Intro to Clinic

Survival Guide to Clinic Written by Chuck Abbick and Danny Rome ***The following information is intended to make your lives in clinic easier. No one did this for us, so we learned the hard way. Please take the time to read this file thoroughly and write notes. The clinic faculty get frustrated when incoming third years flood them with the same questions everyday. Reading this packet will hopefully answer most of your questions.

Anything in bold, underlined, or in a different color is an absolute take home message. If you have any questions during your transition into clinic, or about anything else regarding clinic/dental procedures during your next two years, feel free to email me at dannyrome@gmail.com or send me a facebook message. Good luck to all of you soon-to-be dentists!

PART 1: GENERAL COMMUNICATION PRINCIPLES HOW DO YOU KNOW IF YOU’RE ANY GOOD AT COMMUNICATION? You should be able to do these things. If you can’t, you’ve got some things to learn.

1) Inform/explain: (example) tell a patient about periodontal disease and what they can do about it 2) Motivate/persuade/sell, these three things are similar: brush your teeth 2x/day, save that toothdon’t extract it, get a bridge 3) Make the patient feel good: build rapport, build a relationship, relieve anxiety, entertain 4) Talk to people from different walks of like: business man, carpenter, toddler, mentally challenged, drug addicts, retirees, chronically unemployed people on welfare 5) Have confidence 6) Don’t let people take advantage of you 7) Recover from mistakes easily 8) You can work with difficult people and they’re happy BE REAL COOL WITH YOUR PATIENTS, DON’T BE A JERK This is the one thing that’ll take you farther than anything else. Be cool, caring, nice, positive, polite, and happy. Don’t let things bother you. If you run into a problem, don’t throw a fit. Don’t act discouraged.

Act as if it’s no big deal, you take care of problems all the time. Patients pick up on this. Patients like this.

They will like you more. They will trust you more. They will be more likely to accept and pay for the treatment you recommend. They will refer you their friends. You’ll enjoy your job more.

Observe the people around you. Who do the students and teachers like the best? The people who choose to be cool, caring, nice, positive, polite, and happy. They’re also the ones who enjoy their job the most.

Don’t you want to be the same way? Don’t you want your patients to love you? You should.

Don’t be mean. Don’t interrupt people. Don’t lose your temper. Don’t give up hope. Don’t be negative.

Don’t talk bad about other people behind their back.

BE CARING Be caring. Let patients know you care. Have you heard this before: people don’t care about how much you know, they want to know how much you care. There’s some truth in that. I say this to my patients: I care about you, and I want to do a good job. I’m gonna work as hard as I can to make sure this is done right.

And pay attention to the little things. Get the light out of their eyes when your not working, and as you’re doing it, say let me get this light out of your eyes. If they’ve been in the chair for an hour, ask them if they need to use the bathroom. If you’re leaving the cube for 5 minutes, ask them if they want to keep lying down or sit up. Many patients enjoy wearing shades for eye protection. It keeps the light intensity down and relaxes them. This is a must for any PEDO patient. Go out and buy a pair, they’re not expensive.

When you do the oral cancer screening, say I’m doing an oral cancer screening and just in case you have anything I want to catch it while it’s small. Finish screening. OK, everything looks normal to me. I’m not seeing any problems. You can do a similar thing when you take their blood pressure, say you’re doing a screening for HTN. These things demonstrate that you care about them.

Also, if the patient tells you something, acknowledge what they said. Don’t ignore it. Example: Student: How are you?

Patient: Man, I’m having a rough day.

Student: Dang, I’m sorry to hear that. What’s wrong?

*****If you give an injection on a patient and/or do anything invasive such as operative/fixed/SRP, and especially extractions, ALWAYS, ALWAYS call the patient that evening to see how he/she is doing. It takes 2 minutes of your time and patients will love you for it. Not only does it show them that you care, but believe me, they will hand your cards out to their close friends and family who need dental care. It’s internal marketing and it works! I’ve picked up several crown and bridge patients from patient referrals.*****

BE POLITE I’m very polite with my patients. When I work outside the school, patients respect me as a dentist just because I’m polite. I don't have that much experience yet, so I don't think I'm the best I can be. But hey, I won’t argue with him.

How can you be polite? Say please and thank you, especially when giving commands. Don’t say open.

Say would you open please. Don’t say turn your head to the right. Say would you turn your head to the right please, (patient turns), thank you-I can see a lot better now.

Say thank you for coming in today, it was fun working with you. If the patient does something that’s courteous to you, thank them. You got here 30 minutes early because you don’t like being late to appointments? That’s nice of you. Thanks, I really appreciate that. If the patient thanks you for something, acknowledge that and say you’re welcome.

Patient: Thanks for seeing me today.

Student: You’re welcome. It was no problem at all. I like it when nice patients like you come in.

BE POSITIVE

You should be positive. How can you do this? When patients come in, you tell them what you find and what you’ll do about it. You give them good news and bad news. Don’t ignore the bad news. You have to tell them the bad news, that’s your job. Don’t ignore the bad news: ignoring bad news doesn’t make it go away. It’s not fun to be the bearer of bad news. However, you don’t have to emphasize the bad news.

Give them the good news and the bad news, then emphasize the good news.

BE CONSTRUCTIVE WHEN YOU CRITICIZE If you have to criticize someone, do it constructively. Don’t make them feel like a piece of crap. Don’t emphasize what they’re doing wrong. Show them the right way to do it, and emphasize doing it right.

The purpose of criticizing is to help the other person. Focus on being helpful. Do it in such a way that really helps the other person. Be gentle. Go easy on them. Don’t be mean.

Did a teacher ever criticize you in lab? Were they a jerk about it? How did it make you feel? You felt like crap, didn’t you? If you act like a jerk, your patients will feel the same way, so don’t be a jerk.

Just because other people are jerks doesn’t mean you have to be a jerk. Be a better person than other people. Be nice. Be helpful. Patients will love you.

EXAMPLES OF BEING POSITIVE 20F. A patient has never had a cavity before. You find 2 small cavities. They might be crushed to hear that they have a cavity. How do you break the news? First of all, don’t say anything until you ask a teacher. You could be way wrong. These “little cavities” might be nothing at all, or they may actually be big cavities. It’s not like we have a lot of experience now. Once you’re sure that they are little cavities, here’s one way to break the news. I want to let you know what a found. I’m not seeing any big problems. However, there are 2 places where the grooves are a little deep, and they have a little decay at the bottom. What I want to do it remove the decay and put a little filling in there to seal up that deep spot. I don’t think this is a big problem. I don’t want you to feel bad. I don’t think there’s much decay down there at all. The filling that we put in probably won’t be much bigger than a sealant. And if we do this now, well take care of this before it becomes a big problem. This is a gentle way to break the news.

Aside: I want you to notice something else. Notice that I didn’t offer the patient any guarantees. I didn’t say There isn’t much decay down there. I said I don’t THINK there’s much decay down there. I also said probably. The filling that we put in PROBABLY won’t be much bigger than a sealant. We think the cavities are small, but we don’t know for sure, so don’t make any guarantees.

22M. He says that he brushes his teeth 2-3 times a day, and he just started flossing every day. You disclose him. There’s plaque all over the teeth. He doesn’t seem to be lying. He must not be brushing very effectively.

30M. Hasn’t been to the dentist for years. Bombed out teeth. Most or all of the teeth can’t be saved.

Complete or partial denture on the top, complete or partial denture on the bottom. First do the exam. Then tell the patient what you found. OK, I’m finished with my exam, so we can take a few minutes to chat.

First of all, I want to thank you for coming in today. It was a good idea to come in to the dental school. I think we can help you out. When I look at your teeth, I see that some of them are broken off, and others have big cavities. A lot of your teeth are too far gone for us to save, so we’ll have to take some of them out. The good news is there we have a lot of great ways to replace teeth, and I’d be happy to work with you and help you out. What I’d like to do is take all of the information and measurements from today and brainstorm with my teachers. We’ll come up with some different options. I’ll have you come back in and I’ll share those options with you and we’ll pick the one that’s best for you. Another positive interaction. Focus on how you can help the patient.

DON’T LET PEOPLE TAKE ADVANTAGE OF YOU You should be cool. At the same time, don’t let people take advantage of you. How can you both be cool and stand up for yourself at the same time? That’s hard to do. Here’s how you do it. Figure out what you’re willing to put up with and what you’re not willing to put up with.

