unit and multiply it times 12, you’re<br />
going to be 40 to 70 percent too low if you<br />
base it off a fee schedule (Fig. 4, page 33).<br />
Tooth<br />
Dentistry<br />
Profit per Hour<br />
275<br />
2 crowns<br />
177<br />
1 crown<br />
163<br />
Composite<br />
Figure 3<br />
326<br />
3 crowns<br />
Centric Relation<br />
Dentistry<br />
The Sweet Spot<br />
Rehabilitative<br />
Dentistry<br />
MD: Wow. So, the crown fee is reliable if you’re<br />
doing one crown, two crowns or three crowns.<br />
But if you have a great case that walks in the<br />
door that you’re excited about, if you take that<br />
crown fee and multiply it times the 12 crowns,<br />
you’re saying there’s almost no way on a case<br />
as complex as that to make the same per hour<br />
if you were doing two crowns.<br />
Interview with Dr. Paul Homoly31
PH: That’s right. You’re better off doing 2<br />
units at a time on six to eight different patients.<br />
Or even on that patient!<br />
MD: Even on that patient. Spend six years doing<br />
two crowns at a time. Your kids will be fatter,<br />
right?<br />
PH: Absolutely right. And that is something<br />
dentists miss all the time. I missed it early<br />
in my career, Mike; I’m sure you missed it,<br />
too. We were so in love with the process of<br />
fixing teeth that we didn’t really see or feel<br />
the bigger picture. When dentists hit their<br />
40s, their backs begin to get sore, their eyes<br />
begin to go. You can’t make up for lost ground<br />
very easily. You are not the practitioner<br />
from 40 to 50 or 50 to 60 that you were from<br />
20 to 30 and 30 to 40. You won’t have the<br />
same energy, you won’t have the same eyesight,<br />
and you won’t have the same stamina.<br />
The earlier dentists learn to set their<br />
fees relative to complex care, the easier it<br />
will be for them to accumulate wealth, to<br />
be able to build a profitable practice and<br />
to have what they really deserve. The practice<br />
of dentistry takes a lot: We capitalize<br />
our own businesses, we hire the people, we<br />
manage the facilities, we do the dentistry,<br />
we empty the plaster trap. We do a lot of<br />
things. And improperly set fees can drag you<br />
right down.<br />
MD: That makes a lot of sense. So, to do that<br />
12-unit case correctly, the 12 times the singleunit<br />
crown fee is the baseline.<br />
NET FEE:<br />
Sum of (Patient Fee - Lab Fee - Office Overhead)<br />
Dentist’s Time<br />
PH: That’s right, that’s the baseline. You said<br />
it earlier, Mike: That’s your base pay. Now you<br />
look at, where should the fee be? When you<br />
look at the sweet spot, I’ve got it set at about<br />
$326 per hour. And that’s net fee per hour.<br />
MD: Define net fee per hour for us.<br />
PH: Net fee per hour is the patient fee minus the lab fee<br />
minus the lab overhead divided by time.<br />
That $326 represents my net fee per hour when I’m doing<br />
3 units all in a posterior quadrant. That’s the safe sweet<br />
spot right there. Now, when we cross the line and start<br />
doing rehabilitative dentistry, where we’re doing those<br />
four variables, now our net fee has to be greater than<br />
that sweet spot. Here’s why: Because if it’s not greater,<br />
we’re not profiting at the level that the risk demands. If<br />
you were an investor and you were to invest in something<br />
that is safe, like U.S. Treasuries, you would accept a<br />
lower return on investment because you’re not making a<br />
tremendous risk in the marketplace. But what if you were<br />
invested in a very volatile, risky investment? What type of<br />
return would you expect there based on risk?<br />
MD: It’s got to be higher.<br />
PH: It’s got to be a lot higher. When you start doing rehabilitative<br />
dentistry, you’re making an investment in a risky<br />
business. Therefore, your net fee per hour must be greater<br />
than what you’re doing on a lower- or no-risk case.<br />
MD: In one sense, these complex cases are sort of volatile.<br />
There are just more things that can go wrong versus a singleunit<br />
crown.<br />
PH: Mike, they always go wrong!<br />
MD: It’s just a matter of getting it right in the end!<br />
PH: That’s right! Even in the end, it can’t be right all the<br />
time. I did rehabilitative dentistry for 20 years, and I can<br />
think of very few cases. You sit down and treatment-plan<br />
a patient. Let’s say you’ve got 12 units of root canals and<br />
implants and all sorts of moving parts in the mouth. You<br />
treatment plan that case out, you get your treatment planning<br />
form out and you color in all the teeth, color<br />
in all the arrows, you get it all done and you<br />
add it up. Now, what’s the probability that the<br />
treatment plan is exactly what you’re going to<br />
do at the end of the case? It’s about zero. There’s<br />
always stuff that will change. We’re going to pursue<br />
excellence. This is a great treatment plan<br />
and I practice in a very excellent way and this<br />
is the way it’s going to be. Dream on! There’s no<br />
amount of excellence that’s going to compensate<br />
for change of host resistance or act of God or anything<br />
else that goes on.<br />
MD: It reminds me of that old thing, how a plane flying from<br />
Los Angeles to Hawaii is off course 99 percent of the time,<br />
constantly correcting for the winds. But hopefully the pilots<br />
get that plane down where it needs to be in the end. It’s a constant<br />
matter of adapting to the environment. Build-ups you<br />
32 www.chairsidemagazine.com
have to do that you didn’t foresee, that you didn’t plan on.<br />
Composites falling out and you’ve got to do some filler, and<br />
now that post is coming out.<br />
PH: Or you laid a flap and what looked like good bone<br />
now is mush and you have to graft the area and allow it<br />
to heal. Or you have a post-operative complication. You<br />
place three or four implants. I remember earlier in my<br />
career, we weren’t as sophisticated about our flap management.<br />
We’d place three to four implants. We’d come<br />
back in about 10 days or so, pull the lip back and you<br />
know what? Some of the cases, the flaps would open and<br />
we would see the tops of the implants, and that’s when I<br />
would feel the heat – the heat from my stomach come up,<br />
like swamp gas settling on my face.<br />
MD: That’s going to take a few minutes off of your life! And<br />
you weren’t being compensated for it, were you?<br />
PH: I wasn’t being compensated for it. So how do you fix<br />
a case like that? You don’t. You let it granulate in. You see<br />
the patient for 15-minute increments every two weeks and<br />
it’s like watching a death march. And the longer you look<br />
at the patient like a little thermometer, your profitability is<br />
going down. Now you’re just hoping to break even.<br />
And specialists wonder why more dentists don’t<br />
refer dental implants or complex-care patients. Because<br />
oftentimes the general dentist is much more<br />
profitable from the sweet spot on down, from 3<br />
units on down, than they are with these big godalmighty<br />
cases that sometimes can take years to<br />
complete. The dentist that refers a lot, Mike, is the<br />
dentist that has abundance in his or her practice.<br />
The dentist who’s doing a lot of bread and butter<br />
dentistry, their bills are paid, they’re making<br />
their profit goals, their staff is happy, they have<br />
a good facility, they feel good about the dentistry<br />
they’re doing. Abundance drives referrals. That’s a<br />
different topic we can touch on another time – the<br />
specialist-generalist relationship.<br />
400<br />
300<br />
200<br />
100<br />
consider adding 5 to 10 percent to my fee<br />
for consultations. Second thing I would<br />
look at is occlusal analysis. What does that<br />
mean? Well, it means that you’re at home or<br />
you’re at the office, you’ve got nobody else<br />
there, the study models in your hand, you’re<br />
on your articulator thinking. This is where<br />
you’re manifesting your wisdom. You get<br />
compensated for that. And occlusal analysis,<br />
with the accompanying Diagnostic Wax-Up<br />
and creation of templates, that’s got to be<br />
worth at least 20 to 25 percent of a premium<br />
fee. Another thing we miss is equilibration.<br />
Mike, I believe that equilibration is one of<br />
the finest arts in dentistry: knowing when<br />
to stop; knowing where to grind. Knowing<br />
when to grind, when not to grind. Knowing<br />
when enough is enough. How much<br />
do we need to adjust bites long-term on<br />
these rehabs? We’re always kind of touching<br />
things up. And equilibration is another<br />
10 to 15 percent on these cases. So, if you<br />
look at the different areas that we typically<br />
don’t charge for, those can add up to 40, 60,<br />
70 percent over those fees that one would<br />
Profit per Hour<br />
275<br />
2 crowns<br />
177<br />
1 crown<br />
163<br />
Composite<br />
326<br />
3 crowns<br />
162<br />
12 crowns<br />
125<br />
12 crowns with 5% remake<br />
MD: Right, but the point being that they need to be<br />
well versed and confident in their sweet spot dentistry<br />
to be able to think about referring out the comprehensive<br />
dentistry.<br />
Tooth<br />
Dentistry<br />
Figure 4<br />
Centric Relation<br />
Dentistry<br />
Rehabilitative<br />
Dentistry<br />
PH: That’s right. And when you sit down and you<br />
treatment-plan your big case, you’re going to add fees to<br />
different areas of the case where we normally don’t add<br />
fees. Number one is going to be in consultation. Consultation<br />
with physician, consultation with specialists, consultation<br />
with laboratory, consultation with other dentists,<br />
consultations with pharmacists – whomever is going to<br />
be involved in the case, consultations take time. I would<br />
charge based on their fee schedule. You<br />
want to end up with your fee for the rehab<br />
case now. You want to end up where your<br />
profit – when you fee a case, plan on a 5<br />
to 10 percent intraoperative remake. Mike,<br />
you work here with <strong>Glidewell</strong>. You see<br />
20,000 units a month go out the door. Give<br />
Interview with Dr. Paul Homoly33
me a sense: What is the average remake rate<br />
of the dentists you work with?<br />
MD: If you combine everything – removable,<br />
fixed, all the different things we do – it’s around<br />
6.5 percent. And that includes me being in the<br />
lab. My personal remake rate here at the laboratory<br />
is about 6.5 percent – and that’s healthy.<br />
We see dentists whose remake rates are 30 to<br />
35 percent, and there’s something wrong there.<br />
We see dentists whose remake rates are, I was<br />
looking at an account the other day because we<br />
got a goofy impression, the most insane impression<br />
ever. It was literally about 8 cm and it was<br />
an impression of just one tooth for a crown on<br />
that tooth. There was no tray. It was an impression<br />
of the prep and about the occlusal third of<br />
the opposing tooth, nothing else. It was crazy.<br />
And the department said this dentist sends that<br />
in all the time; that’s his standard impression.<br />
And when I looked up his remake rate, it was<br />
less than 1 percent!<br />
PH: Well, that may not be good either.<br />
MD: That’s my point! He’ll cement anything.<br />
In fact, we have records. We’re relatively sure<br />
he once cemented a crown intended for one patient<br />
on another patient. I suppose he looked at<br />
the inside of it and prepped the tooth to match<br />
it; we call him “Dr. CEREC” now. It’s just as<br />
bad to have a really low remake number because<br />
it shows you don’t have quality control.<br />
You know, there are 63 steps between when the<br />
impression is taken and the crown is delivered.<br />
A lot of it has to do with the provisional. When<br />
the temporary is on for two weeks, nothing good<br />
happens. Nothing good happens during those<br />
two weeks except the patient’s pterygoid muscles<br />
heal from the lower block that you gave them,<br />
if you’re still giving lower blocks (which I hate<br />
to do). But nothing good happens. Things shift,<br />
things move around. Bacteria gets under the<br />
temporaries and teeth get hypersensitive. They<br />
erupt. So there’s a number of reasons why there<br />
would be a remake rate around 6.5 percent.<br />
CAD/CAM has the opportunity to lower that a<br />
little bit. But that’s what it is and that’s what<br />
it should be. It should not be 35 percent and<br />
it should not be 1 percent. So, 6.5 percent is<br />
right about where it should be, if you’re honest<br />
about evaluating dentistry intraorally and<br />
giving people quality restorations.<br />
PH: So the smart thing to do as a practitioner<br />
is, when you put your final treatment plan together, factor<br />
in additional cost for consultation, occlusal analysis, diagnostic<br />
provisional, equilibrations, nightguard, post-operative<br />
adjustments – then it makes perfect sense to factor<br />
in another 8 to 10 percent for intraoperative remake. And<br />
the patient accepts that fee.<br />
Now, Mike, the patient has paid your premium fee. You’ve<br />
got your premium fee and now you get into the case.<br />
What’s your attitude now about an intraoperative remake?<br />
How much stress does it cause you now?<br />
MD: Just one? Is that all I have? We planned for three!<br />
PH: Right, if you’re planning for 10 percent and you have<br />
5 percent, you don’t have the stress and the anxiety of<br />
the case hanging over you. If you’ve underfeed the case,<br />
everything extra you do is just another straw on your<br />
back, in terms of your profitability. If your case is feed<br />
with the adjustments made to risk intraoperative remakes<br />
and these aspects that I’ve been talking about, now when<br />
the remakes or the failures or the breakdowns or the<br />
changes in the patient’s medical history occur, it doesn’t<br />
become a stressful event for you, not nearly as much.<br />
You might feel bad that you need to redo something, but<br />
economically it isn’t hurting you and the team and your<br />
ability to sustain the practice. Lack of profitability is not<br />
sustainable behavior. And we see it all the time with these<br />
