The Seattle Study Club Journal Vol. 21 No. 1

Vol. 21 Fall

No. 1 2016

FINANCIAL CASE STUDY 16 34

PROFIT MASTERY® 32

S TAY I N G R E L E VA N T 29

CLINICAL CASE 87 19

CLINICAL CASE 86 13

I N S I G H T A N D I N N O VAT I O N 8

GUEST EDITORIAL 2

Jeffrey L. Boone MD

5 C O M M E N TA R Y

David Schwab PhD

Roger Levin DDS

Jim McKee DDS George Mandelaris DDS MS FACD FICD Matt Roberts CDT

Blake Barney DDS MSD Daryl Gasca DDS MSD Carlota Suarez DDS MSD Ruby Lwo DDS

Ta y l o r H u n t e r

Steve LeFever

Cain Watters & Associates LLC

On the cover: see page 12

A p o r t ra i t o f D r. S l o a n M c D o n a l d b y S e a t t l e a r t i s t S o n D u o n g .

Editor-in-Chief • Michael Cohen DDS MSD FACD • Managing Editor • Heather Martin • Clinical Editor • Peter Fay DMD Honorary Journal Advisor • D. Walter Cohen DDS • Design & Production • Janell V. Edwards ® The Seattle Study Club Journal (ISSN 1091-4579) is published quarterly by the Seattle Study Club Journal, Inc., P.O. Box 649, Medina, WA 98039 Telephone 425.576.8000 • Fax 425.827.4292 • seattlestudyclub.com • Copyright 2016 by The Seattle Study Club Journal, Inc. All rights reserved. • No reproductions, photocopying, storage or transmittals without written permission of the publisher.

The opinions expressed by our authors are intended to provide thought-provoking viewpoints of current and relevant issues, but they do not necessarily reflect the views of the Seattle Study Club organization or its affiliates.

®

THE SEATTLE STUDY CLUB JOURNAL 21/1

C O N T E N T S

GUEST EDITORIAL JEFFREY L. BOONE MD

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Brain Health

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lone rider sped down a dirt trail on the slopes above Aspen. The brisk mountain air filled his lungs. The rising sun blazed through the dense forest in golden spears. During the winter, people from all over the world migrate to these slopes and trails for spectacular skiing. But on this day mountain bikes reigned supreme.

At 61, with the skill and fitness of a man half his age, the rider was pushing his limits on this particular morning. On a steep slope, the front tire of his $4,000 bike glanced off a boulder the size of a soccer ball. The bike stopped—the rider didn’t. His next memory was of the bright lights in the emergency room of an Aspen hospital.

The rider was lucky. A head CT scan revealed no bleeding or hematoma. While his concussion involved a loss of consciousness, his recovery was rapid and complete. He had dodged a bullet. Or so he thought.

Three months later, I met with this aging athlete in my office at the Boone Heart Institute for his annual evaluation. Though gregarious, likable and brilliant, this real estate developer had ignored my best medical advice for the previous three years. His executive preventive cardiology evaluations in Denver had revealed multiple asymptomatic anatomic, physiological and biochemical abnormalities endangering his heart and brain. Each year, I implored him to make changes that would allow him to live a long and healthy life. But each time he would point to his active lifestyle and high level of fitness as proof that he was in excellent health.

In this way, he managed to talk himself out of heeding my treatment recommendations and precautions.

His bike accident provided a new opportunity to motivate positive change. The report from his CT in Aspen read: • No acute damage.

• No subdural hematoma or other bleeding related to recent trauma.

• No masses or tumors.

All excellent findings. These are the things that could have killed him on that mountain slope. The next section included less dramatic findings, but ones that popped out to me:

• Cerebral atrophy.

• Microvascular infarctions related to ischemic damage at multiple sites.

Here the radiologist was saying that my patient had a shrunken brain. Not only a shrunken brain, but a brain that had suffered thousands of miniscule strokes over the years resulting in microscopic holes in the brain. He had a shrunken and damaged brain.

This was concerning, but it was the radiologist’s final conclusion that really stuck with me: • Conclusion: normal for age.

Amazing. A renowned doctor in one of the wealthiest communities in the nation looks at a CT scan of a shrunken, microinfarcted brain and accepts this as normal aging. This bothered me not only as a physician, but as an individual around the same age as the patient with an aging brain of my own!

Normal for age. The conclusion struck me as an admission of defeat, an acceptance of slow decline. Anyone who has seen the later stages of dementia knows that we cannot accept that. Every day advances in Alzheimer’s research move us closer to understanding that tragic disease. But, to me, even “normal” mental decline is unacceptable. I want to keep up with my grandkids and my great grandkids. I want to truly enjoy my golden years.

But at that time, I still had work to do. A quick review of my patient’s chart revealed that he had relatives with dementia, a family history of atherosclerosis and significantly abnormal cholesterol for someone so fit.

The pieces began to fall into place. Over the last few years, everyone from UCLA researchers to TIME® Magazine has been embracing a multifaceted preventive approach to brain health. Over the past decade, I have been heavily involved in cardiovascular testing for the NFL Alumni Association. Our team worked closely with neurologists to optimize heart and brain health in retired pro football players. Together, we had noted similarities between the traumatized brains of football players (from years of concussions) and those of dementia patients.

Furthermore, emerging research suggests that

preventing cardiovascular disease—my particular specialty—contributes to the prevention of Alzheimer’s and related dementia.

And now, standing before me, these disparate threads had converged in a single individual.

I turned my attention to my patient, urging him to address his abnormalities and risks.

All too often, I explained, health enthusiasts (especially the fit, lean and attractive) want to deny or explain away their health abnormalities. This patient was a classic case. For years he had avoided the suboptimal numbers in his report, reassuring himself by adding twenty extra miles to his daily rides. I urged him instead to embrace his red flags and strive to improve them to protect his future.

“If you don’t,” I told him, “in a few years you’ll have Swiss cheese between your ears.”

That finally got his attention. In this case I was armed with numerous previous cardiovascular evaluations, a CT scan of the brain and, now, a willingness to change thanks to the troubling brain data. We started our journey to brain health.

Beginning with this patient, I developed a program I believe to be the blueprint for lifelong success in protecting the aging brain. There are a number of interconnected variables that must be monitored and controlled. Luckily, these factors can be measured through advanced testing and managed through aggressive intervention.

Genetics First, we must assess genetics. Genetic predispositions are why a marathon runner can drop dead of a heart attack or an aging Nobel Prize winner can forget the street he lives on.

They are factors uncontrollable through lifestyle alone. In brain health, the worse your genetic risks, the more proactive you need to be in protecting your brain.

Check your Apo E genotype; 3/4 or 4/4 genotypes increase your risk. As I tell patients, if you’ve got a 4, do more. Other genetic tests (MTHFR, Factor V Leiden, Prothrombic Mutation, 11-dhTXB2) can provide insight into your brain’s future. Depending on your particular genetics, homocysteine and clotting may need to be addressed and controlled.

In addition, we test for a genetically inherited sticky, gummy cholesterol called lipoprotein(a). The body contains 60,000 miles

of blood vessels and a great deal of those are located in the brain, the most complex organ in our body. Cleaning out those vessels will optimize health and performance.

Inflammation and Oxidation Second, we address inflammation and oxidation. Inflammation and oxidation are at the root of all disease, including the so-called diseases of aging, which include heart disease and dementia. A number of advanced lipid profiles give us a snapshot of your system’s built-in vulnerabilities so we can address and correct each issue.

Blood Pressure Third, I look at blood pressure, both at rest and under mental stress, which simulates the stresses of day-to-day life. Optimal blood pressure is necessary for overall cardiovascular health. Your vascular system should look like a calm river with smooth banks, flowing consistently and gently at all times. In many individuals, we instead find a raging river, stressing and eroding the banks. Medication and lifestyle improvements can help in calming the waters.

Heart Health Fourth is the heart. Our previous three variables can affect the heart muscle itself, which acts as the engine for our entire body. Therefore, it is crucial that the heart muscle not be thick, stiff or stretched due to abnormal blood pressure, heightened stress response, inflammation and/or oxidation. By controlling these factors, we ensure a strong, supple, flexible heart muscle that will provide healing blood flow throughout the body and the brain.

Lifestyle Fifth, we address lifestyle. Daily exercise is of critical importance. Even a brisk walk for 30 to 60 minutes can have profound effects on brain and heart health. However, avoid severe exercise after age 40! It’s not good for you or your brain to regularly push your body to its limits.

Control stress. Sleep well and don’t sweat the small stuff. Check your heart and blood pressure during stress to see how your system handles it. Oftentimes, successful individuals are more “high intensity,” which means their blood

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pressure spikes in the heat of a tense negotiation or important presentations. Knowing your individual tendencies can be life-saving.

Pursue and maintain close relationships throughout your life. Lifelong connections with family and friends have shown to prolong life and fight off dementia. While the science is not fully understood, emergent studies have shown that maintaining a close network of interpersonal relationships is one of the most important factors for lifelong health.

Develop a Plan I worked with my patient to develop a comprehensive plan to improve his brain health, which necessarily involved addressing his cardiovascular issues. An EEG brain scan showed that his brain had the equivalent performance of an 85 year old. That got his attention. We got to work. We cleansed the waters of his blood stream and smoothed the banks. We addressed his genetic tendencies and fixed his blood pressure. We accomplished all this with an individualized program of medications, antioxidant therapies, lifestyle adjustments and follow-up testing to monitor improvement.

Redefine Normal

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Today our now 63-year-old cyclist’s EEG brain scans show that his brain has the voltage, speed and reaction times that we would expect in a 42-year-old! These results further drive me to ask—who’s to say what is “normal for age?”