For me, there’s really only three things I won’t put up with.

1) Patients who miss appointments. You better not put up with this either. It makes me sad when I see students waste their precious appointments on bums who don’t show up. Every time a patient no-shows, it costs you approx $130.00! The first time I talk to a patient on the phone, I let them know this and I also stress the point that if they no-show once or don’t give a 24 hour for a cancellation, that they will be innactivated and will never be able to be seen at the dental school.

Quite frankly, most faculty say that 2 no-shows is the limit, but I’m impatient and don’t like wasting time. So I make my own rules and if someone wasn’t to waste my time, then it’s their loss.

2) Patients who have big attitude problems. I’m not talking about the average jerk. I’m talking about the super jerk. I’m OK with the average jerk. I can deal with that. Here’s an example of what I wouldn’t deal with (if I were a woman of course): I don’t want a woman to be my dentist. I don’t think women are good dentists. I also wouldn’t put up with people who act violently.

3) Patients who have no trust in your skills. They should know that coming to the dental school is not like going to private practice. We’re students and are learning each day. The minute a patient tell you “I don’t think everything you charted is right” or “No, my previous dentist said that tooth was fine”, then you need to immediately say “I don’t think the dental school is the place for you, and you may need to find another dentist”.

4) Patients who are super cheap. I don’t mind people who like saving money. I don’t mind people who can’t afford the best treatment. I don’t like it when people want the best treatment and then don’t want to pay for it. I don’t have too much of a problem with this in school, but I’ll have to deal with it more after I graduate. Always remind patients that the prices we charge here at the school are about 1/3 of the fees in private practice. Not even public dental clinics are as affordable as we are.

GET PATIENTS TO SHOW UP FOR APPOINTMENTS One of the most important things you can do to succeed in the dental school clinic is to try as hard as you can to get patients to show up. Get patients in the chair. Unfilled appointments do you no good. Missed appointments do you no good. Last minute cancellations do you no good. What can you do to do this?

1) Identify and eliminate the bums.

2) Let patients know that you want them to keep their appointments, and if they can’t do it, please call ASAP (24 hour notice) so you can get someone else in.

3) *Confirm your appointments the night before*. I swear, people forget and get mixed up a lot.

This is all unintentional. You can cut down on this a lot by confirming appointments.

4) Keep a list of patients who can come in on short notice. I call a patient today to fill an appointment tomorrow. I do this.

5) Don’t procrastinate calling patients. Don’t be lazy. And even if you’re a bit nervous calling patients, do it anyway.

Never, Never, Never, Ever……Let a Patient leave the dental chair without a future appointment. Believe me, when you or the patient say, “ I’ll call you later and work something out”, it never happens

and you’ll sorry you didn’t plan ahead. Patients who walk away with your card and an appointment date written on the back will very likely commit and feel obligated to keep the appointment. If patients don’t have their schedule with them, tell them that you’ll call that evening to schedule the next appt. Even if the next appointment is a 6 month perio recall, go ahead and schedule it.

SMALL TALK Small talk aka building comfort and rapport aka BS-ing with the patient. It’s usually a good idea to make small talk at the beginning of a phone call or at the beginning of an appointment. You don’t always have to do it. It makes the patient like you and trust you more and makes your job more fun.

Some people feel uncomfortable making small talk. Does the thought talking to patients make you feel nervous and terrified? If this is you, try doing two things. 1) Use open ended questions. 2) Use give and take.

What’s the difference between an open ended question and a closed ended question? It takes a lot of words to answer an open ended question. Example: What are your plans for this summer? It takes one word to answer a closed ended question. Example: Are you glad it’s summer? If you’re making small talk, open ended questions are better. If the patient is wearing a rubber dam, closed ended questions are better.

Ask open ended questions when 1) you want the patient to talk a lot and 2) you want the patient to control the direction of the conversation. Ask closed ended questions when 1) you want the patient to not talk a lot and 2) you want to control the direction of the conversation yourself.

What is give and take? It’s when you ask the patient an open ended question. Then you let the patient answer. Then you answer your own question yourself, sharing a little something about yourself in the process.

Example #1: Small talk with closed ended questions.

Student: Did you have a good Thanksgiving?

Patient: Yes. Student: Did you see your family?

Patient: Yes. Student: Did you go home?

Patient: No, they came here.

Student: Did you eat a lot of turkey?

Patient: Yes. I guess this works, but it seems boring to me. It feels more like an interview than a conversation. And pretty soon you’ll run out of questions to ask the patient and you’ll feel awkward.

Example #2: Small talk with open ended questions.

Student: How was your Thanksgiving?

Patient: It was nice.

Student: What did you do?

Patient: I had thanksgiving dinner at my house. It was the first time I ever cooked a whole Thanksgiving dinner all by myself.

Student: What did you serve for dinner?

Patient: You know, I tried this new sweet potato casserole…

When you ask open ended questions, the patient opens up more. Start your questions with the words how, what, or why.

Example #3: Small talk with open ended questions and give and take. Try doing this when the patient really doesn’t open up.

Student: How was your Thanksgiving?

Patient: Good.

Student: Mine was pretty good too. What did you do?

Patient: I went home.

Student: Me too. I went to see my parents. They only live 2 hours away, but I haven’t seen them since summer. I was really happy to see them.

Patient: That’s nice. Where do they live?

Sometimes you can’t get a patient to shut up. You wait for them to stop talking, but they don’t. You wait for them to take a breath, but it seems like they don’t need to breathe. You want them to shut up. You want to discourage conversation. What can you do?

You can try to discourage conversation non-verbally. How? Don’t look at them, and don’t just sit there.

Do stuff. Go type on the computer. Set up your instruments. Put the blood pressure cuff on the patient and take the BP. Put the napkin chain on, lean them back, turn the light on. Then put the mirror right above their blabbering mouth. If you’re just standing in the hall, start to walk and motion for them to walk with you. They usually get the hint. If not, then you might have to say something. Here are some examples of what to say.

Are you ready?

Let’s go ahead and get started.

Would you open wide for me please?

We have a lot of stuff to do today and we don’t have a lot of time. Let’s focus real hard on getting stuff done, OK? AVOID TOUCHY SUBJECTS I generally don’t talk about certain things at all with patients. Religion and politics and death are the some worst topics. Whenever you discuss religion and politics there’s a chance that you’ll offend them or make them really mad.

HUMOR People say use humor with your patient. It makes them feel good and relieves their anxiety. I say it’s ok to be funny, but it’s more important to be caring. If you’re a funny person and you want to crack jokes, that’s ok. Just make sure to be caring too. Otherwise you come of as an arrogant jerk. If you’re not a funny person, it’s ok. Don’t feel bad, and don’t try too hard to be funny. Just focus really hard on being caring.

It’ll have a better effect than being funny.

If you do crack jokes, you should avoid self-deprecating humor. Example of self-deprecating humor: you screw something up and say Gosh, I’m an idiot.

AVOID JARGON/SPEAK AT THE SAME READING LEVEL AS THE PATIENT I feel that many dental students and teachers generally use too many big words. Why is this a problem?

When you explain something, the most important thing is to get the patient to understand. It’s easier for people to understand things when you don’t use big words. There was a table clinic about this last spring.

Now don’t talk down to people. I’m not saying talk down to people. What I’m saying is: phrase your ideas in a way that’s easy for the patient to understand.

BE SUCCINCT Some people talk forever and they still can’t get their point across. This is annoying. Don’t do that. When you explain things, don’t talk forever. Keep it short and to the point.

THE SCHPEEL A lot of dentists develop their own personal schpeel for various topics. A good schpeel will make present information in an easy-to-understand manner and it won't leave out any important information. Listen to your instructors when they give their schpeels and start to develop your own.

An example, explaining why antibiotics won't cure an odontogenic infection: Patient: Can you just give me some more antibiotics for my toothache?

Student: Antibiotics won't make the toothache go away. They won't cure the infection inside your tooth, because the they can't get inside the tooth. We can get the antibiotics all around the tooth, but just not inside it. The only way to treat that infection is do a root canal, or take the tooth out. Let's say that the infected tooth is like a burning house. Using antibiotics is like spraying water on the outside of the burning house. It helps a little, but the house keeps burning.