doctors who come back from the institutes – and I’ve got<br />
nothing against the institutes, I teach at most of them –<br />
but they come back with this idealistic attitude that as<br />
long as you pursue excellence and you trim your own<br />
dies and you use microscopes and you have these special<br />
gizmos they told you to buy that you’re not going to have<br />
problems with your cases. You are going to have problems<br />
with your cases. And that’s normal. My point here in<br />
this discussion is to charge for them.<br />
MD: You’re right, because losing profitability is not a longterm<br />
strategy. The lack of profitability would absolutely get<br />
in the way of quality dentistry, unless you’re independently<br />
wealthy from an outside source and you’re doing dentistry<br />
as a hobby.<br />
PH: If a dentist is not profitable and then reaches his or<br />
her 50s or 60s and they begin to think about bringing<br />
in an associate, now this tendency to suffer from lack of<br />
profitability brings an associate to transition into the practice,<br />
to buy the practice. If the practice is not profitable<br />
and the dentist is buying into it, that ushers in a whole<br />
other layer of complexity relative to: 1) the failure of the<br />
buy-in; 2) the dentist is not modeling good profitable behavior.<br />
So we have this lack of profitability culture, this<br />
legacy that is passed on from dentist to dentist to dentist,<br />
which is a shame.<br />
34 www.chairsidemagazine.com
Several years ago, Reader’s Digest magazine had a phantom<br />
patient that went from office to office. And I forget<br />
the situation, but apparently the fees that came back<br />
ranged anywhere between $2,000 and $25,000. One of<br />
the journals had the patient’s X-rays and all that. And I<br />
looked at that case and thought: The only dentist who<br />
got it right was the dentist who charged $20,000. Because<br />
he was the guy that took the models, was putting<br />
them in the splint, who did the equilibrations, who did<br />
the case well. And the dentists who cried about it<br />
were the ones losing money because they didn’t know<br />
how to set fees, and they thought this guy was a bandit.<br />
He’s not a bandit; he just knew what he was doing.<br />
Big difference there.<br />
MD: You mentioned to me a study that you have in which<br />
more than 100 dentists participated, doing the same type<br />
of thing as the Reader’s Digest article. This is probably long<br />
overdue in dentistry, because dentists had a knee-jerk reaction<br />
to it: Oh my gosh! It’s not like in dentistry we take an<br />
FMX into a machine and then out comes a treatment plan<br />
with the fees already on there. It kind of would be nice in<br />
a sense: “Your case is going to be $20,000.” And the patient<br />
gasps and we just say, “It’s the machine! We all use the same<br />
one. Go to the dentist down the street and he’ll tell you the<br />
same thing.” Because now you’re taking the emotion out of<br />
the dentist and the guilt about telling somebody they need<br />
$20,000 worth of dentistry. So, it was a study that was done<br />
by some friends of yours, where they had 126 dentists treatment<br />
plan an 8-unit case, with some other things that needed<br />
to be done. There, you also saw fees all across the board. Tell<br />
our readers about that study.<br />
PH: Ken Mathys and I teamed up years ago, and taking<br />
what I’ve described as this right-fee solution, that’s the<br />
brand we use for this. And that’s taking your fee schedule<br />
and proportioning it so that the fees of different procedures<br />
you do make sense to each other. For example, the<br />
care and skill and judgment of doing a simple posterior<br />
crown may be less than the skill needed to do a Locator ®<br />
Bar Overdenture. So there’s going to be a difference of<br />
skill between those two.<br />
Ken is a CPA, and he runs a company called <strong>Dental</strong> Practice<br />
Advisors (dentalpracticeadvisors.com). I asked Ken to<br />
use his CPA stamp-of-approval on the spreadsheet that I<br />
gave him. That is, take it up to the CPA level of accountability.<br />
Well, he and his team did a wonderful job. What<br />
they did in 2006 is take 126 of their best clients, dentists<br />
who are working under a financial plan and who care,<br />
and they gave each of these dentists the same 8-unit case.<br />
And this 8-unit case involved changes in vertical dimension<br />
and anterior guidance and those sorts of things.<br />
Ken worked it out; he worked with another dentist to put<br />
this case together, all the different appointments,<br />
what they would need to do. Then<br />
he gave this sample case to 126 dentists and<br />
asked them: How much time would you<br />
spend doing it and what would you charge?<br />
The numbers these dentists came back with<br />
were all over the place. Fewer than 15 percent<br />
of the dentists made any change in fee<br />
relative to changing those four variables –<br />
anterior guidance, vertical dimension, condylar<br />
position or incisal edge position.<br />
MD: So, essentially, they just took their crown<br />
fees and multiplied it times eight?<br />
PH: Exactly. Eighty five percent of the dentists<br />
did that. When you look at the profitability<br />
aspect of it, close to 20 percent of the<br />
dentists were netting out less than if they<br />
were doing single-unit posterior units.<br />
MD: Wow, talk about a kick in the groin.<br />
PH: It’s amazing. When you see the math<br />
you just want to shake your head. The big<br />
culprit is time. The biggest mistake a dentist<br />
can make is to look at his profit and say, I<br />
need to find a cheaper lab. A cheaper lab is<br />
not the answer. What you want is a lab that<br />
can get the job done right the first time. The<br />
answer to many of our profitability issues<br />
has to do with time and leadership. Time<br />
is the divisor. That is, if you use two hours<br />
instead of three hours, that’s a huge difference<br />
in profitability. Time is a big culprit.<br />
Ultimately, Mike, you arrive at a fee that<br />
might be 40 to 70 percent more than you<br />
would normally charge.<br />
MD: What does the average dentist say when<br />
it’s suggested to them that they need to do that?<br />
Do they say, “I can’t do that”?<br />
PH: Exactly. They look at it and say: “I have<br />
a hard enough time selling a $10,000 case.<br />
Now you’re saying that it’s a $17,000 case?”<br />
Well, it is based on the amount of time and<br />
risk that you have to do. And they say, “Well,<br />
I can’t sell that.” That’s where it goes into<br />
leadership. That’s when the dentist needs to<br />
look in the mirror and say to him or herself,<br />
“What do I need to do in how I present care<br />
to patients? How do I train my team? How<br />
do I run my facility? How do I earn the right<br />
Interview with Dr. Paul Homoly35
to charge $17,000? How do I, as a practitioner<br />
and as a leader, signal to the marketplace<br />
– my patients, my team – that we’re<br />
worth it?” Because the difference between<br />
the $10,000 and the $17,000 reconstruction,<br />
when it’s done well, is huge. You can’t be<br />
doing reconstructions half-assed, because it<br />
will come back to haunt you. So the higher-fee<br />
cases are more difficult to sell. Case<br />
acceptance for the high-fee case is something<br />
that I have focused on for the last 20<br />
years of my life.<br />
MD: Now, in those 20 years that you’ve been<br />
focusing on high-fee case acceptance, is there<br />
a huge difference between case acceptance for<br />
a $10,000 case and a $17,000 case? Don’t they<br />
both sound relatively expensive to the patient?<br />
100%<br />
Case<br />
Acceptance<br />
0%<br />
$1,000 $5,000 $10,000<br />
Figure 5<br />
PH: Absolutely, yes. You know there’s a case<br />
acceptance curve, where case acceptance is<br />
real high when the case is real low (Fig. 5).<br />
But as you cross that $5,000 to $6,000 mark,<br />
that’s where I see case acceptance drop<br />
down. Is case acceptance that different between<br />
the $10,000 and $17,000 level? Not<br />
really, but enough psychologically for the<br />
dentist. Not so much in the patient’s mind,<br />
but it is in the dentist’s mind. So factoring<br />
in proper case acceptance dialogues and essential<br />
conversations that you have, those<br />
conversations need to be entirely different<br />
at the $10,000 level up than at the $5,000 level down. And<br />
that’s been the topic of some of our other articles.<br />
MD: Yes, we’ve talked about that before. So a dentist who’s<br />
reading this or listening to this and realizes, wow, I bought<br />
this practice 13 years ago and I just took over at whatever<br />
Delta-approved fees the previous dentists had and we’ve tried<br />
to make increases every year based on our ZIP code as time<br />
went on. Maybe I should take a closer look at my fee schedule<br />
before I get too much farther into this to see if my fees are<br />
in the right place and make sure that when I’m operating<br />
at the sweet spot, I am making the net profit per hour that I<br />
deserve.<br />
PH: I’d contact Ken at <strong>Dental</strong> Practice Advisors. For<br />
years I did the fees and analysis, but they are far quicker<br />
at it and more complete. What they’ll have you do<br />
is submit two or three of the large cases you’ve done,<br />
your fee schedule and your profit and loss<br />
statement. And they’ll look at it comprehensively.<br />
They’ll look at how much money<br />
you need to live; that’s where they’ll start. How<br />
many days do you want to work? How much<br />
money do you need to live? This will create the<br />
profit per hour that you need to make. Then<br />
they’ll look at your practice overhead and your<br />
fee schedule. They’ll adjust your individual fee<br />
schedule such that the fees are balanced up<br />
to that 3-unit level. Then they’ll look at your<br />
complex-care cases to help you look at and<br />
see, what is the profit you have? And what’s<br />
amazing, when you come back from a profitability<br />
analysis or a fee analysis like that, you<br />
come back with some hard data on a piece of<br />
paper. Now you can sit down with your team<br />
and say: Listen, when we did Mrs. Smith, that<br />
case where we all pulled our hair out, we made<br />
less on a per-hour basis than when we’re just<br />
fixing individual teeth. When you can see it in<br />
black and white, Mike, that becomes a great<br />
leadership tool. It becomes more real to everyone.<br />
And now, I can sit down with my dental assistants<br />
and say: You know, you’ve been asking for a raise the last<br />
several months. See this profit point that we have right<br />
here? In order for me to give you a raise, we’re going to<br />
need to move that profit point up. A lot of that has to<br />
do with time. So let’s think together: How can we shave<br />
an hour or two off of these longer procedures without<br />
reducing quality. How can we do that? When the team is<br />
engaged – engagement means they’re thinking on their<br />
own without my direct influence – they’ll help create the<br />
solution, they’ll support the solution.<br />
MD: Sure. And now she is responsible for her own raise. The<br />
doctor says, I want to give you a raise. I think you deserve<br />
36 www.chairsidemagazine.com
one; you’re a fantastic employee, and here’s what we need<br />
to do in order to get to the point where we can do that. Or,<br />
if the staff is on some sort of bonus plan, certainly adding<br />
that extra fee on there – especially if the doctor is a financial<br />
arrangements person who doesn’t want to quote the $17,000<br />
versus the $10,000. The doctor has got to feel a lot better about<br />
making bonus payments to the staff when they’re charging<br />
the right fee for these complex cases.<br />
PH: And when you see it in black and white and you<br />
know it’s the right fee, now your leadership can take over.<br />
Establishing a fee for complex-care cases is a process. It’s<br />
not an emotional thing; it’s a process. When you have a<br />
process, you have the ability to lead because you can always<br />
go back to the tool. You can always go back to the<br />
fee analysis and say, OK, we’re doing better – now we<br />
just need to do a little bit better. You’re not just constantly<br />
raising the bar for the sake of raising the bar … because<br />
people get burned out on that. You cannot constantly<br />
ask people to perform better if they don’t have the right<br />
intrinsic reasons to do so. And the fee analysis provides<br />
that. It’s in black and white.<br />
I would suggest visiting the <strong>Dental</strong> Practice Advisors Web<br />
site to get started. For the skills related to case acceptance,<br />
visit my Web site: paulhomoly.com. I can teach you<br />
and your team the essential philosophies and conversations<br />
that make it easy for your patients to say yes.<br />
MD: That sounds like some great advice. I don’t know what<br />
the hardest job in the world is, but I can say that if every job<br />
in the world paid exactly the same, I’m not sure I’d still be a<br />
dentist. It is a difficult job. We’re working in a very sensitive<br />
area of people’s mouths and they tend to be afraid of us. It’s<br />
difficult and therefore we need to be compensated for it.<br />
PH: Highly compensated!<br />
MD: The only way to make sure that’s going to happen is<br />
to make sure your fees are in place. Whether it’s the 1-, 2-,<br />
3-unit sweet spot crown fee that’s in place or the 12-unit case<br />
that you think is going to make you financially independent,<br />
in reality you’re going to make less money on that than on<br />
the 3-unit case unless you get your fees in order. So it’s something<br />
I would definitely encourage dentists to take seriously.<br />
Contact Ken for guidance on fees and to see if they are in<br />
fact in the right place. You don’t want to practice for 30 to<br />
40 years and then find out you did everything right, except<br />
charge the right amount for procedures.<br />
hope the audience hears what I’m going to<br />
say right now. I’m not advocating that you<br />
go and raise your fees 40 to 70 percent. I’m<br />
