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PLUS Associate Agreements Your Perio Protocol Curing Light Checklist SPRING 2017

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When you’re ready to purchase or start a practice, count on Wells Fargo Practice Finance to help you achieve your goals: · Up to 100% financing to help you acquire an existing practice or start one from scratch · Competitive fixed-rate loans with preferred pricing for ADA® members · Complimentary planning resources and professional support to help your practice thrive To get started, call 1-888-937-2321 or visit wellsfargo.com/thenewdentist to request your free Preparing for Ownership workbook. Wells Fargo Practice Finance is the only practice lender selected especially for ADA® members and endorsed by ADA Business ResourcesSM.

All financing is subject to credit approval. ADA® is a registered trademark of the American Dental Association. ADA Business ResourcesSM is a service mark of the American Dental Association. ADA Business Resources is a program brought to you by ADA Business Enterprises, Inc., a wholly owned subsidiary of the American Dental Association. © 2016 Wells Fargo Bank, N.A. All rights reserved. Wells Fargo Practice Finance is a division of Wells Fargo Bank, N.A. 3030-0816-PF-The-New-Dentist-Ad

Download your free copy of Preparing for Ownership. wellsfargo.com/thenewdentist

FROM THE PUBLISHER’S DESK

Advisory Board

Dear Readers, Welcome to the Spring issue of The New Dentist™ magazine.

ou love your job as a new dentist, but that doesn’t mean it isn’t stressful. There’s a lot to think about, after all, from diagnosing and treating patients to dealing with various HR issues. Yes, dentistry can be stressful, but there are ways to reduce that stress so you can focus on growing your practice. Here are a few common stressors and what you can do to eliminate them: You’re ignoring the business side of dentistry. This is important whether you’re an associate who plans to own a practice some day or if you’ve already purchased an office. Take the time to educate yourself and become comfortable with this part of your role. If you don’t, it will lead to stress for you, your team and your patients. You’re too involved with the business side. Yes, you read that right. There are some dentists who feel they need to be involved in every little detail. They have difficulty trusting others and struggle with letting team members take ownership of their systems. If this describes you, try to give up control and trust your team to do the jobs you hired them to do. Ask them for updates but take yourself out of the decision-making process. This will reduce the number of tasks you have to perform each day, lowering your stress level and freeing up more time to focus on patient care. You’re always hiring. Not only is turnover stressful, it also hurts your practice. If you’ve noticed an increase in turnover, ask yourself why. It could be because team members don’t have enough guidance and feel lost. Provide the direction they need through detailed job descriptions, performance measurements and training. This will help you create a stable, productive team that’s happy to come to work each day. In this issue… We’ve put together articles that will help relieve your stress and grow your bottom line. On page 8, Jason Wood, Attorney for Wood & Delgado Dental Attorneys, outlines what should be part of associate contract negotiations, and Dr. Danny Domingue talks about the importance of training in Part two of a three-part series on implants. That can be found on page 20. Learn how to choose the best curing light on page 10 and what to look for in a matrix system on page 14. Dr. Jose-Luis Ruiz discusses occlusal health on page 22 and Dr. Tom Snyder makes the case for buying a rural practice on page 6. Finally, learn how to establish a perio protocol on page 18 and take in advice from Dr. Gordon Christensen on page 26.

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Christopher Banks, DDS Inwood, WV WVU, 2011

Bryan Basom, DDS Columbus, OH Ohio State, 2007

Rebecca Berry, DMD Oakland, ME Tufts, 2011

Julie Boerger, DMD Patchogue, NY University of Montreal, 2010

Hal Cohen, DMD Haverford, PA Temple University, 2010

Larry Dougherty, DMD San Antonio, TX Nova Southeastern, 2008

Dennis Frazee, DDS Mooresville, IN Indiana University, 2012

Lindsay M. Goss, DMD, MPH Chandler, AZ ASDOH, 2010

Erica Haskett, DDS New York, NY NYU, 2008

Aaron Layton, DDS Fort Collins, CO Indiana University, 2010

Leah Massoud, DMD Morgan Hill, CA Tufts, 2009

Katie Montgomery, DDS Marysville, OH Ohio State, 2006

Michael Potter, DDS Quincy, WA University of Minnesota, 2014

Tyler Scott, DDS Loudonville, OH Ohio State, 2009

Mary Shields, DMD, MPH Louisville, KY University of Louisville, 2011

Matthew Silverstein, DMD, MPH West Hartford, CT University of Pittsburgh, 2012

Nicole Smith, DDS Newport Beach, CA NYU, 2009

Gregory Snevel, DDS Cleveland, OH Ohio State, 2011

Here to help,

Sally McKenzie, Publisher

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TABLE OF CONTENTS

SPRING 2017 S P R I N G 2 017 PUBLISHER

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Renee Knight renee@thenewdentist.net SALES AND MARKETING