Another example, explaining the benefit of putting a crown on a root canal tooth: Now that we finished the root canal on this tooth, the infection appears to be clearing up quite nicely.

On the other hand, teeth that have had root canals aren't as strong as they once were. There's a risk risk this tooth will fracture in such a way that we can't fix it. You might bite down on a cherry pit or a steak bone in bite just the wrong way, the tooth may break. Then again, you could live the rest of your life and the tooth may never break. There’s about a 50/50 chance. If we put a crown on this tooth, that gives you protection from fracturing the tooth. And it gives you a great chance of keeping that tooth until you’re a little old man. And if gives you peace of mind, and you don't have to worry about the tooth breaking. Now the decision is yours. If you’re willing to take the risk of breaking the tooth and losing the tooth, you don’t have to get a crown. However, if you want the protection and the peace of mind, we'd be happy to work with you. My recommendation is to go ahead and get the crown, and if you were my dad or my brother, without a doubt that's what I'd do. So I've given you my recommendation and now the ball's in your court. Whenever you decide that you’re ready, just give me a call and we’ll set up an appointment.

NON-VERBAL COMMUNICATION Communication experts say that when you talk to people, your non-verbal communication is much more powerful than your verbal communication. Two significant factors are your voice tone and your body language. Be aware of your voice tone and body language. When you’re frustrated, do people get mad at you even though you’re trying to be polite? Maybe you’re communicating to them with your voice tone and your body language. Start to be aware of this.

DON’T OVER PROMISE AND UNDER DELIVER DO UNDER PROMISE AND OVER DELIVER *DON’T GUARANTEE ANYTHING* Don’t guarantee anything, that’s a cardinal rule! It’s unethical to guarantee anything in our profession. Nothing in dentistry lasts forever, and there’s no such thing as perfection.

Patients will ask “Do you promise me that my tooth won’t be sinsitive once you fill my cavity?”

Your response could be “ I hope it won’t be sensitive, but we won’t know until the job is complete.”

You receive no benefit from offering guarantees. If you don’t follow through with the guarantee, then you’re a liar and a scumbag. Use the words maybe, might, probably, and I think.

If there’s a big cavity, you don’t know for sure what it’s gonna take to fix it. It might need a filling, it might need endo/buildup/crown, or you might have to extract the tooth. Don’t say we can fix that cavity with a filling. You don’t know if you can do that or not. If you say something like this, that’s called over promising, that’s making a promise that you can’t necessarily keep. Don’t do that. You should say I don’t know if we can save the tooth, we may be able to save it, but we may need to take it out. You’re preparing the patient for the worst case scenario. This is called under promising. You should do this.

If you under promise and you’re wrong, and you actually can save the tooth, then you’re a hero and the patient loves you. If you over promise and you’re wrong, and you actually can’t save the tooth, the there’s disappointment, the patient questions your honesty, and gets mad. This is one way lawsuits get started.

Broken guarantees.

When giving anesthesia, don’t say a little bit of pain now, no pain later. That is over promising. Don’t do that. You don’t know how well the anesthetic will kick in. You can say I’ll be as gentle as I can, I’ll do everything I can to make this easy on you.

If you’re doing a filling, and it’s taking forever, don’t say we’re almost done, only 20 more minutes.

Because it might take you an hour longer. You don’t know for sure that you can be done that fast. You can say we’re getting closer to the end, if we’re lucky, we might be done in 20 minutes.

CONFIRM YOUR APPOINTMENTS I recommend calling your patient the day before the appointment to confirm the appointment. Don’t think that this is annoying to the patient: most patients really appreciate it. Very few patients find it annoying.

And I know it’s a hassle to confirm your patients. You have too much stuff to do already, you don’t need more stuff. But if you confirm your patients, you’ll have less missed appointments. It’s as simple as that.

How bad do you want your patients to show up?

What to do if you have an empty appt slot or a patient cancels/noshows……

1) Go to e-chair and learn something. They almost always need extra help in e-chair. You’ll get time units and maybe a pulp extirpation or a great patient who needs comprehensive dental care and wants you to do it. I’ve taken on over 10 patients from echair who needed endo, crowns, bridges, implants, and SRP. You never know what you’re going to get, and the more you’re down there, the chances of you getting some good stuff are higher.

2) Go to Oral surgery and yank some teeth. You can do this only if you’ve had your rotation in OS. Every tooth extraction is different and you’ll learn something new with each one you do. If you haven’t had your rotation, go up there and assist the OS residents. They’re always doing amazing cases and could use assistants. Assisting a resident gives you 1 time unit and you’ll learn something cool that’ll hopefully give you more confidence with complicated extractions.

3) Assist in Grad perio or Grad Endo. You get 1 time unit for each time you assist a resident and you’ll also learn some cool tricks/techniques. I’ve learned a lot just by watching them do some crazy procedures.

4) Assist your buddy in clinic. Even though you only get 0.5 time units for this, when the faculty see that you decided to stay in clinic as opposed to go home, they will respect you more and give you a better evaluation when clinic grades are due.

If you want to be finished with graduation requirements a semester early and have all your times units….. do one of the 4 options above everytime you don’t have a patient.

Going home and doing nothing is simply LAZY, the faculty don’t like this, and the more you skip, the likely you’ll be crunching to finish requirements come graduation time.

You’re paying to learn something from this place, and going home during clinic hours is a waste of money. Once you graduate, you’ll be paying a lot of $$$$$$ to learn from CE courses.

PART 2: TELEPHONE CALLS

ADULT NEW PATIENT: FIRST PHONE CALL (ADULT PATIENTS THAT ARE NEW TO THE SCHOOL) The first phone call is very important. You don’t just make an appointment. You start to build a relationship. You get the patient to like you. You explain all the rules and hassle that goes along with the dental school. You let patients know that missing appointments isn’t acceptable.

It’s important to not make the appointment right away. Wait. Talk to the patient for a while. Then make the appointment after you’ve talked for a while. Why? You want to figure out if someone is flaky before you give them an appointment. Don’t give an appointment to a flaky person. Don’t waste your valuable appointments on flaky people. If you choose to give a flaky person an appointment, or a teacher makes you see a flaky patient, make sure you lay down the law real clear BEFORE you give them an appointment.

Here’s the general pattern for my phone calls.

1) Introductions and rapport 2) Chief complaint: what does the patient want 3) Set expectations: what does the student want 4) Make the appointment 5) Final details 1) INTRODUCTIONS AND RAPPORT Patient: Hello.

Student: Hi. My name is Kate Williams, and I’m calling from the dental school. Could I talk to Mr. Chris Rice please?

Patient: This is Chris Rice.

Optional: Student: What would you like me to call you?

Problem: Mr. Rice is OK. Doing this shows the patient you care and gives them respect.

Student: Nice to meet you Mr. Rice. I’m Kate and I’ve been assigned to be your dentist. How are you today?

Patient: Real good, thanks.

This is a great time to chat with the patient and make small talk.

Student: Do you have a few minutes to chat right now?

Patient: Yes, I’ve got a few minutes.

Asking them if they have a few minutes is a good idea. You need at least 5 minutes to talk about everything you need to talk about. A patient in a hurry won’t give you that. If you just set up and appointment and don’t talk about other stuff, it could hurt you later. If they don’t have time to talk right now, tell them you’ll call back later, and if they want to call you in the mean time, that’s ok.

Problem: Patient can’t understand you. Speak slow, loud, and enunciate. You need to do this for some elderly people.

Problem: Patient has a hard to pronounce name. You have no idea how to say it. Give it your best shot.

Then say I don’t know how to say your name, can you help me? Say it back to them, remember it, write it down.

2) CHIEF COMPLAINT: WHAT DOES THE PATIENT WANT? Student: Do any of your teeth hurt?

Patient: No, they’re doing ok.

Student: That’s good. I’m glad to hear that.

Figure out right away if they’re in pain. If they’re in pain, addressing the pain should be your top priority.

The first appointment may be an emergency exam rather than an comprehensive exam.

Student: Tell me, what is it that you’d like me to do for you teeth?

Ask them what they want. This again shows respect and lets them know you care. The response might be real short, or they might talk for several minutes. If they talk for a long time, don’t interrupt. Many students feel a strong urge to interrupt. Fight it. If you find yourself interrupting a patient, stop. Say I’m sorry, I interrupted you, keep going.