not saying that. What I’m saying is, when the<br />
case is complex we need to think about taking<br />
our fees up. To make it easy for you:<br />
don’t take them up all at once. Maybe take<br />
that 6-unit case up 20 percent, just to build<br />
your confidence in quoting a higher fee, and<br />
keep bumping it. Don’t make the jump; don’t<br />
go cold turkey on this thing. Build your confidence<br />
with it. That way, when you begin to<br />
slowly escalate your fees for complex care,<br />
you will become more and more accustomed<br />
to quoting a higher fee.<br />
MD: That’s one part of it, but the other part<br />
is making sure that the base single-unit crown<br />
fee for the 1-, 2-, 3-unit case is in the right place<br />
as well. And it might be! Or it might need to<br />
go up only $40 or $100. Or maybe it is in the<br />
right place, and then you just need to worry<br />
about more complex cases. But why not find<br />
out? Isn’t it kind of like getting blood work<br />
done? The good news is that you find out everything<br />
is fine and you don’t need anything. You<br />
don’t say: Well, that was a waste of time and<br />
money. Instead you say: Oh good, everything’s<br />
all right. Why not find out that your fees are in<br />
the right place now so you don’t have to worry<br />
about it 20 years from now, when things didn’t<br />
turn out the way you thought they would.<br />
PH: And now you can pursue quality and be<br />
compensated at a level that will help perpetuate<br />
your practice and makes the pursuit<br />
of quality a sustainable event.<br />
MD: Excellent. Well, thank you for stopping by<br />
today. I loved the opportunity to finally discuss<br />
fees with you, and I know that the readers and<br />
listeners of Chairside will love it as well. CM<br />
For questions related to this interview or learn more about<br />
Dr. Paul Homoly, call 800-294-9370, visit paulhomoly.com or<br />
e-mail paul@paulhomoly.com.<br />
PH: Remember, Mike, you and I were going to have this<br />
fee conversation last year, at the beginning of 2009. And<br />
we both agreed: I don’t know if we should be talking<br />
about raising fees when the economy is tanking. So now,<br />
a lot of indicators say we’re coming out of that, and I<br />
Interview with Dr. Paul Homoly37
Biologic<br />
Shaping<br />
– ARTICLE and CLINICAL PHOTOS<br />
by Daniel J. Melker, DDS<br />
When performing conventional crown lengthening, the previous margin of the old restoration is used to determine<br />
the necessary amount of bone to be removed so there will be adequate space for the biologic width.<br />
By adequately creating a space for the biologic width, the new margin will not infringe upon it.<br />
A potential problem of this procedure is that a significant amount of bone will be removed, weakening the tooth or creating<br />
a weakened furcation area. The more bone removed in the furcation, the greater the likelihood of future problems<br />
with maintenance. It is critical to try to preserve as much bone as possible in order to support the tooth, especially in<br />
the furcation area. The clinical prerequisites and steps for success with biologic shaping are as follows:<br />
1. All previous restorative materials and decay should be removed.<br />
2. A core build-up should be placed where necessary to add volume to the teeth. The material should be a<br />
composite-bonded resin. The core helps the periodontist determine where the final margin placement of the<br />
new restoration will be.<br />
Biologic Shaping39
3. Acrylic provisionals should be placed with<br />
Durelon (3M ESPE ; St. Paul, MN) temporary<br />
cement. Durelon is antimicrobial and helps<br />
decrease sensitivity.<br />
4. Remove provisional at time of surgery for<br />
access. Ideally, a mosquito forcep is used with<br />
a gentle rock at the incisal third of the occlusal<br />
surface of the provisional.<br />
5. Shape the tooth surface and remove old<br />
margin, as well as 360 degrees of CEJs. A<br />
flat-ended bur with a 4-degree taper is best for<br />
biologic shaping. A diamond grit is best.<br />
6. Correct any reverse architecture and remove<br />
any necessary bone where biologic width<br />
issues are still present. The goal is to create an<br />
osseous contour identical to the soft tissue<br />
contours that take place when forming a new<br />
biologic width.<br />
Figure 2: With the provisional removed, the surgeon now has<br />
the ability to treat the tooth vertically.<br />
7. Add sufficient connective to protect the bone<br />
from bacterial infiltration. The co-nnective also<br />
protects underlying periodon-tal tissues from<br />
impression material and cementation irritation.<br />
8. Once the flaps are adapted using 5-0 chromic<br />
gut suture just coronal to the osseous support,<br />
potassium oxalate should be used to help<br />
decrease sensitivity. The liquid is applied to the<br />
root surface for 45 to 60 seconds and then<br />
lightly air-dried. Repeat two to three times.<br />
Figure 3: The depth of the margins can be seen with inflammation<br />
noted on the distal of tooth #19.<br />
Figure 1: Biologic width violation along with a severe inflammatory<br />
response.<br />
Figure 4: A split thickness flap is retracted to see the underlying<br />
defects and location of the existing margin. Note the<br />
reverse architecture present and close location of the existing<br />
margin to the bone.<br />
40 www.chairsidemagazine.com
9. Cement provisional with polycarboxylate<br />
cement (i.e., Durelon or Dentsply Tylok ® ; York,<br />
PA). Tylok may be more ideal for cementation<br />
during surgery, as it is water-soluble.<br />
10. Homecare consists of chlorhexidine used twice<br />
daily, in both the morning and evening. Previ-<br />
Dent ® (Colgate; NY, NY) should be used at bedtime<br />
to help decrease sensitivity. After meals,<br />
the patient should rinse with water or Listerine<br />
to remove excess food particles.<br />
Figure 5: The use of a coarse diamond bur on the tooth<br />
surface to remove the old margin. By doing this procedure<br />
first, there may be less osseous removal after completion of<br />
shaping.<br />
11. At four weeks, the provisionals are either remade<br />
or relined leaving 1 mm of space to allow<br />
for continued biologic width growth in a coronal<br />
direction. No margination of the tooth surface<br />
should take place at this time.<br />
12. At 14 weeks, chamfer margins are placed just<br />
coronal to the gingival collar and impressions<br />
are taken. A recommendation of one #7<br />
SilTrax ® (Pascal Company; Bellevue, WA) cord be<br />
placed in the sulcus for retraction of tissue.<br />
When endodontics is present the new margin<br />
may be placed within the sulcus. In these<br />
cases, a ferrule effect is recommended.<br />
Figure 6: The tooth is grossly smoothed. With the old margin<br />
removed, space for the biologic width is created without<br />
excessive bone removal.<br />
Figure 7: A superfine diamond bur is used to further smooth<br />
the tooth surface. This allows for long-term maintenance of<br />
the tooth.<br />
Figure 8: A diamond round bur #8 is used to create a parabolic<br />
architecture. A parabolic architecture is created to mimic<br />
the soft tissue contours, which are created after the new formation<br />
of the biologic width. The highest point of bone should<br />
be interproximally, as is the soft tissue. The buccal and lingual<br />
bone should be in a more apical position.<br />
Biologic Shaping41
■ Reasons for Biologic Shaping<br />
1. Replace or supplement the current indications for clinical crown lengthening.<br />
2. Minimize removal of supporting osseous structure.<br />
3. Facilitate supragingival or intrasulcular margins to preserve the biologic width.<br />
4. Eliminate developmental grooves.<br />
5. Eliminate previous subgingival restorative margins.<br />
6. Reduce or eliminate furcation anatomy and thus facilitate margin placement.<br />
7. Allow supragingival or intracrevicular impression techniques.<br />
8. Facilitate hygiene and maintenance procedures.<br />
9. Reduce or eliminate cervical enamel projections.<br />
10. Facilitate ideal restorative emergence profile. Flat is better than fat contours. CM<br />
Daniel J. Melker, DDS, is in private practice and can be reached at 727-725-0100.<br />
Figure 9: Parabolic architecture created for ideal architecture<br />
for placement of tissue over the bone.<br />
Figure 11: Occlusal view showing 360 degrees of perfect<br />
tooth surface to place a margin at the gingival collar once it<br />
has healed.<br />
Figure 10: Tissue sutured just coronal to the bone with 5-0<br />
chromic suture material.<br />
Figure 12: Final restoration with margins placed into the<br />
sulcus.<br />
42 www.chairsidemagazine.com
Social Media and<br />
Marketing the Modern <strong>Dental</strong> Practice<br />
– INTERVIEW of Glenn Lombardi<br />
by Michael DiTolla, DDS, FAGD<br />
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<br />
I speak with you, we’re talking about Web site design or Google AdWords and optimizing search engines.<br />
Today, however, we’re focusing our talk on social media and how this new form of communication is impacting dentists. I<br />
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,<br />
I follow United Airlines on Twitter (@UnitedAirlines). I fly 100,000 miles with them every year so I’m interested in what’s<br />
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<br />
online to rebook your tickets. They also do special “Twitter fares,” where for a two- or three-hour period they’ll have an airfare<br />
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<br />
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<br />
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<br />
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<br />
media to promote their practice and get in touch with their patients, I would love to hear about it.<br />
Social Media and Marketing the Modern <strong>Dental</strong> Practice45
Glenn Lombardi: Well, let me start by differentiating social media and traditional marketing: While traditional marketing<br />
involves the dentist marketing to patients, social media involves patients marketing to patients. It’s interactive, it’s<br />
exponential, and the reach is phenomenal. It’s a very cost-effective medium, and it’s a great way to share information<br />
and engage with patients while enhancing your brand and improving your reputation.<br />
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<br />
marketing to patients. So instead of the typical advertising relationship that we’re all familiar with, it’s almost like third-party<br />
endorsement, where it’s a patient telling another patient about your services. It’s like me telling another dentist how much I<br />
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<br />
that I think you’re great, it takes on another meaning. That’s really very profound, isn’t it?<br />
GL: It is testimonial driven. Social media is connection. It’s building relationships<br />
online. For example: Suppose a woman comes into the office for a<br />
whitening treatment. She’s so pleased with her new smile that she goes home,<br />
visits her Facebook page and posts a picture of her new whitened smile to<br />
show all of her friends. She’s excited, right? That’s part of the connection, that’s<br />
part of sharing. All of her friends are going to see her newly whitened teeth<br />
and then comment or write on her wall about how great her teeth look. What’s<br />
the next question going to be? “Where’d you get the new smile?” That’s where<br />
the connection begins, that’s where the referral begins. And that’s the power<br />
of a patient testimonial.<br />
MD: Wow, funny you mention that because last year, I was in a weight loss contest<br />
with somebody here at work. I lost 50 pounds and he lost 15 pounds. And I took<br />
his money, and that was great, but even more fun – and I didn’t even think about<br />
it until just now – was, I went to my Facebook page and immediately deleted every<br />
profile picture of me with a double chin or where I appeared to be pregnant at<br />
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<br />
cards. And I changed the photograph that I send out in my seminar packets. So, you’re right: As soon as that monumental event<br />
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<br />
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<br />
of my weight loss.<br />
GL: Referral marketing. Great application.<br />
MD: You’ve told me before that dentists are actually leading the way in the health profession for having Web sites. And I think<br />
everyone will agree that it’s necessary for established practices to have a Web site. Today we’re talking about how social media<br />
can enhance that even more. Explain to me how dentists can utilize the power of social media, and what kind of content they<br />
can provide to make this happen.<br />
GL: First, you want to set up a social media network with profiles on Facebook and Twitter. Facebook is a great place<br />
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<br />
the fastest growing age group being 35- to 55-year-old females. It’s a great targeted market for dentists.<br />
MD: Boy, that’s exactly who we’re going after in the dental practice, isn’t it?<br />
Social media<br />
is connection.<br />
It’s building<br />
relationships<br />
online. ”<br />
GL: Exactly. You’ll want to set up your Facebook page as Fan-based, meaning without friends – strictly a business profile<br />
site. There are a number of things you can put on your Facebook site, including logos and photos of your office that<br />
are cohesive with the look and feel of your Web site. You’ll also want to add any videos you might have from vendors<br />
like Invisalign or <strong>Glidewell</strong> or any videos you’ve taken of patient testimonials. Third, you’ll want to include content,<br />
such as tips for healthy smiles or articles about practicing good oral hygiene. And finally, you should announce any new<br />
services or products your practice is offering, such as mouthguards and why this new product is beneficial.<br />
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<br />
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<br />
“<br />
46 www.chairsidemagazine.com