Perhaps it is time to redefine normal.

I believe my brain, at 65, should be performing as well as it ever has. That is my definition of normal and it can be for you as well. All that is required is a commitment to take control of your health. Advances in brain health are on the cutting edge of medicine. My hope is that someday this protocol will be widely adopted to heal the aging brain, but until then each individual must be proactive.

I urge you to be aggressive. Don’t wait. Normalize everything, starting as early as possible.

It’s never too late, but it is optimal to start by age 40.

The future of medicine is in a comprehensive, multidisciplinary approach to disease. The entire body is an interconnected system and it logically follows that the health of one system greatly impacts the others.

The focus of my career has been to stop heart disease and stroke. As I saw success in achieving that goal, I found myself with an aging patient population. These individuals—as well as aging family and friends—have reinforced to me that a long life is only worth living with your mental faculties intact.

As the Baby Boomers age, brain health is on all of our minds. The August 22, 2016 issue of TIME Magazine featured an article titled “Untangling Alzheimer’s.” This piece synthesizes a number of recent studies and journal articles on Alzheimer’s. In a sidebar suggesting changes which “may protect the brain as you age,” the first bullet point reads: “Of all the things you can do, reducing the risk of heart disease has the strongest evidence of benefits for the brain.”

I have seen the truth of this statement in my own practice.

I expect that, in coming decades, these brain health issues will be researched, studied and formalized. Old hypotheses will be supported or rejected and new data will emerge. We are still not close, as a medical community, to a full understanding of the human brain. However, through my own clinical work with patients, I have seen vast and measurable improvements in the performance of this unfathomably complex organ.

I believe that, by optimizing the measures we do understand, we can create a healthier system and live longer, better lives. I urge you to take steps to heal your own aging brain and embrace your future.

Dr. Boone is a consultant in cardiometabolic health, preventive cardiology and stress medicine in private practice in Denver, Colorado. He is the president, CEO and medical director of the Boone Heart Institute, a Denver-based health care organization dedicated to the eradication of heart disease and stroke. Dr. Boone’s unique clinical approach focuses on aggressive prevention of cardiovascular disease, including evaluation of the cardiovascular consequences of mental stress, the early clinical use of the latest cardiac imaging techniques and the advanced detection and treatment of cardiometabolic risk. Dr. Boone may be reached at 303.762.0710 or info@ booneheart.com. More information is also available at booneheart.com.

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1. Everything Matters Equally There is a temptation to add things to a todo list and then fall into one of two traps. First, going down the list sequentially, which means that the priority order is dictated not by the importance of the task, but by when it was added to the list. Just because something was put on the to-do list yesterday does not mean that it should be at the top of the list today. The other problem is that we start with the things we want

to check off the list, either because they are easy to do or we do not mind doing them, then we put off the hard work until later—and later.

Keller and Papason propose a new twist on the 80/20 rule, which posits in this case that a minority of causes or efforts lead to a majority of results. If 80 percent of success comes from doing 20 percent of the tasks, then dentists must drill down to find the 20 percent of the 20 percent and keep going until only one thing remains. As the authors state, “Start with as large a list as you want, but develop the mindset that you will whittle your way from there to the critical few and not stop until you end with the essential one.” That priority becomes not just an item on a list of priorities (plural), but the one critical task that must be accomplished. The lesson is that everything does not matter equally; one thing matters most.

In a dental practice, the one thing may be finishing a task (e.g., going chartless), deciding on a major new equipment purchase or mapping out the team CE schedule for the year.

First, choose the priority, then see it through until it is completed. It is true that other work still needs to be done, but the priority work gets the most time and attention—which is why it is the number one priority.

2. Multitasking is Good In a very interesting chapter, the authors talk about the fallacy of multitasking. They point out that our brains have a finite amount of computing capacity. When we multitask, we end up doing several things not nearly as well as we could do one thing. For the busy doctor, this means not trying to do the one thing while at the same time reading emails, shuffling through the stack of stuff on the desk, signing checks, glancing at news stories on the internet, and trying to squeeze in a quick phone call. We have been taught that multitasking is both desirable and necessary, but research shows that distractions are just that—interruptions that compromise the quality of work and make each task take that much longer to complete. The one thing you are trying to accomplish is important. Give it your all.

DAVID SCHWAB PHD

n my speaking, consulting and social media content writing business, I interview doctors who use lasers in their practice. The doctors are often enthusiastic about lasers for specific applications and point out that this technology allows them to perform minimally invasive procedures. Patients report satisfaction with this high tech modality and doctors are very often pleased with the clinical outcomes.

The term “laser” conjures up associations such as “amplification,” “energy,” “intensity,” “concentration” and “focus.” These same terms need to be applied to the business side of a dental practice, but doctors frequently say they are too busy to shine sufficient light on the critical administrative activities that support patient care. The problem is that patient care certainly needs to take precedence, which leaves only precious hours (sometimes a day or a half-day per week at most) for the doctor to focus on the business of running the practice. There are two solutions to this problem—one is to have an office manager whose entire job is to handle administrative matters that permeate every part of the practice and then report back to the doctor who makes major decisions, and the other is for the doctor to create a laser-like focus when working at his or her desk, rather than at the dental chair.

Gary Keller and Jay Papason provide lucid and illuminating tips for staying focused in The One Thing: The Surprising Simple Truth Behind Extraordinary Results (Bard Press, 2013). The authors start with a list of “the lies that mislead and derail us.” Here, then, is a list of misperceptions. (My summary is a restatement of some key points to make them relevant to a dental practice.)

COMMENTARY

The Dental Business Laser: The One Thing You Need

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3. Big is Bad I have heard doctors say that they do not want their practice to get too big. They do not want to have to hire more staff and certainly not additional doctors because all those personalities would change the practice, and not necessarily for the better—at least that is the fear. The reality, however, is that high tech equipment is expensive. Couple those costs with all the other rising overhead items and it is becoming increasingly difficult for a solo practitioner to stay profitable.

There needs to be a plan to grow and the plan needs to be made in advance, not on a “we will see what happens” basis. The authors of The One Thing relate how J.K. Rowling did not write her first Harry Potter book and then start thinking that perhaps a sequel would be a good idea. She actually envisioned years of Harry’s adventures at Hogwarts before she wrote the first book. Here is another eye-opening anecdote from the book: “Before Sam Walton opened the first Wal-Mart, he set up his future estate plan.

By thinking big before he made it big, he was able to save his family an estimated $11 to $13 billion in estate taxes.”

There are forward-thinking doctors who know the importance of thinking big. They set audacious goals and they strive to achieve them.

Some independent doctors look at corporate dentistry not as competition, but as inspiration, and create multi-office practices. The one thing that the business side of dental practice has to include is growth—and a plan to get there.

Ask the Right Questions Once these myths have been dispelled, the task is to find the one thing that the practice should use as its central focus. How does one go about finding the one thing? Keller and Papason state that you must first ask the right question, because “the quality of any answer is directly determined by the quality of the question.”

Listed below are three questions I use to help practices get down to the one thing:

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What is the greatest obstacle to practice growth/success?

Note that the question calls for a “one thing” answer. The response is not designed to elicit a laundry list of obstacles, such as dental insurance, bargain-hunting patients, competition, not

enough office space or difficulty in attracting new patients. Instead, the question calls for someone to think through all the factors and determine the one thing that is inhibiting practice growth.

What is the most important positive change that you will make in the practice over the next three to six months?

The positive change could be replacing an unproductive team member, upgrading the computer system or expanding hygiene hours. It is a near-term decision with long-term consequences.

What is the most important strategic decision that needs to be made in the practice?

Anyone who runs a business makes decisions every day, but this question is about a big decision. The answer could be whether to hire additional staff, equip a treatment room, accept certain insurance plans, advertise, move to new office space or hire an associate. The answer will be a major decision that will help identify the one thing.

Now let’s look at a hypothetical scenario and examples of answers that lead to the one thing:

Greatest Obstacle Not enough office space. If the practice is busy but limited to what can be produced in the existing treatment rooms, then there is an artificial cap on growth. When the schedule is full and patients are being booked out for several months, then this is equivalent to the widget factory that is operating at 100 percent capacity.

If demand for widgets exceeds the supply, then the only way to create more widgets is to move to a bigger factory.

Most Important Short-Term Change Expanding hygiene hours. The current hygienist works four days per week and is booked solid, but the practice is open five days a week.

By bringing in a part-time hygienist to cover the fifth day, the practice will increase production and also give patients more options when they schedule.

Most Important Strategic Decision Move to new office space and hire an associate. The new office space is part of the doctor’s master plan. The doctor will work four days per week instead of five in the new office and the new associate will start out by working two days per week and expand to four. The part-time hygienist will be given the opportunity to grow the hygiene schedule to four days per week.

Using these questions, the one thing that the practice has to focus on is: Moving to new offi ce space.

This decision is made with the knowledge that the practice is growing beyond its current walls and there will be a great opportunity to expand from one doctor and one hygienist to two doctors and two hygienists.

Notice how the one thing provides great clarity. If the one thing had not been identified, there would have been many opportunities for distractions, including:

also increase income due to increased production. Finally, when the doctor decides to retire, the expanded practice will be more saleable as a two-doctor, higher-production practice.

This example shows that by asking the right questions, one can come to a conclusion and focus on the one thing that needs to be done and not get sidetracked. Making major decisions is difficult, but making decisions with a laser-like focus makes the process easier. Once the one thing has been accomplished, the process needs to start over to identify a new most important priority.