I usually get involved with dental dialogue at this point too. I venture guesses as to what may be causing their problems and what I can do about it. Don’t get too detailed. And of course, don’t make any guarantees. Tell them you’re only guessing at this point.

3) SET EXPECTATIONS: WHAT DOES THE STUDENT WANT? Student: Have you ever been to the dental school before?

Patient: Just once for the screening appointment.

Student: OK. You might already know this, but I just want to tell you a little bit about how the dental school works.

(APPOINTMENTS) The first appointment is just the exam. You come in, we do the exam. After you leave, I talk with the teachers and figure out what you need, then I call you and let you know what we come up with.

The appointments are three hours long. If you need a lot of work, it’ll take a lot of appointments.

The appointments are either at 8:00 or 12:00, that’s it. If you need to cancel or reschedule an appointment, please call me at least a day or two in advance. (This is their first notice about canceling/missing appointments.)

(PAYMENT) The dental school wants you to pay for the appointment the day you come in. I’ll do my best to give you an estimate before you come in. The first appointment is usually $95, that covers the exam, the x-rays, and the impressions. Once I figure out what kind of treatment you need, I can give you an estimate for that. Payment plans are available.

(PARKING) The parking is terrible. The lot is too small and we usually run out of spaces. If you don’t come early, you’ll have to find a space in the street. I always park on the street and walk 3 blocks to get to the school.

(BABYSITTING, I'll only say this if I think the patient might have little kids) If you bring children with you, you have to bring someone to watch them for you. We can’t watch them.

Student: Did you know any of this already?

Patient: Most of it, ya.

Student: Any questions about any of it?

Patient: Nope.

Student: Are you ok with it?

Patient: Ya. If someone wants to be a patient here, they have to be ok with all of this. If they’re not OK with it, then they can’t be a patient here. Don’t make an appointment. Don’t waste your time. Don’t waste their time.

Problem: $95 is too expensive. If it’s really a problem, then the patient can’t afford treatment at the dental school.

Problem: I already paid $53 for the x-rays. OK, then you pay $42 instead of $95 (95-53=42) Problem: Patient lives 4 hours away. This may or may not be a problem. Anyone who is willing to drive that far must have a very good reason for coming here. Ask them why they come so far (usually to get the cheaper care). Suggest that they find a closer dentist. Emphasize that appointments are longer and something that takes 3 appointments in private practice might take 6 appointments here. And if plans don't work out absolutely perfect the first time, it might take 8 appointments. What if you attempt to cement a crown, and it doesn't fit and has to be remade? What if you forgot to take a bite registration, and you need it to mount their casts, and the patient has to come in just for a bite relationship? Little problems like that are a reality, and there's a good chance that something like that may come up. It's important that the patient knows this and is OK with it.

4) MAKE THE APPOINTMENT Student: Would you like to make an appointment for the exam?

Patient: Sure.

Student: Do you have your calendar there?

Patient: I’m grabbing it right now.

Student: Good. My first available appointment is Monday June 3rd at 8:00. Would that work for you?

Patient: That’s not good for me.

Student: I have two other appointments that week, Tuesday June 4th at 12:00 and Thursday June 6th at 8:00. Are either of those ok?

Patient: Let’s do the Thursday appointment.

Student: OK, I’m writing this down. That’s Thursday June 6th at 8:00. (This is repeating it back to the patient.)

When I make appointments, I usually don’t say “When would you like to come in?” I usually say “These are the appointments I have, do any of them work for you?”

It’s very important to say the day of the week (Thursday), the month (June), the day (6th) and the time (8:00) all together. And when you make the appointment, repeat it back to the patient. Why? It’s so easy to get dates and times mixed up. People get them mixed up all the time (Oh, I thought the 6th was a Wednesday. Or, I thought you said 9:00, not 8:00.) When patients get mixed up, they don’t show up to appointments, and you suffer. Try very hard do make sure the patients don’t get things mixed up. That’s why you repeat it back to them.

Student: If for some reason you can’t come in, please call me as soon as you can. Call me at least a day ahead of time. (This is their second notice.)

Patient: OK. Student: Let me give you my phone number. Do you have a pencil?

Patient: Ya. Always good to ask if they have a pencil before you tell them something to write down.

Student: OK, my phone number is 913-blah-blah-blah. That’s my cell phone, that’s the best way to get ahold of me. If I don’t answer just leave a message. I’m usually able to call you back within a day.

Saying this and doing this is courteous. Patients usually appreciate this.

Student: I’ll try to call you the day before to confirm.

Patient: OK. If you say this now, then when it actually comes time to make the confirmation phone call, you don’t have to feel like you’re bothering them. Patients usually appreciate confirmation calls.

Problem: None of the appointments are OK. Say These are the only times I have. If none of them work for you, I can’t make you an appointment right now. If something frees up, call me. Otherwise I can call you in a few weeks and see if anything works then. Or you could try to get in at another dental clinic.

Problem: Patient has very limited availability. For example, the patient can only come in Fridays. Or the patient wants to come in the same time as his wife (another student is the wife’s doctor); this is a hassle because you and the other student have to coordinate your schedules with the patients’ schedules, and sometimes you have to coordinate with the teachers’ schedules too. It can get way complicated real quick.

Ask yourself, are you willing to put up with it? Do you want this patient bad enough to accommodate their requests? Or is their request impossible to accommodate, and you’d rather not see the patient?

If you’re willing to accommodate them, say this. The dental school isn’t very flexible and it may be a challenge accommodating your needs. I’ll try as hard as I can to accommodate you, and maybe everything will be OK. If you can’t accommodate them, say this. I don’t think this can work out. The dental school isn’t very flexible, and if someone wants to be a patient here, they have to be flexible and work with the school.

We tell people this when they sign up to be a patient here. If the only day that you can come in is Friday, I don’t think the dental school can meet your needs. I don’t have any Friday appointments at all for 2 months. And even then half of the teachers aren’t here on Fridays. If something changes with your availability and you can come in on other days, maybe we can give it a try. Otherwise, there are hundreds of dentists in town. Maybe you can go see one of them. That’s the best I can do, and that’s all I have to say. I wish there was something I could do, but there isn’t. I don’t have any control over the school. OK, if something changes and you still want to come in, give me a call, OK? All right. Bye bye. Then write it up in the record. These phone calls can be hard. If you’re considering doing this, I recommend asking a teacher for help.

5) FINAL DETAILS (PHONE NUMBERS) Student: This phone number that I’m calling you at, 913-blah-blah-blah, is this your cell phone, home phone or what?

Patient: It’s my cell phone.

Student: Do you have a home phone number: Patient: Ya, it’s 816-blah-blah-blah.

Student: Do you have a work phone number or anything else?

Patient: Ya, my work phone. It’s 785-blah-blah-blah.

Student: Anything else?

Patient: I have email, but I never check it.

Student: What’s the best way to get ahold of you?

Patient: Usually my cell phone.

It’s a really good idea to get all the contact info. It may be really useful at some point in the future. If I’m trying to get in touch with the patient, I can now call cell, home, and work phone numbers. When I call to confirm, often times I leave the patient voice mails on all 3 numbers.

(MEDICATIONS) Student: Let me ask you this, are you taking any medications?

Patient: Yes. Student: You don’t have to tell me about it right now, but I’ll ask you all about it when you come in.

I want to know the name of the medication, how to spell it, why you’re taking it, how many mg are in a pill, and how many pills you take a day. Would you mind writing this down and bringing it in to me?

Patient: I can do that.

Student: Thank for doing that, I really appreciate it. That’ll save us some time when you come in.

(DIRECTIONS) Student: One more question. Do you know how to get to the dental school?

Patient: It’s confusing, but I think I can get there.

Student: Works for me.

Sometimes patients really don’t know how to get here. Giving them directions now might prevent them from being late.

Student: Well, I think we covered everything. I don’t have anything else to say. Do you have any questions for me?

Patient: Not right now.

Student: Sounds good. Well Mr. Rice, it was a pleasure talking with you, and I look forward to meeting you when you when you come in. If you need anything before then, feel free to give me a call.

Patient: Thanks.

Student: No problem. See you later.

Patient: Bye. It’s always good to be polite.