eally does work. But it never goes anywhere from there and they never send another in because dentists, in the past, didn’t feel<br />
comfortable telling other patients about it. But you’re saying this Facebook page is a great way to let everyone know, “Hey, we<br />
now offer these anti-snoring appliances.”<br />
GL: That’s a great example. Now the dentist can post on Facebook his or her own personal experience that testifies how<br />
the appliance helped reduce or eliminate their own snoring. It’s a great way to relate with a patient on a personal level.<br />
It’s a way to build loyalty and trust from your current patients.<br />
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<br />
from doctors was the dreaded tour of the office, where it would be the doctor walking around showing the patient the surgical<br />
suites and sterilization areas and lab areas. You can just imagine the patient watching the video and saying, “Oh, gross,” as<br />
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<br />
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<br />
appliance for himself and now he doesn’t snore anymore. It would make the dentist seem more human and at the same time<br />
let a group of fans know about this new service you provide, which you tested on yourself before releasing to them.<br />
GL: Right. And as those fans read and hear and understand what your practice has to offer, they’ll talk to their friends<br />
who may have similar issues. For instance, if Mary knows about Sue’s husband and his snoring problems, she may say,<br />
“Check out this Facebook post from my dentist about how to prevent snoring with a new device.” Then the simple<br />
content shared on Facebook has reached its true viral potential. You’ve done nothing but post a message to Facebook,<br />
which is free, and in turn you are generating a new patient to your practice.<br />
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<br />
fan page is different from a personal page.<br />
GL: Yeah, and you might want to have both – one for personal use and one strictly business related. But either way,<br />
you definitely want to have a business profile with fans for your practice because this is how you really start to grow<br />
your practice and see patients take an interest in what you have to say. These fans could be existing patients, potential<br />
patients or even friends of patients, and they’ll have the ability to post, comment and interact on your social media<br />
pages.<br />
MD: Now it seems pretty simple to pick a local example: Sprinkles Cupcakes in Newport Beach has a ton of fans because people<br />
are pretty passionate about their cupcakes. They are fantastic. And every day Sprinkles tweets a secret phrase that, if you go to<br />
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<br />
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<br />
a fan page, how do you go about getting fans? That seems like it may be slightly more difficult.<br />
GL: When you first set up your Facebook and Twitter accounts, you’ll want to add these social media icons to your Web<br />
site homepage with a direct link back to your social media pages. Then, when patients visit your Web site, they can click<br />
on them and be directed to your Facebook page or follow you on Twitter.<br />
Another way to generate fans is in your office. Whether you post a sign that says you are now on Facebook and Twitter,<br />
or you ask your staff to inform patients of your social media presence, simply communicating the message will help<br />
attract new people to your pages. And, if you’re doing marketing in the neighborhood, whether it is direct mail or ads,<br />
put your Facebook and Twitter icons on all of your marketing materials with URLs to your social media pages. People<br />
will see these images and know that they can connect with your practice that way.<br />
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.<br />
If I have almost no self-esteem, why would anyone want to follow me on Twitter? For a dentist who is sitting in their<br />
practice right now saying, “I’m boring. My dental practice is nothing exciting. I’m not doing dentistry to the stars, why would<br />
anybody want to follow me on Twitter?” What would you say to a dentist like that?<br />
GL: I would say to the dentist, you have three options: First, if you are comfortable integrating social media into your<br />
practice, you should move forward with it and try managing it on your own. Set up your profiles, share information and<br />
begin building your fan base and interacting with patients.<br />
Social Media and Marketing the Modern <strong>Dental</strong> Practice47
Second, if you’re not comfortable with social media or don’t have time to manage it effectively on your own, you can<br />
have someone else manage it for you. Officite can write your content and post it for you – once, twice or even four times<br />
a month. It’s a great way to outsource that service to a professional who can become your social networking partner<br />
and build a strong presence for your practice on Facebook and Twitter. One of the things that Officite offers when we<br />
set up your Web site is to include a blog page, which is an integral part of social networking. This blog feeds your social<br />
networks, so all you have to do is post to your blog and then your Twitter account and Facebook page are automatically<br />
updated with that same content. This really streamlines the entire management process.<br />
A third way to jumpstart your social networking is to empower someone on your staff to take the lead. There’s probably<br />
an assistant or office manager who’s already interacting on Facebook and Twitter who can create the content and<br />
manage the social media sites for you.<br />
It’s important for dentists to understand that those who wait to get Web sites have a much tougher time coming up in<br />
the search results than the dentists who have been doing it the past three to five years. The early adopters are now the<br />
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<br />
behind when competitors in your neighborhood are generating new fans to their Facebook pages and attracting new<br />
patients.<br />
MD: That’s a great point. As you listed off those three options, you squashed every possible objection a dentist could have. Because<br />
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<br />
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<br />
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<br />
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<br />
objections. But if you would have said to him, “Look, you can pay and have a professional do it or you can delegate someone<br />
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<br />
shouldn’t be willing to try it.<br />
It’s funny you mentioned the blogs because I follow probably seven or eight blogs, only one of them being dental related, and I<br />
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<br />
the blog can update these other forms of social media. So is the blog kind of the centerpiece in this strategy?<br />
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<br />
sets up your Facebook and Twitter page with content. Not to mention that a blog is a great way to reveal<br />
your credibility, engage with patients and boost your search ranking. In fact, Google now spiders Twitter and Facebook,<br />
and the information on these social networking sites can actually appear in the search results when a relevant search<br />
is performed.<br />
In addition to the Facebook and Twitter feeds, you’ll notice that reviews about your practice are also visible to people<br />
searching for you in the local maps results of Google. For instance, if you type “Dentist, Park Ridge, Ill.” into Google, the<br />
new local Google Maps results will display what’s known as the Google 10-pack: 10 dentists in Park Ridge with phone<br />
numbers, Web addresses and reviews for each listing. These reviews have become an extremely important factor for<br />
dentists in terms of managing their online reputation and earning high rankings in the search results. So it’s imperative<br />
for dentists to manage their reputation online as it relates to how their practice is portrayed on the Internet.<br />
MD: Interesting. So, the online reputation is something that I look at in regards to, as I mentioned before, restaurants on Yelp.<br />
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,<br />
you can be pretty well assured that it’s a quality establishment. And if you look through all of those reviews, there’d be<br />
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.<br />
But I know dentists who have told me, because of a couple random lawsuits that are going on – specifically with Yelp – that<br />
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<br />
you from somebody who didn’t have a positive experience. And that one bad review will never be replaced with a good review<br />
if you don’t encourage it. Explain to our readers a little bit about managing this online reputation.<br />
GL: What you want to do is manage and audit your online reputation. There are a couple ways to do that. The first thing<br />
you want to do is simply perform a Google search for your name and practice and see what comes up in the results.<br />
48 www.chairsidemagazine.com
Take a look at any reviews posted to find out what patients are saying about the quality of your practice. This can give<br />
you basic insight into your current online image.<br />
Second: Sign-up for Google Alerts using your name, your practice and other words or electives specific to you. Then,<br />
anytime anything is written about you on the Internet, you will get notified by Google via e-mail, telling you where the<br />
online source came from and what was written about you.<br />
Third: Manage your online reputation by encouraging positive patient reviews. We recommend that you collect e-mails<br />
as patients come through the office. And people who have a Yahoo or Google e-mail are the ones to ask, “Hey, you had<br />
a positive experience. Would you mind giving us a review?” Why is it important to use a Yahoo or Google user? Because<br />
they already have logins for these accounts. All they have to do is Google your name, click on your profile in the local<br />
business center, click on “Add a Review,” type it in – and BAM! You have a review. Even if you get one positive review<br />
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<br />
positive ones will outweigh the one or two bad ones. Not only will a favorable review be influential for prospects deciding<br />
whether to visit your practice, but reviews also effect where Google ranks you in the local maps results. The more<br />
positive reviews you have, the better the ranking.<br />
MD: Yeah, it’d still be a 99 percent positive review. You know, it’s always been<br />
recommended that you ask patients for referrals, to refer other patients. And<br />
a lot of dentists struggle with this. Personally, I had to almost become robotic<br />
and memorize a line to be able to say to patients: “Hey, John. We’re just about<br />
done with your appointment today, but I just want to tell you that we love<br />
having you here. Whenever you come in, everybody gets excited. You show up<br />
on time. You pay your bills on time. You are actually our ideal patient. And I<br />
know that birds of a feather flock together, so if you’ve got any friends or family<br />
who need dentistry, we would love to see them.” And then you would hand the<br />
patient a couple of business cards. You pay the patient a compliment and tell<br />
them, you’re our dream patient and you’re fantastic, we love having you here.<br />
If you’ve got any friends or family who are in need of a dentist, have them stop<br />
by and tell us that you sent them and we’ll take great care of them.<br />
It’s a way to build<br />
loyalty and trust<br />
from your<br />
current patients. ”<br />
Most dentists you talk to would say, “Ah, I just can’t do that! I just can’t walk<br />
in and have that conversation with a patient. It sounds desperate, it sounds<br />
like I’m begging. Maybe someone on my staff could do it.” And they probably<br />
could, but it’s not as powerful. It is a difficult thing to do, but nobody argued<br />
that it’s a bad idea to pay a compliment to a patient. It’s not easy to be a dental<br />
patient, but then to ask them for a referral? Otherwise, the patient comes in for<br />
his or her appointment and see the front office receptionist sitting there with 5,000 charts behind the desk. They see four other<br />
people in the waiting room, but the patient doesn’t know those patients are waiting for the hygienist and not the dentist. To the<br />
patient it looks busy in there and it probably never occurs to them, I should make them busier.<br />
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<br />
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<br />
seems like that would be a painless thing to ask for in the office versus saying, “Hey, send us more patients.”<br />
GL: Exactly. At Officite we actually provide our clients with review cards, where the front office staff can actually hand<br />
a card to the patient that describes how to complete a review on Google or Yahoo. It has a simple process laid out. So,<br />
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<br />
and make that review happen.<br />
Start with patients you know or that you are confident have been satisfied with your services time and time again. Again,<br />
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<br />
goal. Get comfortable with the review process, let it work itself out, and your patients will take care of the rest.<br />
MD: You can even tell your patient, “We’re having a contest to see how many positive Google reviews we can get.”<br />
“<br />
Social Media and Marketing the Modern <strong>Dental</strong> 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<br />
a chance to win some sort of prize or even a special offer for a dental service.<br />
“<br />
When you first set<br />
up your Facebook<br />
and Twitter accounts,<br />
you’ll want to add<br />
these social media<br />
icons to your Web<br />
site homepage with a<br />
direct link back to your<br />
social media pages. ”<br />