Contact ads@thenewdentist.net or 877-777-6151. Visit our digital media book at www.thenewdentist.net/ mediabook.htm

Copyright ©2017 The McKenzie Management Company, LLC. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, without permission in writing from the publisher. Authorization to photocopy items for internal or personal use is granted by The McKenzie Management Company, LLC for libraries and other users registered with the Copyright Clearance Center.

FE AT U R ES Think Outside the Box: 6 Creating Wealth in a Small Town or Rural Area Negotiating Your 8 Associate Agreement Your Curing Light Checklist

What’s Your Perio Protocol? Do Not Try This at Home: How to Get the Training You Need to Successfully Place Implants The Must-Know Rules for Occlusal Health

What CareCredit is Doing for New Dentists The Case for Sectional Matrix Systems

The New Dentist™ magazine is published quarterly by The McKenzie Management Company, LLC (302 N. Chestnut St., Barnesville, OH 43713) on a controlled/complimentary basis to dentists in the first 10 years of practice in the United States. Single copies may be purchased for $8 U.S., $12 international (prepaid U.S. dollars only).

Dr. Gordon Christensen 26 on Recognizing and Overcoming Challenges

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20 D E PARTMENTS 2 Publisher’s Message 28 Skinny on the Street 28 Index of Advertisers

Disclaimer — The New Dentist™ does not verify any claims or other information appearing in any of the advertisements contained in the publication and cannot take responsibility for any losses or other damages incurred by readers’ reliance on such content. The New Dentist™ cannot be held responsible for the safekeeping or return of solicited or unsolicited articles, manuscripts, photographs, illustrations, or other materials. The opinions, beliefs, and viewpoints expressed by the various authors and contributors in this magazine or on the companion website, www.thenewdentist.net, do not necessarily reflect the opinions, beliefs, and viewpoints of The New Dentist™ magazine or The McKenzie Management Company, LLC. Contact Us — Questions, comments, and letters to the editor should be sent to renee@thenewdentist.net. For advertising information, contact ads@thenewdentist.net or 877.777.6151. Visit our website at www. thenewdentist.net to download a media kit.

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Cash Flow Optimized is a service mark of The PNC Financial Services Group, Inc. (“PNC”). Banking and lending products and services, bank deposit products, and treasury management services, including, but not limited to, services for healthcare providers and payers, are provided by PNC Bank, National Association, a wholly owned subsidiary of PNC and Member FDIC. Lending and leasing products and services, including card services and merchant services, as well as certain other banking products and services, may require credit approval. All loans and lines of credit are subject to credit approval and require automatic payment deduction from a PNC Bank business checking account. Origination and annual fees may apply. ©2015 The PNC Financial Services Group, Inc. All rights reserved. PNC Bank, National Association. Member FDIC

Think Outside the Box

By Thomas Snyder, DMD, MBA, Director Transition Services Henry Schein Professional Practice Transitions

Creating Wealth in a Small Town or Rural Area If you’re still working as an associate and find yourself frustrated because you can’t identify a practice to purchase or a dental group to join as a partner, it may be time to look at alternatives that could require you to relocate. This is a big decision that becomes more complicated if you are married and your spouse has a great career in progress. And if you have immediate family in your area, this can further compound a potential relocation decision. In working with young dentists for many years, one point they tend to overlook is the long-term earning potential a dental career affords. Imagine earning an average of $300,000 annually over a 20-year period. Even without considering inflation, that equals a $6,000,000 career earnings stream! So it is with this thought in mind that I have written this article offering you a solution to your frustration as well as a sound approach for wealth accumulation. The access to care problem in both medicine and dentistry has risen dramatically in the last 10 years. In our dental profession, the number of Dental Care Health Professional Shortage Areas (as defined as one dentist per 5,000 people) has grown from 1,853 HPSAs in 2001 to 5,381 HPSAs as of September 2016! This is a 290% increase! So why has there been such a dramatic increase? We have found dentists who established their practices in small towns or rural areas are having an increasingly difficult time finding associates or purchasers to buy their practices. Why? The primary reason is the majority of today’s dental graduates desire to practice in urban or suburban areas. Granted these areas usually provide more social, cultural and educational opportunities than small towns or rural areas, but from a dental career point of view, it may make good business sense for you to reconsider your career strategy—especially if you seem to be stalled from making real progress. Here are a few points to consider:

GROWING COMPETITION AMONG DENTISTS IN URBAN AND SUBURBAN MARKETS It goes without saying that many recent graduates are having a 6 THENEWDENTIST.NET S P R I NG 2 0 1 7

more difficult time finding ownership opportunities, especially in suburban and urban areas. Because many doctors have deferred their retirement plans, as evidenced by the retirement age now averaging 69 years old, the opportunities in these areas for ownership has diminished. There are more qualified purchasers than sellers in these markets. This is not at all the case in rural areas and small towns. Most dentists in these locations are doing quite well financially because many communities do not have enough dentists, and consequently, patient demand is rather high. Less competition means more economic opportunity for you!

ACCELERATED LOAN FORGIVENESS In addition to practicing in a dental shortage area as part of the National Health Service Corp, certain states offer loan forgiveness programs based on the number of years a doctor practices in a defined dental shortage area. Practicing in these locales can accelerate your ability to retire your student loans. Moreover, if you decide to buy a practice in a small town or rural area, chances are you will be able to purchase an excellent practice at a very attractive price because of the lack of supply of qualified purchasers. You’ll likely get a better return on investment for these practices than if you purchased a similar practice in an urban/suburban area.

HIGH PROFIT MARGINS When valuing rural or small town offices, we find many practices rarely have overhead exceeding 50-55%. This is true for two primary reasons. One, the cost of labor in these areas is a lot less. Two, the occupancy costs are lower, as is the cost of real estate. Therefore, purchasing a professional building in these locales can be a tremendous financial investment for a doctor wishing to buy a practice with the real estate. Even if you decide to rent instead of owning, your facility expenses ratio will be significantly lower as well. So, higher net profits mean more resources to allow you to retire your education debt quicker as well as to build net worth more rapidly than your classmates who practice in urban and suburban locations. PRACTICE START-UP OR PRACTICE PURCHASE? If you opt to buy in a rural area or small town, you may find yourself facing an interesting dilemma. You can relocate to a small town to either purchase an existing practice at a great price, or conversely, you may decide to start your own practice in that same area and probably be quite busy from the outset! In many small towns and rural areas, practices are selling at about 50% of last year’s gross receipts and in some cases even lower than that. So, it is possible to buy an extremely

successful dental practice for a relatively low price. Start-ups may also work based on the number of dentists and their relative ages in a particular community.

LIFESTYLE CHANGES I also have had conversations with dentists who currently own a practice in a large city but have grown tired of the fast pace, fierce competition and tough economy. They have a desire to simplify their lives. So, for someone who wishes to slow down, increase income and reduce stress, relocating to a small town or rural area may be the best solution. Relocating is a big decision, but if you carefully analyze your economic situation, you might realize purchasing a practice in a rural area or a small town is the best decision you can make for your career and your future success.

Dr. Tom Snyder is Director of Professional Practice Transitions for Henry Schein Professional Practice Transitions. He is a nationally recognized speaker, author and consultant. Dr. Snyder received his DMD from Penn Dental Medicine and his MBA from The Wharton School of Business at the University of Pennsylvania. He is also a member of the faculty at Penn Dental Medicine. Dr. Snyder serves as a regular contributor to Dental Economics and The Dentist’s Network and is a contributing author to The New Dentist™ Magazine.

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Negotiating Your Associate Agreement Know What to Keep Out of Your Associate Agreement

or the last three or four years, you have been inundated with learning the clinical nature of becoming a dentist, learning that millimeters will be your worst enemy for the next few decades, and of course being an American, actually learning what a millimeter is for the first time. Now you have been thrust into the real world with a pat on your back and a diploma that cost you what most people’s homes are worth. Bewildered, you set out to acquire your first job, not fully realizing just how important that first job will be to the rest of your career. Choose the right job and it can fast track you into practice ownership and allow you to quickly satisfy your debt obligations from dental school. Choose poorly and it can cause you to enter a world of subsistence, where you are making enough money to satisfy obligations but are not able to “get ahead,” always living from paycheck to paycheck. That is definitely not a road you want to go down. With so many new dentists competing for the same jobs, how can you negotiate an associate agreement that is going to benefit you? How do you have negotiating power as a new grad? It’s rather simple. Knowing the practice you are negotiating with and what to keep out of your contract will allow you to fine tune your approach and secure your first job.