ESTABLISHED ADULT PATIENT (ADULT PATIENTS THAT AREN'T NEW TO THE SCHOOL) These will either 1) be on recall (they don't have any work that needs to be done) or 2) have unfinished dental wok. If you are assigned a patient that's been to the school before, try to figure out whether or not they have unfinished work before calling them. This will influence what you say in the phone call.

RECALL PATIENTS Telephone calls for recall patients are generally less involved than telephone calls for recall patients.

Likewise, a recall patient exam is generally less involved than a new patient exam. This is because recall patients typically 1) aren't in any pain, 2) you don't find any dental work that needs to be done, 3) only want a cleaning, 4) instead of an FMX they need 4 BWX or no x-rays, and 5) their medications and restorations and other information is already in the computer. If a recall patient does have a problem, please do take the time and effort to address that problem.

For the most part, the new patients that get assigned to want an appointment really bad. They made an effort to become a patient at the dental school. They've waited on the waiting list, they've already come in for a screening appointment, and they've been waiting for a student to call them. Now you're finally calling. They're very happy to hear from you and very eager to talk to you.

With recall patients, you never know what you're gonna get. Maybe the patient wants a recall appointment and they've been waiting for someone to call. Maybe they're due to come in but they don't really want to.

Maybe they've been trying to come in for an appointment, and they've been calling the school and their old

student doctor, and the old student doctor didn't return phone calls. Maybe they started seeing another dentist. Maybe they're a problem patient. You never know. It's best not to make any assumptions.

When you call recall patients for the first time, here is a good set of objectives for the phone call.

1) Inform the patient that you are the new student doctor.

2) Ask if they have any dental problems 3) Let them know when they are due for recall.

4) Invite them to make an appointment.

I think saying “I'm calling to schedule your checkup” is a bit pushy, whereas “I'm calling to let you know that you're due for your check-up” is a more pleasant approach. Maybe a practice management consultant would disagree, but if you tell a patient they're due for a check-up and they still don't want to come in, I'm not gonna force them.

Student: Hi my name is Dr. Kate Williams, and I'm a dental student, and I'm calling from the dental school. Is Mr. Chris Rice there?

Patient: This is Chris Rice.

Student: Well hello Mr. Rice, nice to meet you.

Patient: You too Dr. Williams.

Student: I just wanted to call and let you know a couple things. First of all, I'm your new student doctor. I looked at your record, and I saw that Jay Joshi was your last student doctor. He graduated and he's not here any more, so you've been assigned to me, and if you need anything at all, I'd be happy to help you out. Are you having any problems with your teeth right now, or are they doing ok?

Patient: They're doing ok.

Student: Good. I'm glad to hear that. Well I also wanted to let you know that I was looking in your record, and the last time you had an exam and cleaning was September. That was about 8 months ago. Usually we'd like to get you in here every 6 months or so. Are you interested in making an appointment?

Patient: Yes I am.

Student: Would you like to make one right now?

Patient: Sure.

For established patients I usually don't talk in detail about the dental school (long appointments, bad parking, etc). I also don't offer to give directions.

I do: 1) 2) 3) 4) 5)

ask them to give me 1 day notice if they can't make it ask if they have any other telephone numbers they can be reached at give them my telephone number ask them if they'd like a price estimate for the visit ask them to bring their med list if they're on a lot of medications.

PATIENTS WITH UNFINISHED WORK Here are the objectives for calling patients with unfinished dental work 1) Inform the patient that you are the new student doctor.

2) Ask if they'd like to continue with their dental work.

3) Ask if they have any immediate or urgent concerns (broken tooth, crown fell off) 4) Invite them to make an appointment.

5) First appointment with you is diagnosis only.

Student: Hi my name is Dr. Kate Williams, and I'm a dental student, and I'm calling from the dental school. Is Mr. Chris Rice there?

Patient: This is Chris Rice.

Student: Well hello Mr. Rice, nice to meet you.

Patient: You too Dr. Williams.

Student: Say listen, I just wanted to let you know that I'm your new student doctor. I saw that Jay Joshi was your last doctor, but he graduated, and he's gone, and now you're assigned to me.

Patient: Cool.

Student: According to your record, it seems that you still have some dental work that needs to be done. I was wondering if you'd like to pick up where we left off.

Patient: Yes, I'd like that.

The first appointment with and patient will be a diagnosis. If the diagnosis takes a long time, that's the only thing you will do that appointment. After you've done a few diagnoses and done some other procedures a few times, MAYBE you can do a short easy diagnosis and a short simple procedure the same day.

Some patients grumble at this. They don't want to come in for another diagnosis. They think it's a waste of time. They just want to get the work done. They'll ask if you can do the diagnosis fast and get some work done. You may feel shy, reluctant, and guilty when you tell patients “The first appointment is just a diagnosis�

Don't feel bad, and don't let patients make you feel bad. It's not your idea or your decision to do the diagnosis first. It's the school's rule and you have to follow the rules. If a patient fusses at coming in for a diagnosis, explain that this is the school's rule, and transfer diagnoses are part of being a patient at the school. According to school policy, the order of business is: 1) Do a diagnosis 2) Get the patient treatment planned 3) Perform the treatment indicated on the treatment plan It doesn't matter that the patient already has a treatment plan with the old student doctor. That goes out the window. You can use that old treatment plan as a guide for what you will do, but you have to devise a new treatment plan with a treatment planner.

Student: Great. I'd be to make an appointment and I'd be happy to work with you. For your first appointment with me, we'll do a diagnosis because the school's rules say the first appointment with your new student doctor is a diagnosis. Mainly, that gives me a chance to get to know you as a patient, get me familiar with your case, and check over your treatment plan. I'll verify that the proposed treatment needs to be done and see if we need to add or change anything. A couple days after that appointment I'll discuss your case with with one of my faculty and then we can continue doing your dental work.

And of course I then: 1) set up and appiontment 2) ask them to give me 2 days notice if they can't make it 3) ask if they have any other telephone numbers they can be reached at 4) give them my telephone number 5) ask them if they'd like a price estimate for the visit 6) ask them to bring their med list if they're on a lot of medications.

PEDO PATIENTS Pedo clinic is only open MTWTF in the morning and Tuesday and Thursday in the afternoon. It is closed MWF afternoon. There is a special place in the CMS scheduler for pedo appointments. You can't book a chair in pedo if all the chairs are full.

For the most part, pedo patients have primary teeth and are 12 and younger. Patients who have no more primary teeth and are 13 and older go to the general clinic.

Sometimes you know the patient's name but you don't know the parents' name. So when you call on the phone who do you ask for? This is what I do.

Student: Hi my name is Chuck Abbick, and I'm a dental student at the dental school. Madison Hernandez has been assigned to be my patient, and I'm calling to talk about setting up an appointment. Who would I talk to about that.

Parent: You can talk to me, I'm his mom.

Student: Good, I'd be happy to. Tell me, what's your name?

Parent: Annie Hernandez.

Student: Well nice to meet you Annie.

Parent: You too Chuck.

You can consider talking about these things too.

1) Ask how the child does at the dentist, just to get an idea of what you're in for.

2) Ask if the parent has other children. It's nice to know if the other children are patients at the school and who their student doctor is. Or, if the other children have never been to the dental school, you can invite them to make an appointment.

3) A parent has to be present at the appointment. If a parent can't come, there's extra paperwork to do.

4) Sometimes setting up appointments in the children's clinic is difficult because you have to coordinate your schedule, the pedo schedule, and the patients schedule. And the pedo clinic is only open at certain times. And it fills up fast. You'll do your best to set up a time that works for everyone.

5) Please call me 2 days in advance if you can't make it.

6) Price estimate.

If the patients have never been to the dental school, give them the new patient info. Please note that adult new patients go through screening before they are assigned to you. Pedo new patients have not went through screening. So when you call pedo new patients, be aware of that, and understand that a higher percentage of pedo patients might not work out.

If the pedo patient misses a lot of appointments, don't hesitate to lay down the law.

Usually pedo appointments are 60-90 minutes. Most appointments don't go 3 hours. A lot of children won't sit still for 3 hours.