MD: I mentioned earlier that I’m sitting here with my iPhone in my pocket,<br />
and it’s buzzed a few times. And I don’t know whether it’s tweets from Lance<br />
Armstrong telling me where he’s cycling today, but I spend a lot of time getting<br />
information – whether it’s from Twitter, Yelp, Urbanspoon, Facebook even – on<br />
my iPhone. It’s become an important device in my life for managing what’s<br />
going on and how I interact with the world.<br />
When Apple released its 2009 fourth fiscal quarter financial results, it set more<br />
records and sold more iPhones then ever before. Just when I think that everyone<br />
has an iPhone, Apple goes and makes a record profit. What should dentists<br />
be doing to take advantage of the fact that everybody carries a smartphone<br />
and stays so closely connected to the world of social media?<br />
GL: Number one, their practice Web site should be iPhone compatible.<br />
This was one of the first things Officite did about a year ago when the<br />
iPhone grew in popularity. We made it possible for all of our dentists to<br />
have an iPhone-compatible Web site with easy navigation and quick links<br />
to phone numbers, appointment requests and social media sites so that<br />
patients on the go would always be able to access their dentist’s site. Remember,<br />
patients are busy and they want to make one click to get where<br />
they’re going.<br />
The iPhone is where more than 50 percent of your information is going<br />
to be gathered, reviewed and read, and this includes social media sites.<br />
Today you see kids, my 15-year-old included, who are on their iPhones<br />
more than the computer because that’s how they access their Facebook.<br />
And this is a great way to expand your reach to potential patients who may never see your direct mail, ads or even<br />
Google searches. As this generation grows up with social media and advanced technology like the iPhone, it’s necessary<br />
to adapt your strategy to reach out to an entire new patient base that is growing very quickly.<br />
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<br />
effective punishments we have left is to turn off the texting and take away the laptops. It is their connection to friends and to<br />
the world. And you’re right: This is the generation of patients who are coming next.<br />
In general, most of the discretionary choices I make are somehow reviewed on social media before I go out and interact with<br />
any given business. It makes total sense to optimize things for the iPhone – it is unique and it has broad appeal. As an information<br />
portal, it makes a lot of sense.<br />
GL: Four or five years ago we all started booking travel, buying books and other consumer products online – and that<br />
drove companies’ behavior to sell online. And the same goes today with the growing popularity of the iPhone.<br />
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<br />
computer anymore. When you search for a restaurant, you’re pulling out your iPhone. When I drove over here from my<br />
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<br />
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<br />
are and how people gather information about your practice.<br />
MD: Another area I’m interested in hearing about is YouTube. You briefly mentioned it earlier and I guess it’s something that<br />
would be considered a social media site, but we’ve produced many clinical education programs here at the lab and we’ve<br />
put them out on iTunes. We notice they are immediately downloaded, but we’ve also found out they’ve ended up on YouTube,<br />
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<br />
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<br />
50 www.chairsidemagazine.com
went there I’d be given a key to the country because a lot of dentists there have watched these videos. So it’s gotten easier. We<br />
use HD cameras in the operatory for filming; we’ve also got some cheaper handheld cameras. And then you get down to the flip<br />
cameras, or even the iPhone having a video camera, but I wonder: Do you have many of your dental clients doing videos and<br />
posting these? Whether it’s before-and-after shots or something else, is that considered social media, too?<br />
GL: Yes, and what that does is increase your case acceptance and expand your reach to patients searching for specific<br />
patient education videos. You can post your video to your YouTube account, and then link it to your Facebook and Twitter<br />
accounts. This is a great way to tie all of your networks together while providing a visual interpretation of a service,<br />
product or even a patient testimonial.<br />
MD: Even something as simple as bleaching before-and-after pictures, which I think many dentists take for granted now. It<br />
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<br />
seems like almost every Google search that I do, when the results pop up, there is always an ad that says, “Slaughter your yellow<br />
teeth! Murder your yellow teeth!” It’s an obviously Photoshopped before-and-after: someone with teeth the color of cheddar<br />
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<br />
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<br />
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,<br />
most conservative, certainly the most affordable esthetic procedure that we have, and I think dentists sometimes go out and get<br />
fixated on the “almighty” veneers or the crown and they forget about lowly bleaching – which, for the average American, is the<br />
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<br />
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<br />
communicate with your patients and show them something that really 80 percent of them could benefit from.<br />
GL: Yes, exactly. So whether you produce that video yourself in the office using a patient – which always has a positive<br />
effect – or you get a video from a dental manufacturer like <strong>Glidewell</strong> that provides free patient education, putting a video<br />
on your Web site and social media pages is only going to enhance awareness about the services you offer. So, you’re<br />
right – a high percentage of your patients would probably benefit from a certain treatment and continually educating<br />
and informing patients about these procedures via your social media channels could eventually convince them to come<br />
in for the bleaching treatment. You could even tweet to your followers that you’re offering a special on tooth whitening,<br />
but it has to be Thursday afternoon. That might be a way to enhance and grow your revenue while filling chairtime.<br />
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<br />
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<br />
over. So they must have filled that inventory. Do you have some dentists doing that, filling some excess inventory that way?<br />
GL: We do, because dentists always know when their slow period is going to be. Whether it’s around the holidays or at<br />
the beginning of summer, dentists can plan their social media strategy in advance for the months business will be slow<br />
in order to increase the chances of filling chairtime. This might involve preparing blog posts, tweets or Facebook posts<br />
to inform patients that they’re having a special offer on cleanings or that a new procedure is available.<br />
MD: When we talk about blogging for the practice, part of it certainly could be video blogging, correct?<br />
GL: Yes, and I definitely recommend supporting text in your blog with a video.<br />
MD: From a patient perspective, it seems like a video blog would be very compelling. It’s almost like a behind-the-scenes look<br />
at what happens or what’s available or what could happen in a dental office. I don’t think “Extreme Makeover” or “The Swan”<br />
would have been as successful as they were if they didn’t include some kind of glimpse behind the scenes of what happens. So<br />
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<br />
pictures of the past week or the past month or something like that. I can see patients really taking an interest and wanting to<br />
watch that and learn about it.<br />
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<br />
Sports Item is a video now. As consumers, we are drawn to visuals. So the same should be true of dentists. Whether you<br />
build the video yourself or obtain a video from a vendor, posting it on your blog can generate a lot of interest. It grabs<br />
a patient’s attention and says, “Look, we have a new video of a patient receiving whitening or a new animation about<br />
Social Media and Marketing the Modern <strong>Dental</strong> Practice51
anti-snoring devices.” That is going to create interest as long as it’s kept brief and compelling, and hopefully increase<br />
your number of appointment requests.<br />
MD: That’s a good idea. We, even as a laboratory, have products that dentists probably aren’t even aware of. There are products<br />
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<br />
to wear a custom-made mouthguard. We made him one recently that looks nicer than the one that the players for the Anaheim<br />
Ducks wear, and it’s their colors and their logo. Now, every kid on the team wants one. Dentists always ask me, “Well how<br />
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;<br />
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<br />
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<br />
month.” It’s products like this that dentists traditionally don’t think of as restorative dentistry, a short little blurb about this<br />
custom-made athletic mouthguard for kids playing basketball or baseball or hockey. I mean, what a great way to get some new<br />
families into your office that you may not have met. And now they’re able to become ambassadors for the practice. They tell<br />
everyone, “We got a great new custom mouthguard. Now my kid’s the envy of everybody on the team.”<br />
GL: Absolutely. Not only do you get one more family in the door with a new innovative marketing tool, but you may<br />
also get the whole sports team in your office. Again, that’s another way to market your practice. It’s always important to<br />
consider marketing services to your community, such as a local sports teams, to help bring in new patients.<br />
MD: As always, Glenn, after speaking with you today I walk away with a greater appreciation for the power of the Internet<br />
and what marketing the modern dental practice is really all about. One of the things that really impresses me is, unlike the<br />
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.<br />
You mentioned the word “free” once or twice during this interview and talked about how the updates you’re able to do via<br />
the social media sites, which are free once they’re set up. That’s pretty impressive. Marketing the modern dental practice looks<br />
clean, and a lot less embarrassing at times, because we can use video and photographs in a more authentic way to market the<br />
dental practice. The Internet, which some dentists may view as a necessary evil, really seems to be becoming more classy. You’ve<br />
opened my eyes once again today to what social media can do for a dental practice, as well.<br />
GL: Dentists should not be intimidated by social networking. In fact, they should embrace it as an integral part of their<br />
online marketing strategy. A simple blog on your Web site synced to your Facebook, Twitter and YouTube accounts can<br />
significantly increase your Web site traffic, improve your search ranking, enhance your online reputation and, ultimately,<br />
attract new patients to your office. With anything related to social media, it’s patients marketing to patients, a powerful<br />
thing called referral marketing. So make sure you don’t overtly try to sell or market. Just be personal and learn to<br />
actively engage with your patients.<br />
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<br />
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<br />
Officite?<br />
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<br />
walk them through the process of setting up a social network and blog. If they choose, we can manage the entire process<br />
for them, as well as monitor their online reputation. Plus, we can even help with the online review process by providing<br />
our reputation marketing kit, which gives them everything they need in the office to generate positive reviews<br />
and manage their online reputation.<br />
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<br />
to be marketing a dental practice, as well. Thank you for your time, Glenn. I really appreciate it. CM<br />
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<br />
visit officite.com. To contact Glenn Lombardi, e-mail GLombardi@officite.com.<br />
52 www.chairsidemagazine.com
The Deceptions<br />
of Rubber Gloves<br />
I<br />
t has been more than 25 years since the<br />
public panic over AIDS, Hepatitis B and<br />
infection control prompted government agencies<br />
to mandate the use of examination gloves<br />
in dental the practice. In response to public<br />
outcry, the American <strong>Dental</strong> Association,<br />
the Centers for Disease Control, and the<br />
Occupational Safety and Health Administration<br />
established guidelines for infectious<br />
disease control that include the routine<br />
use of eyeware, face masks and gloves by<br />
dentists and their staff as a way of preventing<br />
the spread of disease in dentistry. For the most<br />
part, these guidelines have been significantly<br />
ineffective and, in many cases, harmful. It is<br />
time for a change.<br />
– Article and Clinical Photos by Ellis Neiburger, DDS<br />
To many clinicians and public health scientists, using gloves, masks and eyeware when treating patients seems reasonable<br />
and rational. Although these devices are generally assumed and touted to protect both the patient and the dental<br />
staff, many dental scientists and clinicians seriously doubt the effectiveness of masks and gloves, citing the rarity of<br />
any disease transmission and numerous hazards associated with their use. 1-45 In this article, I will focus on examination<br />
gloves and document evidence-based facts that support the notion that glove use has been recommended on an<br />