The authors of The One Thing sum up their philosophy with a Russian proverb: “When you chase two rabbits, you will not catch either one.”

David Schwab, PhD provides seminars, original social media content, consulting and patient education videos for doctors. Contact him through his website at davidschwab.com or call 407.324.1333.

Searching for an associate.

Because there is currently no additional available space in the present facility, lining up an associate is premature and counterproductive until it is known that the new office space will be available on a specific date.

Buying a retiring doctor’s records.

The goal is to move the present practice to a new facility, so buying records may be something to consider once new space and staff are in place. Looking for records to buy before the practice expands may lead to finding those records too soon. Purchased practice records are only valuable if the patients are reactivated and encouraged to come to the new facility immediately.

Doing nothing.

There is always a temptation to do nothing, but in this case not seizing an opportunity would be costly. Because the practice cannot grow due to space limitations, the cap on production will eventually be a problem as overhead outpaces the practice’s ability to tame it. In this scenario, the doctor is working five days a week and moving to a new office and hiring an associate will allow him or her to work four days a week and

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Taking the Comprehensive Approach to Increasing Per-Patient Production

E

ROGER P. LEVIN DDS

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ven general dentists and specialists who’ve been in practice for less than a decade may still be subject to outdated attitudes about patients and production. Macroeconomic forces and other developments have changed the rules of practice success in recent years, but there’s still a lingering complacency— a belief that the challenges we face now will somehow resolve themselves in time.

In fact, we’ve witnessed a profound shift in the dental economy. Consumer (i.e., patient) behavior has been altered not only by financial pressures but also by a growing number of sources for oral health care services. With more new doctors hanging out their shingles, more older doctors postponing retirement (due to their own financial problems) and more service delivery models available, dentistry has become a buyers’ market. Some patients are avoiding visits to the general dentist altogether, while others, though still interested in seeing a dentist regularly, are seeking more for their money. The supply of dental services exceeds the demand for those services and the situation is not expected to improve any time soon. This is not an argument for pessimism, but it does show that GPs and specialists need to acknowledge the new rules and adapt to them with enthusiasm, energy and innovations.

The process will work best if you begin by taking a broader view of your role in the oral health of your patients.

Making the Best of Dentistry Available For general dentists, the point can be illustrated by imagining two hypothetical patients.

One calls your office with a toothache. You see her later in the day and solve her problem.

She’s grateful and gladly pays her copay, but politely declines when your front desk coordinator offers to schedule her for a hygiene visit and general dental exam. The visit amounts to a service transaction, not the beginning of a relationship, and you may never see her again.

Compare that with another patient who calls the same day. He hasn’t seen a dentist for years

and thought it would be a good idea to have a checkup and cleaning. Given an appointment the following week, this patient hopes to form a relationship with you for oral health care, just as he has with his primary care physician, eye doctor and allergist. He doesn’t have an immediate problem but, if he ever does, he wants someone he can trust to give him advice and excellent treatment or referrals. This man understands the value of relying on experts and, when it comes to dentistry, the job can be yours… if you’re able to take advantage of this opportunity.

The point here is to illustrate the difference between being asked to react to patients’ immediate needs and approaching patients with the idea of becoming their oral health care expert. In the role of expert, you’ll be expected to watch over them protectively, detecting and correcting oral problems early. You’ll enable patients to take advantage of the latest dental technologies. And you’ll educate them about the many cosmetic and other elective dental services you and specialists can use not only to solve problems but also enhance their lives.

With fewer patients available these days, this broader role—more satisfying for both you and your patients—opens the way for strong, longlasting and more productive patient-practice relationships.

Think of it this way: dentists now need to do more with what they already have. If increased competition dictates that you’ll have fewer patients, your strategy should be to raise per-patient production by taking a more comprehensive approach to dentistry.

From the specialists’ point of view, this approach on the part of GPs translates into two plans of action. One is to form and strengthen referral relationships with GPs who offer comprehensive care to their patients, because they are likely to yield more referrals over the long term. The other is to refer your patients back to GPs. Look at interdisciplinary care as a two-way street—a relationship in which both practices, as well as the patients, will benefit if it is handled properly.

Getting New Patients Off to a Great Start For the purpose of redefining the GP’s role with patients, it’s easiest to begin with a blank slate—new patients.

The mouth of a new patient typically offers more opportunities for production than that of a patient you’ve been seeing for years, if for no other reason than the fact that you’ve already provided most or all of the treatment an existing patient needs (we’ll discuss wants a little later). Often, new patients haven’t seen a dentist recently, or ever, and are therefore likely to have a number of issues you and specialists may have to address. This means that even if a patient presents with an immediate need, like that toothache mentioned earlier, you and your staff must do what you can to bring that patient back for a more thorough and well-orchestrated introduction to your practice.

In non-urgent situations, that introduction should consist of what I refer to as the New Patient Experience. There are five basic components: New Patient Call The experience actually begins before the patient first sets foot in your practice. Although prospective new patients may have heard about you from a friend or family member or checked out your website (which must be professionally designed, well-written and enticing), their first real contact with your practice will occur when your front desk coordinator answers their first call to your office. This is the classic “first impression,” and must therefore be carefully planned in advance.

The overriding objective in handling this call is to get the caller to make an appointment… and show up for it. But it’s not that simple. The front desk must also begin laying the foundation for a relationship, such as by building value for you and your staff, conveying enthusiasm and positive energy and gathering personal facts you’ll be able to use during the first appointment to establish rapport. It’s a lot to ask of the person who takes the call, which is why you should provide carefully crafted scripting and training—role-playing works best—to ensure that the call goes as planned and achieves the desired results.

New Patient Welcome The next phase of the experience occurs when new patients first walk into your office.

Staff members, alerted about these new arrivals at that morning’s team meeting, must turn on the charm, providing a warm welcome and giving the impression that your practice is a highly professional yet pleasant place. Yet again, excellent training with scripts is essential.

Comprehensive Examination When patients move back to the treatment areas, you—and probably your hygienist— become responsible for deepening the practicepatient relationship. This means taking a few moments for “small talk,” learning a little bit about the patient’s life and interests before turning to your clinical duties.

In order to broaden the scope of what you offer patients—and what they rely on you for—you should review your current approach to examining new patients to make sure you are encompassing all areas of oral health care.

The mouth is, in effect, your “territory.” Make it clear to all new patients that you are attentive to every detail regarding their teeth and gums, including any disease or damage, appearance and function. Even if they’ve had good dental care in the past, you want them to conclude that no dentist has been as thorough as you when it comes to ascertaining the state of their oral health. I recommend the following five-part comprehensive examination: 1. Periodontal With periodontal disease so common, your patients deserve an expert evaluation of whether there are signs of it in their mouth and, if so, how severe it is.

2. Tooth-by-Tooth You should carefully examine each tooth, determine if it’s healthy, note any abnormal wear or damage, and check the condition of any restorations.

3. Cosmetic This is the area in which many dentists still miss treatment opportunities.

Identify cosmetic issues that could be addressed with treatment that patients may not even be aware of or know much about.

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4. Implant Any patients with missing teeth are probably candidates for implants. Explain the many benefits and point out that, with outside financing, treatment can be quite affordable.

5. Occlusal Perform a thorough bite evaluation, check for jaw issues and question patients about discomfort or problems associated with chewing and other oral functions, as well as about chronic facial pain or headaches.

Ideal Treatment Plan Once the comprehensive examination has been completed and you’ve discussed your findings with patients, you should develop a treatment plan that’s as thorough as the exam.

It should include all oral health services you want the patient to consider, from those that are immediately needed to those that will eventually be necessary to those that the patients may want you to provide at some point.

Be careful not to overwhelm patients with a long list of procedures. They may get the impression that you’re somehow pushing them to do too much too soon. Make it clear that you want them to be fully informed not only about the state of their oral health but also about the range of modern dental services you can provide to meet their unique, individual needs. Emphasize immediate needs, but give them a sense of the bigger, long-term picture. This will pave the way for future consults in which you present other treatment included in your ideal treatment plan.

This plan, subject to change over time, will serve as the clinical foundation for a mutually beneficial relationship. Presented properly, it will also convince new patients that you truly care about their oral health.

It will also serve as a roadmap for potential referrals. Specialists who have strong relationships with “comprehensive care GPs” can increase production by offering to consult with these doctors and provide informational materials to help GPs explain specialized treatment options.

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Scheduling the Next Appointment To help ensure that new patients actually remain patients, be sure your front desk or

scheduling coordinator gives them appointments before leaving your office. This may be for treatment that the patients have accepted, but, if nothing has been decided, they should be scheduled for a hygiene visit and exam in six months (sooner if you’re concerned about periodontal disease or some other condition that bears watching).

During your time with new patients, you should emphasize how important it is for you to see them at least twice a year. Explain the preventive and diagnostic services (e.g., probing pockets, oral cancer screening, taking x-rays, etc.) and how regular visits also give you the opportunity to perform a brief but vital exam.

Patients should understand that receiving routine professional care is far better than waiting for a dental problem to become obvious to them… at which point irreparable damage may have already occurred.

Your confirmation system should also be well designed. You may continue using appointment cards, postcard reminders and non-automated confirmation calls, but you should also probably take advantage of newer techniques based on modern communication technologies. For example, many practices have begun using automated text messaging services to alert patients to upcoming appointments. If nothing else, get patients’ cell numbers so you can place confirmation calls to their mobile phones, which they’ll be more likely to answer.

Applying the New Patient Model to All Patients If you agree that my recommendations for dealing with new patients make sense, you can probably appreciate how sensible they are—with some modifications—for your existing patients, too.