In pedo, you do the diagnosis and cleaning at the same time. They are charged as a single procedure, not 2 separate procedures. For the exam appointment you might or might not take x-rays, so you're not sure about the fee will be. It may be 1) 2) 3) 4)

Diagnosis/cleaning Diagnosis/cleaning + 2 BWX Diagnosis/cleaning + 4 BWX Diagnosis/cleaning + FMX/pano

So I'd say anywhere between 30 and 80, depending on what kind of x-rays your child needs.

IDENTIFYING AND GETTING RID OF BAD PATIENTS What kind of people do you not want to be your patient?

1) People who can’t afford the first appointment

Your graduation depends on people pulling money out of their pockets. Patients who can’t even pay for the first appointment won’t help you, and the dental school won’t help them. Don’t even give them an appointment, it’ll waste your time and theirs. It’s kind of messed up, but that’s the way the dental school works. They don’t do charity work here. When I figure out a patient can’t afford treatment, this is what I tell them: I want to tell you, the dental school is cheap. It’s about half the price. But it isn’t free. Sometimes people come here and the treatment is thousands of dollars. There are free clinics in the city. You can get work done there, and they don’t charge you. If you want to save money, I’d recommend checking them out. You can get a list of the clinics at our front desk. The number is 235-2100.

They usually go for this. If they do, write up the chart and inactivate them. Of course, give them the option to call you back if they change their mind.

2) Patients who miss a lot of appointments.

Read the chart. If there’s notes about the patient missing appointments, you know that’s trouble. If a patient like this is assigned to you, I suppose you have to call them. You need to let the patient know that it’s not OK to keep missing appointments. These phone calls aren’t very fun. It’s not fun to lay down the law, but you should do it. It’ll make you stronger. And you’ll have to put up with less missed appointments. And it’s easier to lay down the law before the patient misses a bunch of appointments than afterwards.

Student: I was reading your chart and it said you’ve missed some appointments. What happened?

Patient: Some lame excuse… or maybe a valid reason, who knows.

Student: I can give you an appointment, but you have to show up. The dental school has a rule, if you miss two appointments, you can’t be a patient here. If you make an appointment with me, you have to show up. And if for some reason you can’t make it, you have to call me 24 hours in advance.

Otherwise, you can’t be a patient here. Are you OK with this? Can you do this for me? Do you want to make an appointment right now, or do you need to check your calendar?

3) Patients with severe attitude problems.

Most attitude problems can be managed by being patient, polite, and caring. Some can’t. If your patient has a lot of attitude, consider dismissing the patient. Especially consider doing this for denture patients-recall Dr. Elrod talking about the psychotic patient. You’ll need a teacher’s help to dismiss the patient. A friend of mine tried to treat a denture patient with an attitude problem. She wasted 5 appointments on the guy, and did a bunch of lab work, and then told him to go away. She got no time units for those 5 appointments. She should have told him to go away after the first appointment.

4) Patients who are not OK with the hassle of the dental school.

If they’re not OK with long appointments or something, that’s OK. They don’t have to be a patient here.

There are hundreds of other dentists in the city.

REPEAT CANCELLATIONS AND NO SHOWS If a patient is late, and it’s been 10 or 15 minutes, call them. Ask them where they are. If you catch them at home or in bed, that tells you how much they care about you and your time.

Don’t reschedule the appointment right away! If a patient calls to cancel at the last minute and asks for another appointment, don’t give it to them right then. That’s nonverbally telling the patient that it’s ok to miss appointments. You need to let the patient know it’s not ok. You need to find a way to say no. Tell them you don’t have your schedule on you right now. Tell them to call back in a couple days. If they never call back, they’re not serious about dental treatment. Inactivate them. If they actually do call back, lay down the law before you give them the appointment. And you don’t have to give them your first available appointment. You can schedule it a few weeks out.

PART 3: ESTIMATES A GENERAL IDEA OF THE TIME AND MONEY INVOLVED

GIVING ESTIMATES Patients want a general idea of how much something will cost. Sometimes they want to know this on the very first phone call. That's fair question, and it's entirely possible for you to provide a rough idea of what the cost may be.

When giving estimates, make sure to emphasize these points: 1) All the prices you mention are rough estimate. It's just a guess. The price may change. After the diagnosis and treatment planning is done, we can provide a better estimate.

2) You have not seen the patient. Maybe you've seen x-rays in the chart, but you have not seen the patient in person. There's no guarantee that what the patient wants is what we're willing to do. Just because the patient wants a root canal doesn't mean we're going to do a root canal. We will only do a root canal if the faculty think a root canal is the best thing for the patient.

3) If the faculty determine that this is a difficult case, they won't let you see the patient. They will most likely refer the patient to the AEGD clinic.

You never know what will happen An #30 O amalgam can turn into and #30 MODFL amalgam and a crown some day.

You can plan to do an MO on #13 and discover a DO on #12 in the process.

A patient might want a “cleaning” and need SRP. A patient might want “fillings in the front teeth”, and the faculty determines that the maxillary anteriors are non-restorable and recommend TE's (extractions) and an RPD. A patient might want multiple crowns, and the faculty determines that it's a difficult case and refer the patient to AEGD. The clinic may decide to raise fees on all procedures.

PAYMENT PLANS This is how the payment plan works. Diagnosis and x-rays must be completed and paid for. Treatment plan must be in the computer and accepted by a treatment planner. Total cost of treatment must be over $500. Patient applies for payment plan at the patient accounts office. The cost of the application is $10, the patient only pays if approved, $10 is not paid that day, it is paid along with the down payment. Patient accounts checks the patient's credit with all 3 credit bureaus. If the patient has bad credit, they can opt to have a co-signer. If approved, the down payment is 20% of the total treatment fee. Then there are 10 monthly payments of 8%.

DENTURE PATIENTS I'm not a denture expert, but I have had denture patients. I'll share my experiences. If your removable faculty says something different than I do, listen to them, not me.

If a patient wants dentures, this is the information you want from them.

1) Do you have any pain in your mouth?

2) Do you have any natural teeth left? Which ones? Do you want to keep those teeth or take them out?

3) Do you have a denture right now? Top or bottom? Complete or partial? Have you ever worn a denture before? How do you like it?

Now it's fair for you to tell the patient what it's like to get dentures at the dental school. Billboards on I-70 talk about dentures in a day for $129. We don't do that at the dental school. You should tell them a bit about what it's like to get dentures here. Here are some points to emphasize: 1) It takes a lot of appointments, minimum is 7, average is 10.

2) It takes a lot of time. If everything goes perfect, the earliest we can finish your denture is 2 months. Average is 3 months. If maybe more. (Especially if you have to repeat steps, the patient can't come in when it's convenient for you, or you make the dentures around December. The school is pretty much closed all of December. Also consider spring break, fall break, and summer breaks.)

3) You will have no teeth while we make the denture. You will go without teeth for 4-5 months (2 months healing plus 2-3 months to make the denture). If they are not OK with this, consider temporary dentures, or immediate dentures, or going somewhere else.

4) Give them a rough price estimate. They can request a payment plan, and will probably get it if they have good credit. If you don't do the payment plan, oral surgery must be paid for before the work is done, and the dentures must be paid for before they're processed. RPDs must be paid for before the metal framework is fabricated.

5) Dentures are not real teeth. They feel different. Talking and eating is different.

6) After you get your dentures, there will be sore spots. We can adjust the denture to relieve the sore spots. Sometimes it takes a few appointments, but we will work as hard as we can to make the denture comfortable.

7) The top denture usually stays put, but the bottom denture frequently moves around a lot. We can consider placing implants in the mandible to address this.

8) Keep an eye out for problem patients. If you think a patient may be a problem patient, talk it over with a faculty before you get too far.

Example sequence of appointments (no extractions, no remaining teeth, conventional complete dentures).

The minimum number of appointments it takes to get dentures at the school is 7. It may take more. You may have to repeat a step, or a step may take 2 appointments. Or you may want to do more than one wax try-in (eg anterior was trying, full mouth wax try in).