unscientific basis and can increase the risk of infection rather than prevent it. Now that the AIDS scare of the 1990s has<br />
passed, and the disease is better understood, dependable scientific data is available to back this claim. It is time for a<br />
non-emotional re-evaluation of “protection.”<br />
Government regulations, expanding the recommendations of the CDC, now require dentists to wear gloves with all patients.<br />
This may not be in the best interest of either the public or the dental professional. It has been proposed that the<br />
original recommendations of the CDC be re-applied. Those recommendations state that “gloves and protective ware be<br />
recommended, not mandated, for dental care and the use of these tools be determined by the clinician on a case-by-case<br />
basis where the benefits to the patient and safety of the dental staff be the prime focus.”<br />
The Use of Gloves<br />
Since 1985, concerns about AIDS and Hepatitis B have renewed emphasis on infection control and the use of barrierprotection<br />
devices in dental offices. From the original CDC recommendations, a variety of preventative extrapolations<br />
have been made by numerous self-proclaimed experts, organizations and manufacturers in an attempt to one-up each<br />
54 www.chairsidemagazine.com
other while seeking wealth, attention and power. These recommendations have a great emotional appeal and range<br />
from the use of thicker glove materials and longer lengths to double- or triple-gloving. The ADA, CDC, OSHA and<br />
many state dental boards have recommended or mandated the use of gloves for all patient contacts. 1,2 Most dentists<br />
and their ancillary staffs wear gloves, most often composed of latex, which gives the best control and dexterity of all<br />
available glove materials. 3 These elaborate exposure-prevention guidelines are based on a minimal amount of scientific<br />
data concerning the efficacy of barrier protection against viruses in a dental setting. 4,5 Almost all of the scientific data<br />
concerning safety and glove use in dentistry are extrapolations from the medical field. The use of gloves by health care<br />
personnel has been accompanied by a heightened incidence of glove-related problems. 36, 38 Knowledge of these serious<br />
problems have been ignored or suppressed by many dental institutions in an effort to create a false sense of security<br />
among dental workers and patients who are led to believe that practicing Universal/Standard Precautions will protect<br />
them from all infections and dangers inherent in dental practice, and that not using Universal Precautions will doom<br />
them to certain death.<br />
Barrier Protection and AIDS<br />
Unlike glove materials, there are no known bacterial, viral or fungal life forms that are capable of penetrating intact<br />
skin. 5 Intact skin is the best protection against infection. Nonsterile (contaminated) latex exam gloves are the choice<br />
of most dentists not only because of their lower cost but also because they interfere with dexterity considerably less<br />
than poorly fitting vinyl/nitrile gloves. Due to economics, few dentists use the more expensive sterile latex gloves for<br />
non-surgical treatment. Before the 1990 AIDS panic, only about 20 percent of America’s dentists wore gloves, and this<br />
reflected concern mostly about HBV. 7,8<br />
Before 1986, preventing HBV by wearing gloves was only occasionally mentioned<br />
in the literature. 9 At that time, most dentists chose to operate barehanded<br />
because they favored superior dexterity over questionable barrier<br />
protection. 7,8 Occupational infection of dentists or staff members was rare<br />
and even more rarely reported. In those relatively few HBV cases, the virus<br />
was transmitted by accidental needle sticks for which gloves would not offer<br />
protection. 1,9 The rarity of dental-related infections (HBV, herpes), low<br />
mortality rate and the recent development of HBV vaccines has made HBV<br />
a relatively preventable disease and therefore of less concern than in the<br />
past. 10<br />
AIDS, more than any other disease, prompted interest in barrier protection. 1,2,3<br />
This poorly understood, fatal (now chronic) disease originally inspired fear<br />
and panic among the health care, government and public communities. 11 In<br />
the 1990s, fueled by media attention, civil rights of gay people, and governmental<br />
and scientific politics, AIDS took on the undeserved reputation as<br />
the nation’s “number one” disease. In reality, cardiovascular disease, cancer<br />
and diabetes killed millions more people each year.<br />
“Unlike glove materials,<br />
there are no known<br />
bacterial, viral or fungal<br />
life forms that are<br />
capable of penetrating<br />
intact skin. Intact skin is<br />
the best protection<br />
against infection.”<br />
The U.S. mortality rate for AIDS (2007) is 14,561 persons per year. 12 This is a statistically insignificant number (0.0005<br />
percent) compared with the total population of the U.S. (305 million), yet it was once the highest funded and publicized<br />
disease.<br />
Fear of contracting occupational-derived AIDS caused many professionals to quit their jobs or deny HIV/AIDS patients<br />
humane care. This irrational fear – fed by unsubstantiated anecdotal stories of infection from media, politicians, activists<br />
and “safety” merchants-required extreme action from the government and the surgeon general at the time, Dr. Charles<br />
Everett Koop. The CDC responded to the call with the concept of Universal Precautions. This was a form of cover-up<br />
ritual with enough emotional and quasi-scientific appeal to placate the professional and non-professional populace.<br />
Patients relaxed and those with HIV received treatment.<br />
The technique of “protecting” oneself has been used throughout history. Although ineffective, it calms widespread<br />
panic. During the 14th century plague in Europe, physicians “covered up” in special cloaks to confuse the disease devils<br />
(Fig. 1). In the 1918 swine flu epidemic, useless cloth masks covered many faces in an attempt to protect from the flu,<br />
which killed 60 million people. (Some people were shot for failing to wear a mask.) In the 1950s, in preparation for<br />
a nuclear war, schoolchildren were taught to duck and cover under their desks (and not to run to the nearest bomb<br />
The Deceptions of Rubber Gloves55
shelter). In the 1990s it was gloves, mask and eyeware to “cover” the skin and<br />
stop the spread of AIDS, which can only be transmitted from unprotected sex<br />
and IV drug use.<br />
The first case of AIDS was reported in 1959, and since there have been no<br />
documented cases of occupational HIV infection in any dental health care<br />
worker. 1,13 There have been billions of dental patient visits worldwide with no<br />
disease transmission. There is one botched CDC investigation involving Dr.<br />
David Acer, an openly gay Florida dentist with HIV, who was alleged to have<br />
infected some patients (with secret high-risk behaviors). But even Dr. Acer<br />
wore gloves during all patient contact. In 1992, the U.S. General Accounting<br />
Office investigated and reported that this case was so bizarre, and the CDC<br />
did such a poor job in its investigation, that no reliable public policy should<br />
be drawn from the matter. 14,15 The GAO report did state that “gloves do not<br />
prevent most injuries caused by sharp objects, however, and so do not necessarily<br />
reduce contact rates.” 14 The CDC also published six to seven “possible”<br />
HIV transmissions in dentistry, but these, in the words of CDC officials, “were<br />
short on science.” 17<br />
Primarily because of HIV-AIDS concerns, universal barrier protection, including<br />
the wearing of gloves, has been recommended and/or mandated for all<br />
dental staff when in direct contact with a patient. 1,2,3,7 This recommendation is<br />
still in effect. This has increased the use of gloves, along with problems associated<br />
with their use, for both staff and patient. Knowledge of these problems<br />
and hazards and the option of wearing gloves in appropriate situations are<br />
important for the health of the dentist, the dental staff and the patient.<br />
Figure 1: “Cover-up” garb, worn by the 14th<br />
century physician, was believed to shield the<br />
practitioner from the plague.<br />
Mechanical Hazards of Gloves<br />
Gloves pose a number of mechanical problems for the wearer:<br />
Gloves do not offer protection against needle punctures, the leading cause<br />
of HBV and HIV infections in health care workers. 1,2,13,14,16 Eighteen of the<br />
25 healthcare workers in North America and Europe who reported HIV occupational<br />
seroconversion during the years when AIDS first became a concern<br />
developed their infections from large-gauge needle puncture wounds. 1,13<br />
This percentage has increased substantially over the years as the few new<br />
contamination cases reported needle stick-sharps injuries as the prime cause of<br />
seroconversion among medical staff. There have been no documented cases of<br />
dental staff occupationally seroconverting. Sharp punctures are not prevented<br />
by gloves. 1 In fact they have been shown to increase penetrating injuries. 17,18<br />
The hazards of reduced touch sensation caused by gloves tends to contribute<br />
to clumsiness, which often results in increased skin penetrations due to<br />
the insulation of proprioceptive nerve endings in the skin of a dentist’s<br />
hands. 17,18 Solovan, et al. reported 2.3 times as many tissue lacerations in dental<br />
prophylaxis patients treated with gloves compared with work done barehanded.<br />
8<br />
1. In the largest clinical dexterity study to date, 50 dentists who practice in<br />
Lake County, Ill., were tested for the average threshold for perception of light<br />
touch using a dynanometer. 18 Results were 4.4 grams without gloves and 6.7<br />
grams with their favorite gloves, which represents a 52 percent reduction in<br />
light-touch proprioception. There was a 16-fold increase in percutanious injuries<br />
while manipulating endo files (gloved) in a manual dexterity exercise as<br />
compared to the same dentists working bare-handed. 18<br />
2. <strong>Dental</strong> burs, especially those designed to cut acrylic, tend to snag the latex<br />
Figure 2: A dental bur snags a latex glove<br />
and drives into the flesh of the dentist’s hand.<br />
Figure 3: These gloves were burned while a<br />
dental assistant was using a Bunsen burner in<br />
a dental laboratory.<br />
56 www.chairsidemagazine.com
ubber and drive the bur into the flesh of the operator’s hand, creating a deep<br />
penetrating wound 19 (Fig. 2). There is considerable danger in wearing gloves<br />
around rotating machinery.<br />
3. <strong>Dental</strong> lathes and rotary devices can snag gloved fingers and have caused<br />
bone fractures among dental personnel. 20<br />
4. Both latex and vinyl gloves are flammable and pose a danger with the use<br />
of open flame (e.g., wax in prosthodontics) 21 (Fig. 3).<br />
5. Gloves increase the difficulty of handling small instruments such as pins,<br />
burs and endodontic files. 18,21 This impairment increases the time required to<br />
perform normal dental procedures and increases the opportunity for drop<br />
and aspiration accidents. 22<br />
6. Gloves are also poor barriers to many solvents used in dentistry, such as<br />
alcohol, eugenol and methacrylates, as well as composite bonding agents and<br />
some impression silicones. 36, 37 This allows contaminates to enter the gloves.<br />
Figure 4: A pantograph tracing of a free<br />
fractured cross section of latex glove demonstrates<br />
0.005 micron channels. 24<br />
Problems with Barrier Protection<br />
The primary purpose of the gloves is to provide a barrier to the transfer of<br />
microorganisms and other agents. They are fairly effective against organisms<br />
that are 10 microns or larger (e.g., bacteria), but there is little evidence that<br />
they effectively protect the wearer from viruses encountered in practice. 9,23<br />
There have been numerous studies done that show minimal benefits for those<br />
9, 15,24<br />
who wear gloves.<br />
New latex gloves have numerous porosities that are three to 15 microns in<br />
diameter. 24 These porosities increase in size and number when the gloves are<br />
stretched and used. Ten micron voids are the smallest imperfections that can<br />
be detected by usual testing methods. 24,26,27 The capsid of HIV is 0.1 to 0.12<br />
microns in diameter. 27 A hundred of these viruses could pass side by side<br />
through one of the “natural” 10-micron openings in latex gloves. The HBV virus<br />
of Hepatitis B is even smaller, 0.042 microns, which may partially explain<br />
why it is more infectious than HIV 29 (Fig. 4). Vinyl and nitrile gloves have<br />
significantly more rips and openings.<br />
Figure 5: A pantograph of 0.01 micron holes<br />
(dark) in latex gloves after a six-day exposure<br />
to atmosphere ozone. 28<br />
Besides their natural porosity, latex gloves frequently have manufacturing<br />
defects in the form of visible holes 50 microns or larger in diameter. 27,30 From<br />
2 percent to 36 percent of unused latex gloves and 23 percent of unused vinyl<br />
gloves examined had tears or holes that could allow fluids in a patient’s<br />
mouth to leak into the glove, causing “wet finger syndrome. ”26,27 These voids<br />
increase in size and number as the latex is worn or just exposed to atmospheric<br />
ozone 28,31 (Fig. 5). This was corroborated in a report by Brough et<br />
al., which revealed holes in 37 percent to 70 percent of used postoperative<br />
surgical gloves. 32<br />
In separate hallmark studies, both Reignold 9 and Gonzalez 33 presented data<br />
showing that the use of gloves provides dentists little protection against HBV.<br />
Reingold studied 434 oral and maxillofacial surgeons and found that only the<br />
number of years in practice correlated with the number of infections these<br />
surgeons had incurred. The use of gloves showed no increase in protection.<br />
Gonzalez reported only a
than glove-wearing nonreactors, which explained the greater number of HBV<br />
cases. 9<br />