Patients you’ve served for years may not fully appreciate your practice. I’m not saying that they don’t like and trust you and your staff.

They almost certainly do, or they wouldn’t be so loyal. The question is, are all your patients aware of all the services you offer today? Do they know about that cosmetic dentistry course you completed last year or your new technology for taking impressions? Or why professional whitening at your office is so much better than anything they can do at home? You may acquaint new patients with your range of services and

list them on your website, but you can’t expect existing patients to discover them on their own.

One way or another, you have to tell them.

By the same token, you need to perform annual comprehensive exams for current patients and then prepare ideal treatment plans based on your observations. This is important because, just as you and your practice have changed over time, so have your patients. The edentulous woman who scoffed at the idea of implants a few years ago may now be making much more money, wishing she didn’t have to wear a bridge or wanting a perfect smile. You may learn about some of the changes patients are going through, but you won’t be aware of everything. The solution is to keep all patients up-to-date about your practice while keeping yourself up-to-date about patients’ conditions, situations and desires. Doing so will certainly result in increased per-patient production.

enjoy the best that modern dentistry has to offer, and you will increase per-patient production both immediately and in the future.

When working with GPs who take a comprehensive approach, specialists will also benefit, in the form of increased interdisciplinary involvement and a more sustainable flow of referrals.

To see where Dr. Levin is speaking, go to levingroup.com and click on the seminars tab.

Attracting More New Patients with Comprehensive Dentistry There’s one other way that using comprehensive exams and treatment plans will increase production. Many dentists have not yet adopted the systems described here. If this includes doctors in your area, implementing my recommendations will give you a strong competitive advantage.

Today, prospective patients are looking to get more for their money. A caring dentist who takes a comprehensive approach to improving patients’ oral health—and offering a broad range of dental services—will stand out in their minds.

Whether they learn about what you offer from your website, social media activities, traditional promotional materials or word-of-mouth advertising provided by your current patients, these potential new patients will be motivated to call your office.

Conclusion The key to success for general dentists today is building strong relationships with patients—relationships that enable you to provide comprehensive care for years to come. By taking responsibility for patients’ oral health and partnering with them, through comprehensive exams and planning, you can form sustainable practice-patient connections. Your patients will

11

On The Cover—Dr. Sloan McDonald

D

r. Sloan McDonald has always been a pioneer. When she graduated from Louisiana State University’s OMS program she became one of a small number of female oral surgeons in the U.S. But the road to that success was not easy. Sloan had to break down barriers and overcome obstacles to reach her goals. What others may not have realized at the time is that Sloan had a driving force deep inside of her. As a child, she experienced numerous painful oral surgeries herself. These were searing, life-changing experiences that determined Sloan’s course of action. She simply didn’t want another human being to suffer through the pain that she had. Because of her personal experiences, Sloan’s empathy for her patients is heartfelt and her tender/tough persona is a reflection of all that has taken place in her life since her “small kid days.”

Sloan is also a Seattle Study Club pioneer. She was our first female director and she has maintained a successful club since 1992. Now with her partner, Dr. Bob Deloso, Sloan is leading Delta Study Club into the future like the pioneer woman that she is! It is wonderful to honor Dr. Sloan McDonald on the cover of The Seattle Study Club Journal.

—Michael Cohen DDS MSD FACD

12

Active Clinical Treatment • Case 86 Treating Clinicians: Drs. Jim McKee, George Mandelaris and Matt Roberts, CDT

Initial full face view

Definitive full face view

We face many challenges in treating patients. Most involve anticipated or unforeseen consequences of the treatment planning decisions that we make. Some arise from the unanticipated decisions that patients make. This case is an example of how the quality of a clinician’s care and subsequent longevity of the results were potentially undermined by a decision that the patient made.

deemed non-restorable and extracted. Treatment goals were established to augment the bone, place implant supported fixed restorations and improve the patient’s home care for long-term stability.

Age at Initial Presentation: 23 Initial Presentation: June 2010 Active Treatment Completed: February 2014

Review of Treatment Goals This patient presented with a chief concern regarding his failing bridge on teeth nos. 7-13. This Maryland bridge had been placed approximately six years prior to his initial visit and there was recurrent decay on abutment tooth no. 8. He was also congenitally missing teeth nos. 5, 7, 10, 12, 21, 23, 24, 25 & 28 and tooth no. 14 had been

Phase I: Diagnostic Work-Up Diagnostic records were obtained, including fabrication of mounted study models in a fully seated condylar position as well as facial and intraoral photographs. The treating clinicians then designed a sequence for the necessary extractions and created a diagnostic wax-up to coordinate the fabrication of provisional restorations. The entire interdisciplinary team (general dentist, periodontist, oral surgeon, endodontist and lab technician) met to determine the best treatment plan.

Phase II: Initial Therapy Initial therapy began with thorough hygiene treatment and home care instructions to remove the existing plaque.

13

FMX-2016 The importance of home care on the ultimate success of treatment was stressed with the patient at each appointment.

A diagnostic wax-up was fabricated to create maxillary provisional restorations. Teeth nos. 1, 3, 6, 11, 16, 17, M, 26 & 32 were extracted and teeth nos. 2, 4, 8, 9, 13 & 15 were prepped for a provisional porcelain-fused-to-metal bridge from teeth nos. 2-15.

Phase III: Bone Grafting The first attempt at grafting included an intraoral harvest of corticocancellous bone from the anterior mandible for a block graft in the lower anterior region. This attempt resulted in inadequate bone for implant placement.

Three different treatment options were discussed with the patient, including the use of a conventional fixed prosthodontic restoration from teeth nos. 2-15,

14

harvesting extraoral bone for guided bone regeneration or off-label tissue engineering via rhBMP-2/ACS (InfuseÂŽ, Medtronic, Dublin, Ireland). The patient elected a surgical modification of the on-label approved use of rhBMP-2/ ACS (Infuse) for tissue engineering after consulting with the periodontist.

Augmentation of the mandibular anterior and maxillary first premolar to first premolar region was performed in two separate procedures. The rhBMP-2/ACS was mixed with the particulate autograft and placed into the grafting areas, filling all voids and developing the required dimension for the prosthetically driven bone augmentation. The graft was then stabilized using a porous polyethylene matrix with rigid fixation screws.

The results were very successful and allowed the placement of implants in a patient who had started with minimal bone due to congenitally missing teeth.

CBCT of teeth nos. 5-7

CBCT of teeth nos. 10-12

CBCT of teeth nos. 23-25

15

Mobilities Probings

0 0

0

0 0

0

0 0

0

0

0 0

- - -

3 3 4 3 3 3 3 2 2 2 2 2 3 2 3 - - - 2 2 2 2 1 2 - - - 2 2 2 2 3 2 2 2 2 3 2 3 3 2 3 - - - 2/2014

0 0

0

0 0

3 2 3 4 3 3 3 2 3 2 2 2 - - - 2 2 2 - - - 2 2 2 2 1 2 - - - 2 2 2 - - - 2 2 2 - - - 3 2 3 3 2 3 2/2010

FACIAL

FACIAL

RIGHT

LEFT

LINGUAL

Probings

2

LINGUAL

3

4

5

6

7

8

9

10

11

12

13

14

15

3 2 3 3 2 3 3 2 3 2 1 2 - - - 2 1 2 2 2 2 2 1 2 2 2 2 - - -

2 1 2 - - -

- - -

3 3 3 2 3 2 2 2 2 3 2 3 3 2 3 - - - 2/2014

3 2 2 3 2 3 3 2 2 2 2 2 3 2 3 - - - 2 1 2 2 2 2 - - -

Definitive right lateral view in maximum intercuspal position

Definitive anterior view in maximum intercuspal position

2 2 2 - - - 3 2 3 3 2 3 2/2010

Definitive left lateral view in maximum intercuspal position

—Please note areas of gingival inflammation— Probings

- - - 3 2 2 3 2 3 3 2 3 3 2 3 3 2 3 2 2 2 2 2 2 - - - 2 2 2 2 1 2 2 2 2 2 2 2 3 2 3 2 2 2 - - - 2/2014 3 2 3 3 2 3 3 2 3 3 2 3 - - 31

30

29

28

3 2 3 3 3 3 - - - - - - - - - 2 1 2 2 2 2 2 2 2 3 2 2 2 1 2 2 2 2 2/2010 27

26

25

24

23

22

21

20

19

18

LINGUAL

LINGUAL

RIGHT

LEFT

FACIAL

FACIAL

Probings Mobilities

3 2 3 3 2 2 3 2 3 3 2 3 - - -

3 2 3 4 3 3 - - - - - -

- - - 2 2 2 2 2 2 2 2 2 3 2 3 2 2 2 2 2 2 2/2010

- - -

3 2 3 3 2 3 3 2 3 3 3 3 3 2 3 2 2 2 2 2 2 - - -

2 2 2 2 2 2 2 2 2 2 2 2 2 2 3 2 2 2 - - - 2/2014

0

0 0

0 0

0 0

0 0

0

0 0

0

0 0

0 0

0 0

0

Maxillary implant guide

Mandibular implant guide

Maxillary arch implant abutments

Provisional bridge

Phase IV: Implant Placement

Phase V: Prosthetic Reconstruction

A CBCT was obtained six months after maxillary grafting and showed adequate bone volume for the placement of implants. The DICOM data from the CBCT was converted to a SIMPLANTÂŽ (Dentsply, York, PA) file to prepare for CT-guided implant placement using Biomet 3i implants.