1) Diagnosis, pano, removable consult, primary impressions (lab work: custom trays) 2) Final impressions (lab work: master casts, baseplates, wax rims, QA) 3) Wax rims, midline, OVD, jaw relation, choose teeth, etc (lab work: mount casts, set teeth, make the wax look pretty) 4) Wax try in (lab work: QA, wax down, process, remount, facebow preservation, polish) 5) Deliver dentures 6) 24 hour follow up 7) 72 hour follow up Example sequence of appointments (extract all remaining teeth, complete conventional dentures): 1) Diagnosis, panoramic x-ray, study models, removable consult, order oral surgery consult 2) Oral surgery consult. Oral surgery faculty determine pain control (local only, local and nitrous, local, nitrous, and IV sedation), who does the surgery (student doctor, honors oral surgery student, oral surgery resident), how many appointments (all in 1 or divide it up), and determine the fee for the surgery (residents charge higher fees). You must make the appointment for the oral surgery consult with the oral surgery receptionist. Generally, the oral surgery faculty will not do a consult without an appointment. You must be present for the consult. Oral surgery consults are performed in oral surgery clinic. The appointment doesn't need to be in the CMS scheduler.

3) Oral surgery appointments. Sometimes the honors students and residents are booked months in advance and you have to wait. Also, you must wait 2 months after surgery before you make primary impressions.

4) Primary impressions. During this appointment, check the ridges. Are there any sharp spots? If so the patient may have to go back to surgery again.

5) Final impressions.

6) Wax rims, etc 7) Wax try in 8) Delviery 9) 24 hour 10) 72 hour Example sequence of appointments (partial dentures, no extractions, no surveyed crowns) 1) Diagnosis, x-rays (make sure you have BW's and PA's of all teeth), removable consult, study models (after this appointment, do treatment planning and design the partial on paper and the cast, QA the partial design, make custom tray if needed) 2) Perio treatment, operative treatment 3) Rest preps, tooth modifications, impressions for metal frameworks 4) Metal framework try-in and adjustment, tooth selection, jaw relationship 5) Wax try in 6) Delivery 7) 24 hour 8) 72 hour Fees Diagnosis :37?

X-rays: 53?

Study models: 6?

Extractions: 50 per tooth, 64 for 3rd molars, fees higher for residents Alveoplasty: 64? per quadrant Tori removal, tuberocity reduction: each time is different, plan for 100-200 per item Dentures: 399? per arch for conventional, THE O&R Open and report. We do this when the tooth is in bad shape, but we think we save it, but we’re just not sure. An O&R is an investigation. It’s an exploratory procedure. You're “seeing how far the decay goes.”

It’s half diagnostic and half treatment. It usually has three different outcomes. Before you do an O&R, you need to explain this to the patient, and you need to explain the three different outcomes.

1) You remove the decay and place a filling. Maybe you were close to the pulp. Maybe you place calcium hydroxide. Inform the patient that the decay was deep, it may need endo some day, and if the filling is large, recommend a crown to protect the tooth from fracture.

2) You expose the pulp. Now you either have to extripate the pulp (in anticipation of a root canal, buildup, and crown) or extract the tooth. I suppose you could place a temporary sedative restoration, but I think that's a bad idea. In order to do a root canal, the tooth must satisfy these 3 requirements: 1) it's restorable (no vertical root fractures, decay is far from bone), 2) it's periodontally sound, and 3) it's functional/strategic (it occludes with other teeth). Most root canal teeth also need a buildup and crown too. If the patient is an e-chair patient, the patient must agree to become an established patient at the school or we won't extripate the tooth; basically this means that after the e-chair visit, you have to do a diagnosis, FMX, and treatment plan before you can work on the root canal. Prepare the patient for this outcome before you start the O&R. Explain the number of appointments and fees involved with saving the tooth. Is the patient OK with this? Do they prefer TE or saving the tooth?

3) The tooth is not restorable, it needs to be extracted. Does the patient want the tooth removed that day? Are you going to place a temporary filling and do nothing for now? If the patient isn’t ready

to part with the tooth that day, I’d be hesitant to even do the O&R. Have you discussed options to replace the tooth? Does the patient wish to have it replaced? How, implant/bridge/RPD? If implant, have you considered immediate placement of the implant? OK, there’s so much paperwork and hassle to doing implants at school, I don’t know if immediate placement of an implant is even possible here. If bridge, are you considering an ovate pontic?

Fees for O&R outcomes 1) Case 1: emergency exam and restoration. (Note, we generally charge the emergency exam only in e-chair for patients who are not patients of record. For patients of record in the teams, we generally add a no-charge emergency exam to the treatment plan.)

2) Saving the tooth 1. Emergency fee: 39 (if you extripate only, the patient only pays 39+40=79) 2. Extripation fee: 40 (if the patient pays an extripation fee, then the price of the root canal on that same tooth is reduced by 40) 3. Initial exam: 4. FMX: 5. Study models: 6. Root canal: 7. Build up: 8. Crown: 9. Total: 3) Emergency exam and TE. Patient accounts will let the patient pay later if they get a TE. However if they get a root canal or extripation, they must pay the same day.

IMPLANTS A lot of patients want implants. It takes a lot of time and effort to treatment plan and implant. Please make the patient aware of the cost of the implant before you make this effort. It really sucks when you waste a lot of time and effort treatment planning an implant and later find out that the patient can't afford it.

Important points to mention 1) Getting an implant is a long process. Once we start planning, the average time it takes to get an implant in your mouth is 9 months. It can take over a year. If additional bone-building surgeries are needed, the time will be longer.

2) Just to do the implant, the average number of appointments is 6. It can be more.

3) Before we start the implant, you have to have all your cavities fixed and be caught up on your cleanings.

4) Give them a price estimate.

Sequence of appointments (implant retained PFM crown): 1) Diagnosis, FMX, pano (hard and soft copy), study models, restorative consult 2) Surgical consult (sometimes you can get this done on the first appointment, if you can, go for it, if you can't, at least try to do something else during this appointment too, the patient has to have caries and perio disease under control before you do the implant) 1. Prepare models for implant committee 2. Go to implant committee 3. Maybe make a surgical stent and/or a radiographic stent 3) The surgical faculty or resident may request and iCat CT image, this is an additional expense and appointment, this is made at the radiology window, you don't have to be there for the appointment 4) Placement of the implant (if you work with perio, they want you there at the surgery) 5) Follow up visits with the surgeon (you don't have to be there) 1. At this point you wait for osteointegration. Average time is 6 months.

2.

This would be a good time to order parts. Example order: impression coping, implant analogue, abutment 6) Uncover the implant (if it's a 2 stage surgery, you don't need to do this with 1 stage surgeries) 7) Impression (prepare models, have lab prepare abutment and fabricate crown) 8) Seat the restoration That's up to 8 appointments. Sometimes appointments 2, 3, 5, and 6 aren't necessary. That takes it to a bare minimum of 4 appointments.

Sometimes the patient may need additional surgical procedures (bone graft, sinus lift) before the implant can be placed. The faculty performing the surgical should be able to determine whether or not the patient is in need of these procedures.

CROWN & BRIDGE In private practice, a crown takes 2 appointments: the crown prep appointment, and the seating appointment. If the dentist uses a CERAC machine, it's only 1. At the dental school, it usually takes more.

If you can get the prep, impression, and temporary in 1 appointment, then thats good. A lot of times that doesn't happen at the dental school. It may take 2 appointments to do all that. Sometimes 3.

Also, sometimes the crown doesn't fit when we try to seat it. Sometimes we can adjust it a little to make it fit, sometimes we can't. During my time in the clinic, I only had to remake 1 out of 11 crowns. That's not too bad. I've heard stories of other people having to send the same crown on the same patient back to the lab 6 times before it fit.

I tell my patients the average number of appointments for a crown is 3. I also give the fee estimate. I think the school's policy is payment must be made before we start the prep.

For bridges, you have 1 or more appointments to do the prep, temporary, and impression. Then if it's a PFM bridge, you have an extra appointment to do a coping try in. Then another appointment to seat the bridge.

The price of a crown is: 371?

The price of a bridge depends on the number of units.

A 3 unit bridge is 371 x 3 = A 4 unit bridge is 371 x 4 = Etc. If the patient needs a buildup, there's also a fee for that.

PART 4: FACULTY ARE HERE TO HELP

ASKING FOR HELP The faculty are very excited for you to start treating patients. They look forward to meeting you, they want to get to know you, and they want to help. Sometimes things get tense, busy, stressful, and frustrating.

Sometimes you have to wait a long time for a faculty. But no matter what happens, please keep in the back of your mind that faculty want to help.