Most reports on the effectiveness of gloves against viruses involve assumptions<br />
only. Hadler’s report, 34 which is unique because it was distributed by<br />
the CDC, is a typical example in which HBV was supposedly transmitted to<br />
patients by an oral and maxillofacial surgeon carrier. Prior to this discovery,<br />
the surgeon did not routinely wear gloves. No other HBV transmissions were<br />
noted after he began wearing gloves. The conclusion was that the gloves<br />
prevented further transmissions. Omitted from consideration was the later<br />
discovered shorter incubation period for HBV infection, the probability that<br />
the surgeon’s carrier status changed and that newly infected patients did not<br />
immediately test positive after the test surgeon began wearing gloves. This<br />
and three other similar studies were extrapolated by the CDC to apply to HIV<br />
infections and became the prime “scientific” rationale for the recommendation<br />
that gloves be worn as an element of Universal Precautions. 1 At that time, the<br />
AIDS epidemic was peaking and any rationale, scientific or not, would suffice<br />
for CDC action.<br />
Figure 7: Persistent dermatitis on the hand of<br />
a dental assistant after the routine wearing of<br />
latex gloves.<br />
Eventually, the errors in this study forced the CDC to recant and recommend that vaccination be the only effective preventative<br />
measure for HBV. Retracting Universal Precautions would be embarrassing and spark the AIDS panic again<br />
and thus was not implemented. This constituted an official deception that had serious future consequences.<br />
Gloves: An Expensive Contamination Hazard<br />
Most dentists use nonsterile latex gloves instead of sterile gloves because of their lower cost. 6 A 100-pair box of nonsterile<br />
exam gloves costs between $5 and $11 at most supply firms. Sterile gloves usually cost 10 times as much ($50-<br />
$95). The average dentist and staff uses $4,000 worth of nonsterile gloves per year (36 patients a day). 11 Extrapolating<br />
to the 150,000 dentists in America, the nation’s annual cost for dental gloves comes to at least $600 million. This is a<br />
tremendous expense for minimal to no benefit, because the wearing of gloves in dentistry has shown no significant<br />
improvement in reducing HBV (now addressed by vaccination) or AIDS (no documented cases of occupational transmission<br />
in dentistry before or after 1985). To invest this level of resources for a useless exercise defrauds the dentist,<br />
who pays the supply bill, and the patient, who pays the dentist.<br />
Because the CDC and OSHA are primarily interested in protecting the dental staff member rather than the patient, the<br />
contamination potential (for patients) of nonsterile exam is placed secondary to the costs of glove supply. Both organizations,<br />
however, sensibly recommend sterile gloves for some surgical procedures. It is ironic that the nation’s health<br />
organizations insist on stringent infection control measures and advertise the fact as a safety promotion to the public,<br />
yet what they are advocating is that dental staff use contaminated (infected) exam gloves, rather than freshly washed<br />
and disinfected hands as was done before 1985.<br />
Of course, using sterile gloves for all procedures would increase the cost of providing dentistry to such an extent (more<br />
than $5 billion annually) that no one would be able to afford dentistry. It is estimated that using sterile gloves as we<br />
do examination gloves would cost each dentist $40,000 more in supplies each year. 11 In spite of this, infections from<br />
bare-handed and gloved (sterile/nonsterile) dentists have been historically very rare and insignificant. Evidence-based<br />
science shows it doesn’t matter whether you wear gloves, and it never did. Yet dentists continue to believe that placing<br />
contaminated gloves on a compromised patient’s oral mucosa is safe and beneficial.<br />
This is with the consideration that most latex glove products are manufactured and hand-packed in Third World countries,<br />
where facilities are hygiene-primitive and the bathroom hygiene of many latex workers consists of using the<br />
left hand as toilet paper. Soap and clean water is a rarity (Fig. 6). Because exam gloves are considered already contaminated<br />
(nonsterile), they are seldom checked for pathogens. It is assumed that contaminated gloves are not clean.<br />
The hope is that they will be “kitchen clean,” which the CDC, dental organizations and dental boards assume is good<br />
enough for the population.<br />
Microbe contamination is not the only problem. Gloves often are coated with talc or cornstarch, which act as lubricants<br />
and absorbents. There are problems with this, most notably that talc and starch are physical irritants. 36,37 They can cause<br />
58 www.chairsidemagazine.com
inflammation in lesions on the wearer’s hands and can irritate wounds in the patient. Latex rubber ingredients have<br />
been identified as contributing to various degrees of dermatitis, as well as local and systemic allergic reactions. 39 Both<br />
talc and starch are irritants when inhaled and can cause asthmatic exacerbations in susceptible individuals. 28,36,40 The<br />
talc and starch will absorb latex proteins, become airborne and get inhaled by susceptible individuals. This can cause<br />
life-threatening conditions to breathing-compromised people (e.g., asthmatics). The incidence of latex sensitivity has<br />
increased from 3 percent to 6 percent in the general population since 1985 concurrent with widespread latex glove use.<br />
Some researchers consider this to be an epidemic in itself. The incidence of latex sensitivity in the dental community<br />
has soared from 3 percent to more than 22 percent. 47 This appears to be the direct result of wearing latex gloves and exposing<br />
skin and mucosa to the allergenic protein, as this problem did not<br />
arise until gloves became mandated. This is a dangerous change of events:<br />
Many deaths and thousands of serious reactions have been reported due<br />
to the increased latex exposure. 47 Another deception dentists and patients<br />
face is that gloves not only won’t be of much help in preventing disease,<br />
but they can cause considerable morbidity and mortality for which our<br />
patients and staff are seldom warned. This situation wastes money, endangers<br />
lives and discredits the dental profession.<br />
Starch is easily broken down into simple sugars that provide an ideal<br />
growth medium for microbes and contribute to bacterial and fungal<br />
growth on the warm hands of a glove wearer. This increase in resident<br />
and “leaked” microbial growth presents a danger to both the patient and<br />
the operator. 28,32 The components of latex (and other) gloves have been<br />
implicated as contamination hazards that may contribute to urticaria, nonhealing<br />
wounds, asthma, facial edema and toxic shock in health care<br />
workers. 30,38,41 Forty of the 50 dentists (80 percent) in a Lake County, Ill.,<br />
study wore gloves at least 85 percent of the time. 21 Twenty-five (50 percent)<br />
of these dentists reported hand lesions concurrent with the wearing<br />
of gloves. Three of the remaining 10 dentists, who intermittently wore<br />
gloves, also reported hand lesions. All but one of these dentists attributed<br />
the lesions to the wearing of gloves. 18 Tightly fitting gloves keep<br />
contamination close to the wearer’s skin surface. This increased contact<br />
encourages growth and spread of pathogens and increases the likelihood<br />
of allergies and/or reactions.<br />
Nonsterile gloves are not only contaminated during manufacture but are also quickly contaminated by the natural<br />
flora of the hands. To illustrate, this author did an experiment. Thirty-one unused, multibrand, nonsterile gloves were<br />
swabbed with sterile saline/cotton swabs and individually plated on typto-soy media. Cultures were incubated for 24<br />
hours. Six (19 percent) of these gloves were contaminated with gram-positive cocci, spore formers and fungi. There are<br />
numerous other studies that repeat these findings. 16,23,24,26,29<br />
Considering that these microorganisms are augmented with a starch growth media, warmth and moisture from the<br />
wearer’s hands, the potential for increased contamination and skin breakdown of both the wearer and the patient is<br />
greatly increased. This is why the CDC recommends that dental health care workers who have exudative lesions or<br />
weeping dermatitis, particularly on the hands, should refrain from all direct patient care and from handling dental patient<br />
care equipment. 1 Because most dentists and their staff have microbreaks and other skin lesions as described above,<br />
obeying this order would essentially furlough 20 percent of the nation’s dental staff at any one time.<br />
Allergy Hazards of Latex Gloves<br />
“This is with the<br />
consideration that most<br />
latex glove products are<br />
manufactured<br />
and hand-packed in<br />
Third World countries,<br />
where facilities are hygieneprimitive<br />
and the bathroom<br />
hygiene of many latex<br />
workers consists of using<br />
the left hand as toilet paper.”<br />
Urticaria is a common complaint associated with the use of gloves. 36,39 In a Lake County, Ill., study, half of the glove<br />
wearers experienced dermatitis. 18 Increased IgE reactivity of wearers and patients has resulted in thousands of lifethreatening<br />
allergic reactions, such as anaphylaxis and asthma, to latex glove materials. 39,40,41 Additional allergic problems<br />
have resulted from the starch or talc used inside the gloves. 36 Contact with latex gloves by sensitized individuals<br />
has been life-threatening, as mentioned above. 39,40,41<br />
Between 1988 and 1992, the FDA received reports of more than 1,100 life-threatening systemic and 15 fatal reactions to<br />
latex. In recent years, as the population continues to be sensitized to latex (e.g., rubbing a gloved finger along the oral<br />
The Deceptions of Rubber Gloves59
mucosa), this rate of anaphylaxis cases continues to increase. Both dentist and patient are at risk, and the deception<br />
that everything is safe cannot ethically be maintained.<br />
Miscellaneous Hazards<br />
Gloves also produce other problems not previously mentioned.<br />
1. Latex has a negative taste and “sour rubber” odor to many people. 42 Multi-flavored gimmick gloves are a poor<br />
attempt to correct this problem.<br />
2. Hands are compressed by the elasticity of latex gloves. This restricts the flow of blood, which increases tension<br />
and muscle fatigue. 43 Although proper fit is important, the recommended snug fit is a disadvantage of glove use due<br />
to the elastic nature of latex and the wearer’s nerve pathology caused by the constant compression. 35<br />
3. Gloves impede productivity by restricting movement, limiting manual dexterity and consuming time while gloving<br />
and degloving. 22,37,45 Assuming it takes 30 seconds to put on or take off gloves for each patient, a dentist who<br />
treats 100 patients a week for 50 weeks of the year loses 83 hours of productivity annually. This makes dentistry<br />
less efficient, more costly and deprives the relative poor of needed care.<br />
4. Many patients, especially small children, are offended by the use of gloves. 35 They interpret gloves as a threat<br />
or as an insult that they are dirty or diseased. This level of mistrust interferes with positive doctor/patient relationships.<br />
35<br />
5. The use of gloves has become an issue among the media, patients and dentists. 4,35 Many patients insist on being<br />
treated with or without gloves based on information gleaned from magazine articles, news reports and word of<br />
mouth. Most patients believe gloves are being worn for their protection, but OSHA recommends barrier protection<br />
for the expressed benefit of the dentist and other members of the dental staff, not the patient. 2 There will be serious<br />
consequences when the media learns that most dentists are treating their patients with contaminated exam<br />
gloves.<br />
6. There are additional problems associated with wearing gloves. The use of adhesives, impression materials and<br />
electric pulp testers, which require direct skin contact, are all compromised. 45<br />
7. Gloves are made of latex and plastic, which deplete natural resources, divert crop land (in the starving Third<br />
World) from food production and engorge our limited waste landfills with useless, unrecyclable garbage. If not<br />
buried, most gloves, being considered medical waste, are incinerated, producing hydrocarbon air pollution, CO2,<br />
and increasing the effects of global warming. Therefore, gloves are not green.<br />
Politics<br />
The most serious deceptions are in the political arena. The directives on Universal Precautions came from the Centers<br />
for Disease Control, a branch of the U.S. Department of Health and Human Services. This decision was made by a closed<br />
committee of public health bureaucrats, most of whom had never been in dental practice. It was an attempt to silence<br />
the AIDS panic, not to find the most efficient form of disease prevention.<br />
Surgeon General Koop devised and promoted his UP concept for medical and dental personnel without any consideration<br />
of cost or effectiveness or outside input. On October 29, 1999, The New York Times printed an expose reporting<br />
Koop was financially tied to a prominent glove firm, Allegiance Healthcare Corp. The article stated that he had received<br />
options to purchase 500,000 stock shares of the firm for a 1994 (low) price in exchange for four lectures per year and<br />
advertising rights to his name. This involved millions of dollars. Koop was accused of also trying to downplay the allergy<br />
danger issue in Congress because, as he told CDC representatives, “It would cause more harm than good and<br />
frighten hospital workers out of using gloves.” Eventually Koop ended up with a failed health care Web site, worthless<br />
stock, angry investors and a TV ad contract to sell “first alert” medical warning devices to the elderly. It seems that science<br />
was not a part of this formula.<br />
It is amazing that dentists, their organizations, OSHA, dental boards and America as a whole accepted the pronouncements<br />