After nine months of healing, maxillary implants were placed using stereolithographic tooth supported guided surgery in site nos. 3, 5, 6, 11, 12 & 14. Mandibular implants were placed in site nos. 21, 23, 25, 26 & 28 after 10 months of healing using stereolithographic tooth supported guided surgery.

The implants were uncovered five months after placement and found to be integrated and ready for prosthetic reconstruction. Custom milled titanium base zirconium abutments were fabricated for all implants. An implant supported fixed prosthodontic bridge spanning from implant nos. 23-26 was placed in the mandibular arch.

Crowns were placed on teeth nos. 2, 4, 8, 9, 13, 15, 19 & 30 and implant nos. 3 & 14. An implant supported bridge was placed from site nos. 5-7 with implant supported retainers on implant nos. 5 & 6 and a cantilever pontic in site no. 7. An implant supported bridge was placed from implant nos. 10-12 with implant supported retainers on implant nos. 11 & 12 and a cantilever pontic in site no. 10.

Definitive maxillary view

From an ideal standpoint, the treating clinician can prolong the “provisional phase” if home care slips, but from a practical standpoint sometimes there is a limit to how long one can wait before proceeding to the definitive phase of treatment.

For the most part, our treatment goals have been met.

We were able to regain the bone necessary for restoration due to an innovative grafting approach. A maxillary bone core specimen was obtained when the maxillary implants were placed and showed new vital bone formation.

The porcelain-fused-to-metal provisional bridge allowed for a predictable method of long-term provisionalization and was used through the entire treatment.

The complexity of the treatment required a significant financial investment by the patient. The various treatment options were explained in detail beginning at the new patient exam and continued throughout the course of treatment. After understanding the advantages and disadvantages of each option, the patient understood the value and was able to meet all financial obligations.

The importance of long-term periodontal maintenance has been reinforced throughout treatment and the patient’s home care has improved considerably. However, there is still much room for improvement. The patient has been advised that there may be prosthetic revisions necessary in the future due to the extent of the treatment, the limitations of the materials and the unpredictable home maintenance. The patient is very happy with both the aesthetic and functional results of the case.

Dr. Jim McKee is in the private practice of general dentistry, Downers Grove, Illinois.

Definitive mandibular view

Phase VI: Maintenance The patient was placed on a four-month periodontal prophylaxis program. Home care instructions were reviewed and stressed at each appointment.

Commentary In this case, the patient’s initial home care was poor but improved significantly during the early phases of treatment. This is not unlike many of the patients we treat. The question is, “how long will this new behavior last?” Here, the patient’s home care slipped and again improved with reinforcement many times during treatment.

18

Dr. George Mandelaris is the director of Seattle Study Club of Oakbrook and in the private practice of periodontics, Oakbrook Terrace and Park Ridge, Illinois.

Matt Roberts, CDT, is the founder of CMR Dental Laboratory, Idaho Falls, Idaho.

Clinical Treatment Planning • Case 87 Treating Clinicians: Drs. Blake Barney, Daryl Gasca, Carlota Suarez and Ruby Lwo

Initial full face view

Initial profile view

Age at Initial Presentation: 65 Presentation Date: October 2012

to maximize use of the existing implants that were previously placed.

Introduction and Background

Medical History

This patient presented to the University of Washington in October 2012 with the chief complaint of “My top bridge came loose and I’m starting to have discomfort.” He had been treated at the University of Washington in 1993 with a full-mouth rehabilitation that was completed over the course of three years. The patient continued to have dental therapy throughout the next 10 years that included apicoectomies, maxillary and mandibular implants, crown lengthening and fabrication of new full-coverage restorations due to caries. The patient’s follow-up was initially very routine (three-month maintenance intervals) but he then had an absence of care from 2010 to 2012. The patient’s wife had passed away and he had experienced difficult times with low confidence and self-esteem. He returned for additional treatment because he wanted to be able to function without discomfort. He requested that his time in a removable partial denture be limited and wanted

• ASA II. • Patient taking lisinopril for high blood pressure.

• No known allergies.

Diagnostic Findings Extraoral/Facial: • Facial thirds within normal limits.

• Vertical fifths within normal limits.

• Lateral view and full smile shows a tendency towards a retrognathic profile.

TMJ/Mandibular Range of Motion/ Muscles of Mastication and Facial Expression: • Mandibular range of motion within normal limits.

• No clicking, popping or crepitus.

• No deviations of the mandible upon opening.

• No asymmetries upon full smile.

19

Initial maxillary occlusal view

Ceph-2012 Intraoral: Dental: • History of full coverage (metal-ceramic) restorations.

• Missing teeth nos. 1, 2, 4, 5, 8, 15, 16, 17, 18, 31 & 32.

• Existing implants in site nos. 12, 13, 14, 19, 20, 29 & 30.

• Fixed partial prosthetic on teeth nos. 3-11 with abutment teeth nos. 3, 6, 7, 9, 10 & 11.

• Previous endodontic treatment on teeth nos. 3, 6, 7, 9, 10, 11 & 21.

• Splinted PFM restorations on implant nos. 19-20 and 29-30.

• Non-splinted PFM restorations on implant nos. 12, 13 & 14.

• PFM restorations on teeth nos. 3-11, 21 & 28.

Periodontal: • AAP Class I.

20

Initial mandibular occlusal view

Initial smile

Mobilities Probings

0 - - -

0

0

0

0

0

- - - 2 2 3 - - - - - - 10 7 11 3 3 5 - - - 2 3 2 3 3 6 6 2 7 - - - - - -

- - - - - -

- - - 10/2012

FACIAL

FACIAL

RIGHT

LEFT

LINGUAL

Probings

LINGUAL

3

- - -

4

6

8

9

10

11

12

- - - 2 4 3 - - - - - - 6 3 6 3 3 3 - - - 3 3 3 2 2 5 6 4 6 - - -

Initial left lateral view in maximum intercuspal position Probings

7

- - - - - - - - 30

Initial anterior view in maximum intercuspal position

13

14

- - -

- - - - - - - - - 10/2012

Initial right lateral view in maximum intercuspal position

- - - 3 2 5 2 2 2 2 2 2 2 2 2 2 2 3 2 2 2 2 2 3 4 2 4 - - - - - - - - - - - - 10/2012 29

28

27

26

25

24

23

22

21

20

19

LINGUAL

LINGUAL

RIGHT

LEFT

FACIAL

FACIAL

Probings Mobilities

- - -

- - - - - -

- - - 3 2 4 3 2 3 3 2 3 3 2 3 3 2 3 3 2 3 4 1 3 3 2 3 - - I

0

I

I

I

I

0

0

- - - - - - - - - 10/2012

21

FMX-2012

Pano-2012

22

Occlusal Notes

Diagnosis/Prognosis

•

CR ≠ CO.

Diagnosis:

•

Anterior-posterior discrepancy of 0.5 mm.

•

AAP Class I.

•

Group function in both lateral and excursive movements.

•

Recurrent caries.

•

Angle Class I.

•

Defective restorations.

•

History of sleep bruxism with questionable compliance of night guard use.

•

Symptomatic apical periodontitis.

•

Excessive mandibular anterior attrition.

Radiographic Review •

Generalized blunting of root apices.

•

Periapical radiolucencies on teeth nos. 6, 9 & 10.

•

Teeth nos. 3, 6, 7, 9, 10, 11 & 21 endodontically treated.

•

Open margin at the distal of implant no. 30 crown.

•

Quality of bone is within normal limits.

•

Pneumatization of both maxillary sinuses.

Prognosis: •

Teeth nos. 3, 6, 7, 9, 10 & 11 are hopeless.

•

Teeth nos. 21 & 28 are questionable.

•

Teeth nos. 22-27 are good.

•

Overall prognosis is guarded due to prior inconsistent follow-up and preventative care, caries risk and sleep bruxism.

Summary of Concerns •

Can we meet the patient’s high aesthetic demands?

•

What is the best treatment method for the maxillary dentition with limited occlusal function that has recently become symptomatic?

•

Can maxillary implants be placed given the existing periapical radiolucencies and apicoectomies?

•

How can restorations be managed with the existing apical coronal positioning of implant nos. 12, 13 & 14?

•

Is it possible to minimize the use of a removable prosthetic during the course of treatment?

•

Can this case be treated without modifying the asymptomatic mandibular arch?

Stop! Time to Outline Goals/Objectives of Treatment and Treatment Plan

23

Proposed Treatment Plan • Case 87 Phase I: Diagnostic Work-Up 1. Complete a prosthodontic consultation for caries control and determine restorability of teeth.

2. Evaluate pocket depths and attachment loss.

3. Evaluate mobility of mandibular dentition.

4. Obtain a CBCT scan to evaluate bone volume and sites for future implant placement.

5. Evaluate the existing implants for restorability.

6. Evaluate the open margin at implant no. 30.

7. Evaluate prosthetic space for maxillary restorations.

8. Create diagnostic impressions and a wax-up.

9. Determine vertical dimension of occlusion.

10. Determine if the definitive prosthetic will include a fixed implant supported crown and bridge.

Phase II: Initial Periodontal Therapy 11. Perform prophylaxis with oral hygiene instructions.

Phase III: Prosthodontic Work-Up 12. Obtain diagnostic impressions and centric relation bite records.

13. Fabricate provisional restorations.

14. Create a surgical guide for implant placement.

Phase IV: Initial Periodontal Surgery 15.

16.

17.

18.

Extract all natural maxillary teeth.

Immediately place an implant at site no. 7.

Perform ridge preservation at site nos. 9, 10 & 11.

Deliver a temporary removable partial denture.

Phase V: Secondary Periodontal Surgery 19. Uncover implant no. 7 and place a healing abutment.