TYPE OF PRACTICE THAT NEEDS AN ASSOCIATE First and foremost, look at dental practices that actually NEED an associate. There are far too many owners looking for an associate to help “during the busy time” or to “alleviate stress,” but they really do not have enough work to keep you busy. One of the most important questions you need to ask any potential employer is: What are your yearly revenues? For a solo office, you are looking for practices above $900,000$1,000,000 that have year-over-year growth with a healthy new patient flow. You also want to make sure the hygiene department is healthy, as that shows the practice has a good recare system in place as well as the potential for additional work in the future. Far too many young doctors end up in practices that cannot adequately support their production level/goals. Because of this, these dentists do not increase hand speed, which in turn hampers their ability to purchase their own 8 THENEWDENTIST.NET S P R I NG 2 0 1 7

By Jason Wood, Attorney for Wood & Delgado Dental Attorneys

practice in 1-2 years. Your first year of employment should test your boundaries and push you to be faster and more efficient. This will be the bedrock for which your future clinical skills will be based on. Do not compromise on this as the repercussions are far reaching and long lasting. When looking for an associate position, you might want to consider a busy practice that would challenge your skill. The benefits will be immediate and will set you up for the next stage of your career. This leads us to determining the issues you should focus on when evaluating an associate agreement.

COMPENSATION Figuring out a way to incentivize both parties is key to creating a contract that will be mutually beneficial. Too many contracts will only pay you on (i) a per diem (per day) rate or (ii) a percentage of production/collections. The problem? The former doesn’t reward you for selling treatment plans, being efficient, focusing on goodwill development for the practice, etc., and the latter doesn’t protect you from the owner “cherry picking” all the cases and leaving you to do exam checks all day long. Combining these two elements not only protects you, but it incentivizes the owner to provide you with patients. I strongly encourage associates to push for a compensation structure that is the greater of (i) a daily rate or (ii) a percentage of production/ collections. This encourages the doctor to provide you patients and pushes you to work harder. EMPLOYEE/INDEPENDENT CONTRACTOR Do you need the job? Then does it really matter how the owner wants to classify you? No. Many owners will push for you to be an independent contractor (“IC”) because it saves them on taxes, protects them from liability and means they don’t have to pay you benefits. Are you an IC? No, but the risk is on the owner, not you. If you can “give” on the IC issue and get a higher compensation, or a better compensation model, then allow yourself to be an IC. The question you need to ask yourself is this: What does my career look like? If this is a short-term job and you desire practice ownership (which you really should desire) then

the IC/employee issue is not a big deal. If you want to be a long-term associate, working for someone else for your entire career, then the IC/employee classification is a major issue for you. Being treated as an employee will eventually allow you to receive benefits. This is the big issue you can give in on to get what you really need out of the contract. Go ahead and posture like it is a big concern for you, but give in when you get what you need. Not taking a job over this is, in my opinion, foolish.

RESTRICTIVE COVENANTS I recommend looking for a job away from the area you want to own a practice in. This negates the restrictive covenants from being a major issue in contract negotiations and again allows you to “negotiate” as if it is an important issue for you when in reality it isn’t. This usually leads to a better compensation formula, possible guaranteed salary/number of days, continuing education credits, etc. However, if you need to take a job within the area you want to work as a practice owner, you need to know how to negotiate. Most covenants not to compete in associate agreements are for five miles and two years in metropolitan areas (remember there are a handful of states that do not allow restrictive covenants against associates) so anything greater than this may be unenforceable against you. Be up front with your desire to limit the covenant not to compete but also be prepared to offer something that is not in the contract to satisfy the owner. If the owner is willing to consider modifying this provision, offer a covenant not to treat patients of record from the dental practice. This is typically not in associate agreements, but gives owners what they are truly seeking: the inability of a former associate to steal their

patients. It is a great way of sidestepping the issue to give both parties what they truly desire.