from the CDC, an organization of questionable authority and candor, without debate. The CDC has flubbed many<br />
health initiatives, the latest being the severity and criticalness of the H1N1 flu outbreak and botched vaccine supply.<br />
60 www.chairsidemagazine.com
In 1976 it also went out on a limb, declaring the swine flu of that year<br />
was the 1918 variety. It was not, though useless vaccines were distributed<br />
to the nation with hundreds of deaths and thousands of hospitalizations<br />
from adverse reactions. The anti-HIV cream Noroxnol-9, promoted by the<br />
CDC, was found to enhance the spread of AIDS, not hinder it. Former Surgeon<br />
General David Satcher called the CDC labs a national disgrace. Congress<br />
criticized the CDC for changing the definition of AIDS, thus doubling<br />
case numbers in an effort to garner more funding. 17 This sad episode was<br />
termed by the CDC as “the distortion.”<br />
A long series of crises, scandals, reorganizations, mistakes, policy flipflops,<br />
infighting and political interference has left the CDC with a legacy<br />
of questionable competence. Since most infection control procedures are<br />
based on this flawed organization’s recommendations, dentists would be<br />
best served to be more critical than accepting of such government edicts.<br />
“Strange schemes appeared<br />
in the journals, such as<br />
ads stating, ‘Patients love<br />
headbags’ or ‘$20<br />
precision, plastic individual<br />
handpieces.’”<br />
The second area of political deception lies in dental publishing. Originally, a few articles on gloves and other PPEs<br />
appeared in 1980s journals rebutted by other papers opposing their routine use. As time went on, increasingly more<br />
journals printed unsubstantiated horror stories of dentists getting AIDS from patients and other rumors. They published<br />
increasingly bizarre recommendations from so-called infection control gurus increasing the panic. This brought attention<br />
and sold issues. Advertising for disposable (e.g., glove) manufacturers went from 3 percent to 25 percent of most<br />
dental publications’ ad space with the accompanying (financial) pressure on editors to avoid infection control criticisms,<br />
which would hurt business. Strange schemes appeared in the journals, such as ads stating, “Patients love headbags (a<br />
paper isolation bag with a hole for the mouth)” or “$20 precision, plastic individual handpieces (to ensure sterility and<br />
cracked enamel).” Some major dental organizations, profiting from the increased attention, adverted in their journals<br />
and took on the lead to perpetuate the deception that dentists were in danger of AIDS. They accepted whatever the CDC<br />
handed them, because protesting or questioning had some degree of political risk. Instead, they embellished the recommendations<br />
of extremes (e.g., heat sterilization of handpieces) to the detriment of the practitioners and their patients.<br />
Few journals protested and fearful dental staff embraced the deceptions with lemming enthusiasm.<br />
Conclusion<br />
Gloves are imperfect. They often contribute to the breakdown of the natural skin barriers. They are poor barriers to the<br />
transmission of viruses because of numerous voids derived from manufacturing and use. Gloves are cumbersome for<br />
the dentist to wear. Gloves are costly, allergenic, contain irritants and breed microorganisms. The wearing of gloves is<br />
beneficial at times (e.g., deep surgery) but can be hazardous at others. The wearing of gloves should not be mandated<br />
by government edict but left to the discretion of the dentist in situations where the wearing of gloves provides more<br />
benefit than liability. As costs and glove-related illnesses increase, there is no rational scientific reason to continue routine<br />
glove use. It is time for dentists to decide what is best for their patients, not bureaucrats and hucksters. It is time<br />
for re-evaluation of glove use on a case-by-case basis.<br />
What can be done? If the contaminated/sterile glove issue becomes public, there will be extreme pressure to replace<br />
exam gloves with expensive sterile gloves. Each practice will be required to spend at least 10 times more money on<br />
glove supplies. How much will this cost you? In this time of financial difficulty, in which many practices are in economic<br />
trouble and the excesses and window dressings of the wealthier past no longer can be comfortably funded, such<br />
costs would be ruinous. Many dentists will lose their jobs. Many practices will fold. The glove problem must be tackled<br />
sooner or later.<br />
The problem with latex gloves is simple to solve. Dentists must pressure the CDC to declare that gloves are potentially<br />
hazardous and that its recommendations on mandatory UPs (including glove wear) are optional in those cases where<br />
UPs use is more detrimental than beneficial based on the dentist’s evaluation on a case-by-case basis. In this way, glove<br />
use will be determined by the doctor, not the bureaucrat. The blood-borne pathogen concerns of a medical heart surgeon<br />
need not be extrapolated to the dentist doing a prophy on a healthy 3-year-old. OSHA’s blood borne regulations<br />
already have this glove option, to a limited degree, in place (Federal Register 12-6-91. 56:235 p.64129d3ii). Once the<br />
CDC publicizes this change, dentists can once again take command of their practices. It’s your future and your patients’<br />
health, and now is the time to act. CM<br />
The Deceptions of Rubber Gloves61
Dr. Ellis Neiburger is a general practitioner in Waukegan, Ill. Contact him at 847-244-0292 or drneiburger.com.<br />
References<br />
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.<br />
2. OSHA joint advisory notice: Protection against occupational exposure to HBV and HIV. October 19,1987.<br />
3. Editorial: Practitioners surveyed report dramatic increase in glove usage. <strong>Dental</strong> Products Report. 12:1.1987.<br />
4. HolubW. et al.: AIDS, A new disease? American Clinical Products Review, 5:28-37,1988.<br />
5. Fein S: A bad case of one upmanship. <strong>Dental</strong> Economics, 5:23,1988.<br />
6. Most dentists wear gloves, survey says: ADA News, 20(3)1-5:23,1988.<br />
7. Coburn S: AIDS Update, Illinois <strong>Dental</strong> Journal 3:1280129,1988.<br />
8. Solovan D, Uldricks J, Caccamo P, Beck F.: Evaluation of oral procedures performed with gloves: a pilot study. <strong>Dental</strong> Hygiene, 3:122-124,1984.<br />
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.<br />
10. Dentists guard patients, selves against HB virus, ADA News, 20(3):3,1989.<br />
11. Badner V: Dentists and the risk of HIV, New England Journal of Medicine, 319(2):113,1988.<br />
12. CDC. HIV/AIDS Surveillance Report 2007 V19 p.20.<br />
13. CDC Update: AIDS and HIV infection among heath care workers, MMWR, 37: 15-233,1988.<br />
14. GAO, CDC’s Investigation of HIV Transmission by a Dentist. Sept. 1992. p.2-47.<br />
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.<br />
16. Wormser GP, Rabkin C, Juline C: Frequency of nosocomial Transmission of HIV infection among heath care workers. New England Journal of Medicine,<br />
319(5):307,1988.<br />
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<br />
art1.htm.<br />
18. Neiburger EJ: Gloves and manual dexterity, Journal of American Association of Forensic Dentists, 13:1-4,1990.<br />
19. Shapter D: AIDS, what dentists are doing about it, <strong>Dental</strong> Management, 3:32-36, 988.<br />
20. Bonner P: Report D.D.S. alert, 7:19:2-3,1987.<br />
21. Tanchyk AP: Precautions in protection, JADA, 115:2:824, 1988.<br />
22. Hardison J: Gloved and ungloved performance time for two dental procedures, JADA, 116:5:691,1988.<br />
23. Klein R, Party E, Gershey E: Safety in the laboratory. Nature, 34:288,1989.<br />
24. Arnold S, Whitmand J, Fox C, Fox M.: Latex gloves not enough to exclude viruses. Nature, 335:19,1988.<br />
25. Young F (FDA Commissioner) Report: <strong>Dental</strong> Economics, 1:9,1989.<br />
26. Editorial, AIDS found to pass through latex glove undetected, Dentistry Today, 12:12,1988.<br />
27. Katz J, et al.: Fluorescein dye evaluation of glove integrity, JADA, 118:3:327-330,1989.<br />
28. Otis L, and Cttone J: Prevalence of perforations in disposable latex gloves during routine dental treatment, JADA, 118:3:321-325,1989.<br />
29. Tortora G,; Funke B, Case C: Microbiology, An Introduction, 3rd Ed. Benjamin/Cummings Publishing Co., New York, N.Y., 1989, p 327.<br />
30. Boguszewski D: Third national forum on AIDS and HBV. <strong>Dental</strong> Products Report, 1:6,1989.<br />
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.<br />
32. Brough S, Hunt T, Barrie W: Surgical glove perforations. British Journal of Surgery, 76:317,1988.<br />
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.<br />
34. Hadler S, Sorley D, Acree K: An outbreak of hepatitis B in dental practice. Annals of International Medicine, 95:2:133-138,1981.<br />
35. Neiburger EJ: Are we spreading AIDS by wearing gloves, New York State <strong>Dental</strong> Journal, 3:6-7,1988.<br />
36. Fisher A: Contact Dermatitis, 3rd Ed. Lea & Febiger, Philadelphia, PA, 1986, pp 224-279 and pp 630-631.<br />
37. Reitz C, Clark N: The setting vinyl polysiloxane and condensation silicon putties when mixed with gloved hands, JADA 116:3:371-375,1988.<br />
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-<br />
1102,1989.<br />
39. Van Der Meeren HL: Life threatening contact urticaria due to glove powder. Ned. Tijdschr Geneeskd, 132(21):968-970,1988.<br />
40. Slater J: Rubber anaphylaxis, New England Journal of Medicine, 320:17:1126-1130,1989.<br />
41. Dooms-Groossens A: Contact urticaria caused by rubber gloves. Journal of American Academy of Dermatology, 18:6:1360-31361,1988.<br />
42. Yoder K: Patients attitudes toward the routine use of surgical gloves in a dental office. Journal of Indiana <strong>Dental</strong> Association. 64:6:25-27,1985.<br />
43. Brantley C: The effect of gloves on psychomotor skills. Journal of <strong>Dental</strong> Education, 50:10:611-613,1986.<br />
44. U.S. Revenue Forecast of Disposable Glove Market: Dentist, 4:9,1989.<br />
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-<br />
310,1989<br />
46. Christensen Gordon: Operating Gloves. JADA 132;10:1455-1457,2001.<br />
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<br />
Mar;32(3):441-7,2002.<br />
Written by Ellis Neiburger, DDS, for Chairside magazine. Copyright ©2010 Ellis Neiburger. All rights reserved.<br />
62 www.chairsidemagazine.com
Dr. DiTolla’s<br />
Patient Product Review<br />
ou don’t have to be in dental practice too long<br />
to realize that men and floss don’t mix. I always<br />
laugh as I walk by and hear my dental assistant<br />
say, “Alright, Mark, let me show you how to use<br />
the floss threader for cleaning under your new<br />
bridge.” Those might be the most wasted words<br />
in the English language. If an assistant talks and the patient<br />
doesn’t hear it, did she really make a sound? Why is<br />
it we can give the patient three floss threaders, and a year<br />
later when we ask him if he needs any more he says he<br />
still has them. Really? After a year? Are you putting them<br />
in the dishwasher? Having them dry-cleaned? Or perhaps<br />
you never used them in the first place!<br />
Getting any male to floss is a tricky deal. You really need<br />
to catch males while they are young, say around 13, and<br />
let them know that chicks dig guys who floss. Drop some<br />
floss in the pocket distal to tooth #2 or tooth #15, and<br />
then hold it under his nose and let him smell some anaerobes.<br />
Inform him that if a girl ever were to smell that, the<br />
entire school would know about it in about 90 seconds.<br />
Floss every day, and it goes away.<br />
But for men who are out of adolescence, there is a need to<br />
make floss a little more exciting. With every baby boomer<br />
being told to eat steel-cut oatmeal with fresh fruit for<br />
breakfast, here’s a way to kill two birds with one stone:<br />
delicious breakfast dental floss. Bacon, waffles and coffee?<br />
Either I’m watching an episode of “Mad Men” or I’m<br />
using that great new floss my dentist recommended! Go<br />
to accoutrements.com and let the people who brought<br />
you Inflatable Turkey improve the periodontal health of<br />
your male patients. CM<br />
Breakfast Floss from Accoutrements ® , LLC. For more information, call 800-886-<br />
2221 or visit accoutrements.com.<br />
Patient Product Review63
“Uh oh. Looks like I’m gonna<br />
need a rubber ... dam!”<br />
PJ Wells, DDS<br />
Canton, Ohio<br />
1st place winner of $500 lab credit<br />
“eHarmony gets one wrong.”<br />
David Lesansky, DMD<br />
Naples, Fla.<br />
2nd place winner of $100 lab credit<br />
“The tears of a crown.”<br />
John S. Brizendine, DDS<br />
Lake Forest, Calif.<br />
3rd place winner of $100 lab credit<br />
Honorable Mention<br />
“It is guys like you who get on my last nerve!”<br />
Michael T. Reynolds, DDS<br />
Minneapolis, Minn.<br />
The Chairside ®<br />
Caption Contest Winners!<br />
Congratulations to winners of the Vol. 5, Issue 1 Chairside Caption Contest. The winning captions were chosen from hundreds of entries<br />
both e-mailed and submitted online to Chairside magazine when asked to add a caption to the illustration above. Winning entries were<br />
judged on humor and ingenuity.<br />
64 www.chairsidemagazine.com
The Chairside ®<br />
Caption Contest<br />
INTRAoral 2000<br />
“Looks like somebody has a severe case of potty mouth.”<br />
Send your caption for the above illustration along with your name and city of practice to: chairside@glidewelldental.com. By<br />
submitting a caption, you authorize Chairside magazine to print your name in a future issue or on our Web site. You may also<br />
submit your entry online at chairsidemagazine.com.<br />
The winner of this issue’s Caption Contest will receive $500 in <strong>Glidewell</strong> credit or $500 credit toward their account. The<br />
2nd and 3rd place winners will each receive $100 in <strong>Glidewell</strong> credit or $100 credit toward their account. Entries must be<br />
received by May 21, 2010. The winners will be announced in the summer issue of Chairside.