20. Perform ridge augmentation at site nos. 3, 4 & 5 and right lateral window sinus augmentation.

21. After two weeks of healing attach an OSO ball abutment to implant no. 7 for maxillary partial denture retention.

Phase VI: Maxillary Implant Placement 22. Create surgical guide for implant placement in site nos. 3, 5, 6 & 11.

23. Immediately place healing abutments and reline the temporary restoration.

Phase VII: Prosthodontic Therapy 24.

25.

26.

27.

Verify the vertical dimension of occlusion.

Create a wax-up to determine final occlusal scheme.

Fabricate and deliver a fixed temporary restoration.

Verify aesthetics and phonetics.

6 5 4 3

7

I/C

P

I/C

I/C

8

9

P

P

10

P

FPD

12

I/C

FPD

I/C

11

I/C

I/C

UPPER ARCH

2 1

32

13

I/C

15 16

17

LOWER ARCH

31

I/C

30 29

18

FPD

FPD

I/C 28

I/C I/C

I/C

I/C 27

26

25

24

14

23

19

20

21

22

FPD=fixed partial denture I/D=implant supported denture I/C=implant supported crown C=crown P=pontic R=retainer V=veneer

28. Deliver definitive restorations consisting of a single crown on implant no. 3, a three-unit fixed bridge between implant nos. 4-6 and a five-unit fixed bridge between implant nos. 7-11.

Phase VIII: Maintenance 29. Fabricate and deliver an occlusal guard.

30. Place patient on a three-month periodontal maintenance schedule.

All treating clinicians attended the periodontic or prosthodontic program at the University of Washington.

Dr. Daryl Gasca is co-director of Seattle Study Club of Southeast Denver and is in the private practice of periodontics and implant dentistry, Centennial, Colorado.

Dr. Blake Barney is in the private practice of prosthodontics and implants, Ft. Collins, Colorado.

Dr. Carlota Suarez is currently completing her last year of her prosthodontics residency and intends to work in private practice once completing her training and masters, which focuses on custom impression techniques.

Dr. Ruby Lwo is a third-year periodontal resident and wants to pursue private practice in the Seattle area.

®

bel Biocare. In order to improve readability, Nobel Biocare does not use TM/ in running text. Nobel Biocare does not waive any right to the trademark or ein shall be construed to the contrary. Some products may not be regulatory cleared/released for sale in all markets. Please contact the local Nobel Biocare sales ment and availability.

715 Savi Ranch Parkway, Yorba Linda, CA 92887 e 800 322 5001; Technical support 888 725 7100 LLC. All rights reserved. www.nobelbiocare.com

10/14/16 12:13 P

Expanding the Regenerative Portfolio A reliable foundation of sufficient bone is the key to successful dental implant treatment.

Sufficient bone quantity and quality are key factors in all successful dental implant treatment.

That’s why Nobel Biocare has introduced creos regenerative solutions—an extensive array of options for GBR and GTR procedures, which include both allogenic* and xenogenic biomaterials.

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The latest addition to the creos range is the bone graft substitute creos xenogain, a deproteinized bovine bone mineral matrix. Bovine bone graft substitutes

are among the best documented biomaterials. The slow-resorbing scaffold integrates with newly formed bone as a basis for successful implant treatment.

Wide range, many choices The new creos xenogain assortment consists of non-sintered material that is produced using unique processing methods to remove bovine proteins and lipids while preserving the natural bone matrix, which is characterized by micro- and macrostructures, a large specific surface area and low crystallinity.

Available in multiple sizes and application methods, the creos xenogain options are the perfect complement to the creos xenoprotect resorbable membrane, which has already earned a reputation for excellent handling and strength.

If you prefer allografts, Nobel Biocare provides allogenic solutions too.* Similar to the xenogenic line, the allograft range includes a resorbable membrane, called creos allo.protect; and bone substitutes called creos allo.gain. < * Some products may not be regulatory cleared/ released for sale in all markets. Please contact the local Nobel Biocare sales office for current product assortment and availability.

JIM MACK, MANAGING EDITOR, NOBEL BIOCARE NEWS

According to some estimates, almost half of all dental implant cases require a regenerative procedure. Consequently, dental professionals need guided bone regeneration (GBR) and guided tissue regeneration (GTR) products they can trust.

25

The bone sets the tone creos xenogain*

Our extensive range of implant solutions is designed to enable graftless treatment wherever possible. For other indications, or where grafting is unavoidable, Nobel Biocare provides creos regenerative solutions available in both xenograft and allograft* options.

Deproteinized bovine bone mineral matrix with a low crystalline structure and a large specific surface area.3,4,5

DESIGNED BY NATURE, DEVELOPED FOR CLINICIANS CREOS XENOGAIN AND CREOS XENOPROTECT

creos xenoprotect Natural, resorbable and non-chemically crosslinked membrane.

Composed of a network of interwoven, highly purified porcine collagen and elastin fibers.

creos xenogain collagen* A composite of creos xenogain and 10% porcine collagen type 1 for easy graft application, in extraction sockets, for example.

PRODUCT FOCUS: NEW CREOS XENOGAIN* The creos xenogenic assortment features an extensive range of options for a wide variety of clinical indications and preferences.

For your peace of mind, our creos xenogenic products are manufactured according to medical device quality system standards1, resulting in quality products that enable effective and reliable GBR and GTR procedures.2

1

Easy handling Available in a vial, a syringe or a bowl for fast and easy application Two granule sizes and a variety of volumes

2

Treat your patients with confidence Biocompatible6â&#x20AC;&#x201C;9 Unique processing methods remove bovine proteins and lipids3,10 Ca/P ratio similar to human bone3, 5, 11

3

The scaffold for successful regeneration Non-sintered, characterized by microand macrostructures3, 10 Interconnected macropores3, 6, 7 Hydrophilic graft

4

A solid foundation for implant treatment Slowly resorbing scaffold7 Maintains space for bone regeneration7 Integrates with the newly formed bone, building a basis for successful implant placement

References: 1 ISO 13485: 2003, ISO 13485: 2012; 2 Kim Y-T, et. al. J Korean Acad Periodontol, 2007; 3 Data on file; 4 Data on file; 5 Data on file NIBEC Atomic emission spectrometry analysis; 6 Park H-N et. al. J Korean Acad Periodontol, 2005; 7 Park J-B, et al. The Journal of the Korean Dental Association, 2007; 8 Shin S-Y, et al. J Periodontal Implant Sci, 2014; 9 Data on file; 10 Data on file; 11 Kyriazis V, et al. The Scientific World Journal, 2004; 12 Data on file; 13 Data on file. Full references at: nobelbiocare.com/news. * Some products may not be regulatory cleared/released for sale in all markets. Please contact the local Nobel Biocare sales office for current product assortment and availability.

creos allo.protect*

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Fully resorbable pericardium membrane providing strong and stable protection of the graft site during healing.

Broad assortment of bone particulate types, sizes and volumes for different clinical indications, such as sinus floor elevation, socket preservation, ridge augmentation or periodontal defects.

Quick to place and adapts well to the graft site, maintaining shape and size when placed.

Flexibility to choose the appropriate particulate graft depending on patient indication or personal preference.

Easy to handle, making it an excellent choice for most clinical indications.

A TRUSTED SOURCE CREOS ALLO.GAIN AND CREOS ALLO.PROTECT

creos allo.gain* – DBM putty Demineralized bone matrix (DBM) putty is 100% pure allograft tissue with no fillers or inert carriers.

Excellent resistance to hydration, maintaining the required stability and space during the healing phase.

BIOCOMPATIBLE – CA/P RATIO SIMILAR TO HUMAN BONE 2.0

The graph shows creos xenogain is proven to have a similar calciumphosphorus ratio (Mol/Mol) to human bone.

0.5

1.679

1.680

A SCAFFOLD FOR SUCCESSFUL REGENERATION

CREDITS

creos xenogain offers a suitable environment for new bone formation.3, 6, 7 The graph features an analysis of biochemical markers that shows creos xenogain supports the new bone formation process in-vitro.13

This article is a reprint from Nobel Biocare News Vol. 18, No. 2, 2016. © Nobel Biocare Services AG, 2016. All rights reserved. Nobel Biocare, the Nobel Biocare and creos logotypes and all other trademarks are, if nothing else is stated or is evident from the context in a certain case, trademarks of Nobel Biocare. In order to improve readability, Nobel Biocare does not use TM/® in the running text. Nobel Biocare does not waive any right to the trademark or registered mark and nothing herein shall be construed to the contrary. Product images are not necessarily to scale. Some products may not be regulatory cleared/released for sale in all markets. Please contact the local Nobel Biocare sales office for current product assortment and availability.

ALP (Alkaline phosphatase) activity

1.5

Calcium content

1.2

250

ALP activity (nM/ml/min) and calcium content (mg/ml)

1.0 1.0

0

200

0.8 150 0.6 100 0.4 50

0.2 0

creos Human xenogain3, 5 bone11

Pro-collagen content

0

7 Time (days)

0 14

Pro-collagen content (ng/ml)

The creos xenogain bone substitute is biocompatible6–9, and unique processing methods remove the bovine proteins and lipids.3, 10 With a calcium phosphate ratio that reflects the composition in human bone and a low crystalline structure, creos xenogain is accepted by the body as a suitable framework for bone formation.3, 5, 11

Sp e i n t ro c i a l du pricin ctor y g fo S SC mem r b er s

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Select a total of 5 in any combination: creos xenogain bovine bone mineral matrix vials or bowls (0.25 g and 0.50 g) N1110

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Staying Relevant in a Fast-Changing Dental World

W

e have all seen tremendous changes in the laboratory-fabricated dental field over the past 15 years, whether it has been the implementation of new technologies or just the downturn in larger restorative cases.