Sometimes faculty will approach you and ask if you need help. Usually they won't and you have to take the initiative to approach them.

The best time to ask for help is earlier rather than later. If you have a patient coming up, and you don’t know how to handle them, or haven’t done the procedure before, ask for help a day or 2 before the patient comes in. Ask what instruments you need. Ask about the steps of the procedure. Ask how to talk about difficult topics with the patient. Ask how to manage difficult or special needs patients.

Before you call your patients, ask a faculty if they'd be willing to sit with you and look at the patients on your patient list and talk about them. Maybe they can offer suggestions on how to approach managing your patients.

On the other hand, don't ask too many questions at once. That's a way to drive anyone crazy. If you want to find out how many questions is too many, you can say something like, “I have a lot of questions. We only have to talk about a few today, but if you have extra time, we can talk about more.”

It's ok for you to pull the faculty away from the patient and talk. You don't have to do all of your talking in front of the patient, especially if you have a “dumb” question. If they teacher says let's do TE #12, and you don't know what a TE is, that's ok. It's ok to ask the teacher, but you really shouldn't ask in front of the patient. Rather, you should say ok, walk away from the patient, motion to the teacher to come here, then ask what's a TE. Teachers say come to us for help, don’t go to the 4th years. 4th years say come to us for help, don’t go to the teachers. I say go to everyone for help. Ask several people the same question teachers and 4th years, and you’ll get different answers. Then take what works for you.

If you really want to learn more about communicating with people in general, patients, staff, teachers, everyone, then I recommend reading the book How To Win Friends and Influence People by Dale Carnegie. It’s the best book about communicating with people. I recommend that book, and a lot of other people do too.

DIFFERENCE OF OPINION Often times there are several different acceptable treatment options for a patient. There is more than one right way to treat a patient. Different faculty may have different opinions about which treatment is the best treatment.

It's ok to ask different faculty “How do you recommend I treat this patient.” If one particular faculty recommends a treatment plan that makes a lot of sense to you, it's ok to work with that particular faculty.

It's also a good idea to ask that faculty “Would you be willing to work with me on this case” before the patient comes in. Make sure to schedule the patient when that particular faculty is there.

It's ok to discuss advantages and disadvantages to various treatment approaches. It's not ok to say this treatment plan is better than another treatment plan, or this faculty is better or smarter than another faculty.

Once a treatment planner has approved a treatment plan, it's usually not a good idea to get a different faculty to change that treatment plan behind the treatment planners back. It's ok to change the treatment plan with the consent and approval of the original treatment planner.

If you have a difference of opinion with a teacher, I think it's a good idea to discuss the difference of opinion because it opens up the door to more profound learning. It gives you and the teacher to explain the reasoning behind your opinions. However, it's essential to be professional and courteous. Example: Faculty: This #3 is hopeless. We should think about TE. Student: You know, when I look at #3, I think it would be in the patient's best interest to save it.

Why is it that you think #3 is hopeless.

THREE THINGS I’VE NEVER DONE BEFORE There are three things that I had a hard time with. Injections, placing the rubber dam, and detecting and removing caries. You have very little opportunity to practice these things before the clinic. There’s really no way to practice these things outside the clinic. There's nothing wrong with asking for a lot of help.

Especially with the rubber dam. Don’t waste 20 minutes trying to put on the rubber dam. If your teacher makes you use a rubber dam, try to put it on. Spend 5 minutes trying. If you can’t put it on in 5 minutes, ask the teacher for help (or a dental assistant or a fellow student). Or you could ask the teacher to demonstrate the rubber damn right away. Note that you can get a different rubber dam kit from the dispensary that is superior to the one from CSR. I asked a lot of people for help with injections. It’s OK. Right now, I recommend focusing less on relieving the patient’s injection-related anxiety and more on not poking yourself with the needle. Once you’ve done a bunch of injections, then you can start working more on relieving the patient’s anxiety.

Different dentists have different styles. Find a style that works for you.

It took me a while to become confident detecting and removing caries. I especially had a hard time catching interproximal decay on BWX. You can always try these different approaches to caries. If a spoon scoops it out, it's caries. If it's sticky to the explorer it's caries, but you have to make sure it's a “stick” and it's not the “explorer being wedged.” If you use a round bur on the slow speed and the bur is rotation very slowly, the bur will “bounce off and rattle” on solid tooth structure, but it won't bounce of or rattle on caries. You can also use caries detecting solution; ask for SableSeek at the dispensary.

PART 5: TIME MANAGEMENT Can you get a recall exam and a prophy done in one appointment? Can you get an initial exam done in one appointment? Sometimes yes, sometimes no. It depends on your clinical skill level, your time management skill, and luck.

Before the appointment starts, consider all the obstacles that might slow you down. Then consider how to manage those obstacles.

1) Read the record at least a day in advance. If you're not familiar with the patient when they come in, you're losing time.

2) Get the diagnosis, x-rays, and study models accepted on the treatment plan at least a day in advance. Not necessary. A little tip to save a little time.

3) Setting up instruments. Try to get everything you need before the patient comes. If you forget an instrument and have to go get when the patient is in the chair, that's a waste of time. Try to preorder CSR items through CMS. 4) Navigating the computer and CMS. A computer problem sure can waste a lot of time. Learn how to use the computer quickly and deal with computer problems.

5) Get the patient from the waiting room on time or a little early. A lot of students get to the waiting room at 8:10 or 8:15 when the patient was ready to go at 7:50. That's a loss of time. Of course some patient always come late. Not much you can do about that other than talking to them.

6) Get skilled at taking blood pressure, so it doesn't take forever.

7) Get a faculty to sign in. If people are busy, you just have to wait it out.

8) X-rays. Taking x-rays is a problem. For the first 2 weeks, everybody needs x-rays. There aren’t enough x-ray machines or x-ray cubicles. You aren’t allowed to take x-rays until you’ve had your radiology rotation. So you have to find someone to take x-rays for you. And then you have to wait in line. Sometimes there's a list in radiology. Try to get on that list ASAP, then do what you can do on the patient with out x-rays. As soon as radiology pages you, drop what you're doing and get the x-rays. When you finally do get someone to take the x-rays, hope that they do a good job and there's no retakes. Re-taking x-rays is one of the most frustrating and time-consuming obstacles.

9) Medical history. Don't rush or hurry through a medical history, but be efficient. A complicated medical history will slow you down.

10) Medications. Ask the patient to bring a medication list when you talk on the phone. Make sure to include the name of the medication, how to spell it, the dosage, and why the patient is taking it.

11) Oral exam. Get skilled at the oral exam.

12) Tooth charting. You can do a “rough draft” without x-rays, but make sure to chart x-ray findings before you submit your diagnosis to the faculty. Get skilled at tooth charting. Patient positioning plays a big role in how well you can see. Get skilled with patient positioning, the mirror, and the overhead light. Don't forget to spray air on the teeth.

13) Perio probing. If you can get a friend to type the perio numbers while you probe, that is a big time saver. Don't do a sloppy job probing, but pay attention to how long it takes you to probe. If it takes 30 minutes, that's quite a lot of time.

14) Instructor checks diagnosis. For the first few weeks, instructors are very busy. You might have to wait a long time. Not much you can do about it. If you can do more work on the patient in the mean time, go for it. Just make sure the instructor knows where “your place in line” is. You don't want to lose your place in line just because you're not standing there.

15) Impressions. If the patient needs impressions, you can do it while waiting for the instructor.

16) OHI. Another thing to do while waiting.

THE PROPHY

It's possible to do an easy recall exam and an easy prophy in one appointment. However, make sure you know what you need to do for the exam and know what you need to do for the prophy. Don't forget instruments, and don't forget steps. Disclose the patient and show them their plaque in their mouth. Don't forget to floss. Don't forget to give OHI. And make sure to get all the plaque off. To double check, disclose them one more time and look for plaque you may have missed. Look at the gumline and between the teeth. Double check calculus removal on the lower anteriors and upper molars.

CONSULTS If the patient is primarily interested in some type of prosthetic work, try to get that consult the same day.

You want to know 2 things: 1) can this patient be treated in the pre-doctoral clinic, and 2) is this faculty member willing to work on this case with you. If the patient can't be treated in the pre-doc clinic, you want to know that right away. You only want to spend 1 appointment to find this out. You don't want to spend several.