At all levels—from clinician to team to dental technician—we have had to make adjustments in how we approach our business and deliver cases. The Aurum Group has always taken a huge interest in testing, perfecting and applying the latest in dental technology and techniques. Perhaps even more important, Aurum has a long-standing commitment to providing advanced education for its employees. Technology has enabled us to deliver quality work in a timely fashion. Education has enabled us to deliver work via that technology that is predictable and functions according to the doctor’s protocols.

The Impact of Technology

Figure 1. Full upper diagnostic waxup to the lower natural dentition

Figure 2. Occlusion dialed in using tape

Figure 3. T-Scan employed

TAYLOR HUNTER

For any dental laboratory that has survived the turmoil of the past decade, the consistent and planned implementation of technology has been a critical factor. A prime example of this is the new digital marketplace. With the number of digital scanners that are now in doctors’ offices across North America and around the world, it only makes sense for laboratories to go digital.

We can now track, fabricate and deliver cases

seamlessly. The effort and work involved in the lab to make one tooth the analog way was very time consuming. Now, with the touch of a few buttons, dental prosthetics are produced in a manner never seen before.

I was recently introduced to T-Scan® (Tekscan, Inc., Boston, MA), a digital occlusal analysis system. T-Scan allows clinicians to dial in and balance occlusion more predictably. T-Scan will show us exactly which points are occluding with the most force and which tooth has the most load. Some might say that T-Scan is useless in the laboratory setting because there is no true way to replicate a patient’s jaw movement. I would agree that there is no way to truly replicate the movement of the jaw. However, with the use of T-Scan, I am able to balance the occlusion more predictably from left to right and balance the load on each tooth—an invaluable addition to the accuracy of the final result.

Figures 1 through 5 illustrate the T-Scan process on an actual case involving a full upper diagnostic wax-up to the lower natural dentition.

After dialing in the occlusion using tape (Fig. 2) I use T-Scan to determine which points are occluding and where the greatest load occurs.

(Figs. 3 & 4) On the initial set of scans you can see the balance of the occlusion is greater on the left than it is on the right. (Fig. 4) Individual tooth force is also much greater on the left.

29

Figure 4. Initial set of scans

Figure 5. Scans as adjusted after viewing T-Scan

30

After one adjustment exactly where T-Scan indicated the arch is much more balanced from left to right as shown in the second set of scans.

(Fig. 5) Individual tooth force is also much more balanced.

Another exciting new development at The Aurum Group is the implementation of the DSD (Digital Smile Design) system. DSD is an innovative digital method for creating an aesthetic, functional smile design. The perfect smile design is created digitally through the use of photos and videos of the patient in combination with digital impressions, digital mock-ups and digital designs.

We all know there is nothing more frustrating than when a patient falls in love with the provisional restorations and ultimately becomes disappointed with the definitive restorations because they arenâ&#x20AC;&#x2122;t exactly like the temporaries.

With DSD we are able to deliver the perfect

temporary restorations and definitive restorations that are exactly like the temporaries. In the end, it is all about the patient. DSD allows us to treat and restore patients at the highest level.

The Impact of Education Ongoing continuing education is critical to growth in the new fast-paced world of dentistry.

In the dental laboratory, it is very important to be educated on how to make dental prosthetics.

We need to know all the materials and methods available. However, just having the education and knowledge from the laboratory side is often not enough. There are many clinical theories about how to restore a patient. The Aurum Group understands the value of sending technicians to dental courses intended for doctors. The knowledge obtained from these courses makes a world of difference on how we finish cases.

Figure 6. Anterior open bite

Figure 7. Teeth lengthened and bite closed lingually

It is not the doctor’s problem to educate the lab on how to finish cases, it is the lab’s responsibility to go out and obtain that education.

A doctor I have worked with for years restoring neuromuscular cases recently introduced me to a new protocol—DTR (Disclusion Time Reduction) that he is now using to finish all of his cases. DTR is used to treat pain patients (TMD, chronic headaches, tooth sensitivity and neck/shoulder pain). I hadn’t heard of it before and it sparked my interest. I immediately signed up for a class to learn more. DTR uses T-Scan and Bio EMGs to coronoplasty the occlusion and create the best possible bite to achieve full posterior disclusion in the quickest time possible.

T-Scan shows the improvement in disclusion time and also in balancing the bite from left to right. Bio EMGs show that this therapy actually calms muscles—putting the patient in a more comfortable position and curing their symptoms.

The following case illustrates the use of DTR. This patient had an anterior open bite. (Fig. 6) Without restoring at least the anterior teeth, this patient would not be a candidate for DTR therapy. We completed a mock-up to lengthen the teeth and close the bite lingually, creating anterior or canine guidance. (Fig. 7) Now the patient is able to disclude all posterior teeth according to the DTR protocol. Without having learned what DTR is, I would have done this mock-up according to neuromuscular dentistry.

It would have been aesthetic, but a functional failure.

Conclusion I compare the dental industry to the Atari®.

When it was first launched, Atari was the only gaming platform on the market. As technology and education moved forward, gaming systems became better and better. Along came Nintendo®, PlayStation® and Xbox®. If we were afraid of change and advancement, we would still be playing Pong® on the Atari. In the dental world, if we are afraid to invest in technology or learn proven new methods, we will become irrelevant. We will be pushed aside or put in a closet just like the Atari. The only way for us to stay relevant is to embrace technology and further our education. By doing so, we can continue to provide excellent customer care and support and send the patient away happy.

Taylor Hunter has been a practicing dental technician for the past 13 years with The Aurum Group. He studied dental technology at the American Institute of Dental Technology in Provo, Utah.

Taylor has specialized in many aspects of dental technology but his main focus has been on full-mouth reconstruction.

He is currently serving as the laboratory manager for Aurum Ceramic Dental Lab in Las Vegas, Nevada.

The Aurum Group is proud to be the official laboratory of the Seattle Study Club network. We are also always ready to take your call and help treatment plan a case, make a suggestion on restorative materials that might best fit a case situation and answer any other questions or concerns you may have. Don’t hesitate to contact us at 800.661.1169.

31

®

PROFIT MASTERY STEVE LEFEVER

32

How Do You Measure Up?

T

aken together, the balance sheet and income statement represent as complete a financial picture of your company as possible. It’s a common practice (and a sensible one) for businesses to have at least two sets of financial statements (or maybe three)—one for the IRS (with the tax rules and regulations making net profit look as small as possible), one for the banker (adjusted to present the most glowing picture of the business) and one for yourself. But remember, you can’t fool all of the people all of the time. And the worst possible person to kid is yourself. You need clear, concise information that is relevant to the decisions that need to be made.

Incidentally, two or three sets of statements does not imply two or more sets of books. The general journal and the general ledger report all financial events that occur in your practice.

Having more than one set of books implies falsifying financial transactions and that’s a good way to go straight to jail courtesy of the IRS. On the other hand, a company’s financial statements put the information from the books into a format that is influenced by the purpose for which the statements are being developed.

With this in mind, let’s take your financial information and develop a set of measurements which will allow us to monitor both your current position and your progress. We will do this through the development of a series of financial relationships, or ratios. Remember, a ratio is nothing more than one number in relation to another.

However, ratios have the very practical property of reducing a relationship to one number no matter the size of the two numbers involved.

For example, the ratio of 2:1 can be derived from numbers 20 divided by 10, 200 divided by 100, or 200,000 divided by 100,000. The ratio doesn’t care about the absolute size, it only cares about the relationship. And, it’s this relationship we will use to measure and manage your financial effectiveness.

Clearly, the question arises as to which relationships to measure. There are many possibilities, and each financial analyst will have their own preferences. I have chosen to use the

KISS (Keep it Simple, Silly!) principle. That is, enough to get the job done, but not so much as to become confusing. The chart on the right has three basic parts—the name of the ratio, how it is derived and what it measures.

First, you need three years of financial statements or as many as you have. Second, you need to lay out your statements in a spreadsheet format, which is nothing more than putting all the financial data on one sheet, side-by-side, by year. Third, use the same spreadsheet format to calculate your financial ratios.

Take a few minutes to read and study these ratios, how they’re derived and what they measure. Note that the ratios are broken down into three functional areas—balance sheet ratios, profitability ratios and asset management ratios. We will be looking to develop financial “balance,” no one individual ratio is the entire story.

In general, there are three ways to use these ratios to analyze your dental practice. First, to compare your current performance to prior years—revealing trends. Second, to compare your present performance to others in your industry. And third, to compare your ratios to your plans in developing a workable operating strategy.

You operate and manage your firm with limited resources, management, capital and time.

You can’t fix current problems or spot developing ones unless you know where to look. This is an efficient, effective method to keep your finger on the pulse of your company.

Steve LeFever is chairman of Profit Mastery, a Seattle-based firm that, for the last three decades, has provided financial management education, network benchmarking, performance group facilitation and bookkeeping services for closelyheld businesses. Steve was a presenter at Seattle Study Club Symposia in 2015 and 2016 and he will be returning to present at the 2017 Symposium. He has also brought the Profit Mastery program to a number of regional clubs around the United States.

Financial Ratios How Derived

Definition

Balance Sheet Ratios Solvency and Liquidity Ratios Current Ratios

Current Assets Current Liabilities

Measures solvency; the practice’s ability to pay its bills.

Quick Ratio (or Acid Test Ratio)

Cash + Accts Rec. Current Liabilities

Measures liquidity; the practice’s ability to pay its bills without relying on the sales of inventories.

Total Liabilities Net Worth

Measures the practice’s ability to withstand adversity; shows the riskiness of the practice.

Gross Profit Sales

Measures the percentage of each dollar left after deducting the cost of the goods sold.

Net Profit Before Tax Sales

Measures the percentage of each sales dollar left after deducting all expenses except income taxes.

Sales Total Assets

Measures the efficiency of a practice’s assets in producing sales. Shows how many sales are produced by one dollar of assets.

Return on Assets

Net Profit Before Tax Total Assets

Measures the efficiency of each dollar of assets employed by the practice at producing profits.

Return on Investment

Net Profit Before Tax Net Worth

Measures the percentage return on each dollar invested by owners.

Account Receivable Turnover

Sales Accounts Receivable

Measures the rate at which accounts receivable are being collected on an annual basis.

Average Collection Period

360 Accounts Receivable Turnover

Converts the A/R Turnover ratio into the average number of days the practice must wait for its A/R to be paid.

Accounts Payable

Cost of Goods Sold Accounts Payable

A measure of the average length of time it takes the practice to pay its bills.

Safety Ratio Debt-to-Net Worth

Profi tability Ratios Gross Margin Ratio

Net Margin Ratio

Asset Management Ratios Sales-to-Assets

33

Financial Case Study • 16 Two Key Tools to Help Make Confident, Informed Decisions About Salaries and Other Overhead Costs Dr. Smith was in a bind. Her staff had not received raises in a couple of years and she was starting to hear the clamor. She knew the practice was doing well. The collections were up 10 percent over the previous year, but she didn’t feel like she had cash to give and she wasn’t sure how to assess and allocate raises.

Her primary concerns were how to appropriately evaluate the decision to give raises or not and how to determine whether her staff costs were in line with industry averages.

These are common concerns that every business owner has to tackle and they aren’t limited to staff salaries. They apply to every expense in the practice.

Phase I: Adding to the Toolbox

CAIN WATTERS & ASSOCIATES LLC

34

Tool Number One— A Usable Profi t and Loss Report At Cain Watters & Associates (CWA), the first place we guide clients to for help assessing decisions such as these is the profit and loss (P&L) of their practice. It is imperative to have a P&L document that can serve as a usable tool for the doctor, if for no other reason than ensuring that the work and money spent to prepare it in the first place is not lost. We recommend a format where the expenses are grouped in the following manner: • Direct expenses—salaries, lab and supplies.

• Fixed expenses—rent, advertising, utilities, etc.

• Non-operating costs—interest and depreciation.

• Doctor costs—doctor salary, family salaries and perks.

Once organized, P&L reports become highly effective tools for decision-making.

The P&L should be prepared and reviewed monthly. Monthly and quarterly reporting shows how the practice has performed over the short

term, but should also be compared to previous years to see the trends in the practice. Compare revenues and net income to ensure growth and compare expenses line-by-line to assess where you can increase or decrease expenses.

Tool Number Two— Industry Averages Data In addition to comparing expenses to her own previous performance, Dr. Smith and dentists in her situation should know the industry averages for revenue and expenses. For instance, staff salaries in a general dental practice should run between 22 and 24 percent of collections (gross wages, not including payroll tax or associate wages). If a practice is operating at a level less than this, it is an indication that it is efficient and/or that it has room to grow. If it is operating above this level, then this is a good time to assess whether it is overstaffed or paying higher than market wages.

Having information that shows where practices similar to your own fall in line in terms of income and expenses provides powerful insight that can be used as another effective tool in decisions that impact expenses such as raising staff wages.

Dr. Smith sat down with her financial advisor for a review. When they began looking at her profit and loss, they were able to confirm the increase in collections that Dr. Smith knew she had achieved. When they looked at her staff costs, however, her advisor noted that they had increased to 32.2 percent of her collections. This was well above her 28 percent average from the past few years, and 8-10 percent above the industry average according to an annual survey of CWA clients’ performance. Furthermore, her advisor told her that, despite the increase in collections, the net income in the practice was at 28 percent of collections and this was a full 12 percent below the industry average in general dentistry of 40 percent.

Phase II: Benchmarking Dr. Smith was taken aback. She worked very hard to grow the practice and she questioned the validity of the industry averages. Was it really possible for a general dentist like herself to have

staff in line at 22-24 percent of collections and have a net income of 40 percent? These are fair questions. For as long as she could remember, people had thrown around the same industry averages, but how could she be sure these were accurate? Her financial advisor pointed her to the 2015 edition of the CWA How Does Your Dental Practice Compare? report.* Our firm uses financial data from a cross-section of clients nationwide to compile this annual report and benchmarking tool. It provides practice income averages broken out by practice size and specialty and includes collections and overhead expenses.

Dr. Smith reviewed the data in the report for “General Dentist – 1 Doctor” practices and saw that the staff salaries for her peers broke down as follows: Salaries – Office Salaries – Hygiene Salaries – Chairside/Other Total Salaries

6.63% 8.76% 6.76% 22.15%

Dr. Smith found that she was indeed averaging just over 10 percent higher than the average general practice with one doctor. Furthermore, these practices were netting 39.93 percent before non-operating and doctor costs. This confirmed that she was netting just under 12 percent less on her collections than her peers.

Commentary There are three important conclusions to consider from these findings.

1. Staff wages had increased despite not having any raises or hiring additional staff. This led Dr. Smith to believe her staff was working more hours. However, she had not increased the number of days she was working. It was time for an internal review of staff hours. Could the staff members be clocking in early or clocking out late? Taking shorter lunches than the time allotted? These small differences can make a large financial impact.

2. Dr. Smith simply could not afford to give her staff raises. Increasing salaries would have cut further into her profitability. This is not only important

from an annual income standpoint, but would eventually matter to Dr. Smith when preparing to transition the practice to another doctor. Lower income means a lower practice value.

3. Dr. Smith and her advisor noted that her average collections were less than the average one-doctor practice of $1,245,000.

If Dr. Smith could grow her practice to this level, an increase of $200,000, then the staff salaries would decrease as a percentage of collection by approximately six percent. Dr. Smith needed to focus on her own daily productivity to get her practice back in line.

These types of decisions can feel like a burden but, equipped with evaluation tools, doctors can make wise decisions that will positively impact their bottom line and the health of their practice with relative ease. *To download a free copy of the How Does Your Dental Practice Compare? – 2015 Edition, go to cainwatters.com/resources.

Cain, Watters & Associates, LLC is an investment advisor registered with the Securities & Exchange Commission. Information provided does not take into account individual financial circumstances and should not be considered investment advice to the reader. Request form ADV Part 2A for a complete description of CWA’s financial planning and investment advisory services. There is no assurance that other clients’ actual results will be similar to information presented. Estimated future results may not be obtained due to economic, business and personal circumstances.

35

Experience the DIGITAL world of Comprehensive, Interdisciplinary Dentistry!

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• Patients can view each possible treatment option... co-authoring their smile long before it’s completed.

• Individual, emotional and artistic smile designs are created with a proven system – used by over 25,000 dental professionals worldwide.

That World now exists in North America with... DSD (Digital Smile Design) and The Aurum Group • A new generation of software providing complete digital workflows - from Facial analysis and 3D smile design all the way to interdisciplinary planning and fabrication of all components, appliances, guides and restorations needed.

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Join us as we celebrate the 5th anniversary of the The Lucy Hobbs Project Celebration!

THIS YEAR’S CELEBRATION INCLUDES A ROBUST AGENDA OF NETWORKING AND LEARNING: • The Lucy Hobbs Project Leadership Series keynote speaker • • Reunion of previous award winners • • Panel discussion with key industry thought leaders • • CE Presentation(s) •

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GoTo Meeting: OSHA/WISHA, or HIPAA Staff-Training Webinars Our webinar curricula includes the same as what we offer in our in-service trainings, but the training is offered via a remote web seminar program called “GoTo Meeting.” The office simply listens via audio conference while watching a PowerPoint presentation on their computer. This is our newest offering for our out-of-state clients as well as any staff members who might have missed their office’s scheduled in-service training.

OSHA/WISHA Employee Safety and Health Training Curricula includes staff training in Accident Prevention, Bloodborne Pathogens, Hazard Communications (including the new Globally Harmonized System updates), Infectious Waste Management, and the CDC Infection Control program. OSHA/WISHA staff training is required annually.

HIPAA Privacy & Security Training Curricula includes staff training on what you are allowed to do with patients' private information, and ensure that you and your staff know how to ensure you protect your patients’ personal and private information utilizing HIPAA's two “final rules” of Privacy and Security.

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UP TO 25 CREDITS AVAILABLE Approved PACE Program Provider FAGD/MAGD Credit Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement 10/1/2015 to 9/30/2021 Provider ID# 300136

Seattle Study Club, Inc., is an ADA CERP Recognized Provider.

ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry.

Seattle Study Club, Inc., designates this activity for up to 25 continuing education credits.

Making a great impression couldn’t be easier.

3M™ True Definition Scanner Accurate. Easy. Affordable. Your practice needs accurate impressions for successful restorations. The 3M™ True Definition Scanner is proven to be more accurate — and more consistently accurate — than other leading intraoral scanners.1 This scanner helps eliminate retakes, remakes and adjustments. The innovative design allows for fast, easy and comfortable scanning. Plus, the low cost of entry enables you to take the step into digital impressioning. It’s digital dependability.

3M.com/TrueDef

1. For additional information see www.3M.com/TrueDef 3M and 3M Science. Applied to Life. are trademarks of 3M Company.

Used under license in Canada. © 3M 2016. All rights reserved.