POTENTIAL BUY-IN This must be negotiated in connection with the associate agreement, not after you have been there for a year! Your right to acquire needs to be addressed in the document, otherwise it is merely an idea. The formula for the buy-in should be clearly spelled out in the document so there is no confusion later and, if possible, the purchase agreement and partnership agreement should be agreed upon as well. There are many issues that are truly unimportant when it comes to negotiating your first job. By focusing on the top two or three provisions of your contract, you will be much more successful at getting what you want, while at the same time giving up things that are meaningless to you. At the heart of this, though, is choosing the right practice to start your career. Search for practices that guarantee your ability to produce at a feverish pace. Banks will see you can handle larger practices, allowing you to qualify for a larger loan and buy a bigger practice with higher cash flow. In this scenario, you’ll be able to satisfy debt obligations much faster than if you worked as an associate in a practice that does not provide a steady flow of patients. Your career is a bunch of stepping stones. Make sure your first step is the right one. Jason Wood is partner at Wood & Delgado, a law firm that specializes in representing dentists for their business transaction needs on a national basis. Jason can be reached at 800-499-1474 or by email at jason@dentalattorneys.com.

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Your CURING LIGHT Checklist

Ready to invest in a new curing light? Here’s what you should consider.

hen restorations fail, it can be pretty costly for your practice. Some unhappy patients will return to your office so you can fix the problem, which costs you time and keeps you from seeing other patients, while others might be so upset they make an appointment with another dentist. Neither scenario is good for your young practice, making it vital to get it right the first time. Restorations fail for various reasons, and one of them is an inadequate cure. Many dentists think all curing lights are the same and as long as the light is shining they’re getting a proper cure, but unfortunately that isn’t the case. Investing in a highquality curing light is key to successful outcomes for both your patients and your practice. “You want to make sure the bottom of the composite you’re placing isn’t “mush.” The depth and breadth of cure inside the restoration is something we’re unable to evaluate clinically,” said Dr. Robert Lowe, who uses the VALO Grand curing light from Ultradent products, which is designed to give clinicians confidence that proper curing is achieved. “You have to use good instruments that will ensure the entire restoration is getting a total cure.” There are many features to look for in a curing light, from lens size to ergonomics. Here’s a checklist of what you should ask yourself before purchasing your next curing light. 10 THENEWDENTIST.NET S P R I NG 2 0 1 7

By Renee Knight, Editor

Does it have multiple wavelengths? Curing lights with multiple wavelengths, such as the bluephase from Ivoclar Vivadent, help ensure the material is polymerized, said Danny Forcucci, Senior Marketing Manager, Clinical. Incomplete polymerization not only leads to failures, it can result in a variety of problems for your patients, including post-op sensitivity and secondary caries. To prevent this from happening and to help ensure dentists achieve polymerization, the bluephase’s Polywave LED features a halogenlike broadband spectrum from 385 to 515 nm. How big is the lens? The bigger the lens, the more curing surface the light will be able to reach at once. The VALO Grand, Ultradent’s newest curing light, features a 12 mm lens—which is 50% larger than the previous model, Brand Manager Mike Simmons said. “This ensures you have width and breadth of light coming out of the lens that will hit the entire restoration,” Dr. Lowe said. “You’re not curing the restoration in sections. The concentration of the light is not in the center of the lens but in the whole diameter. You don’t have to move the light around to get the cure.” What materials does it cure? Before you buy a curing light, make sure it can actually cure the materials you use in your practice—and that it can cure any material you might want to use in the future. “From year to year or month to month I might want to try this bulk fill or another brand that’s supposed to be more esthetic in

From the advisory board “Light-cured composite restorations are an essential part of any dental practice. To ensure these light-cured materials are able to function as intended, a proper curing light is paramount to clinical success.” -Dr. Hal Cohen “I could spend a fraction of the money on some cheap Amazon light, but I couldn’t sleep at night knowing that a piece of equipment I use every day may be made by cutting corners. If I can’t be 100% certain that the cure is the best possible I wouldn’t put it in my mouth, therefore I wouldn’t put it in my patients’ mouths either.” -Dr. Aaron Layton, who uses the VALO curing light from Ultradent “The curing light is an instrument I use in my practice every day. I want a quality cure so my work stands up to the test of time.” -Dr. Larry Dougherty, who uses the 3M Elipar S10

the anterior or a cement I heard about at a conference,” said Dr. Laura Barres, a new dentist who uses the bluephase. “I’m new and I haven’t used everything, and I don’t want to buy a new light for each material I try. I want one light that does it all with confidence.” What’s the angle of the lens? This is important when it comes to accessing the posterior. The VALO Grand’s lens angle is about 10 degrees, Dr. Lowe said, making it easier to get the light as close to the material as possible for an effective cure. Is it cordless? A cordless light is easy to transport between operatories and eliminates the need to drag a cord across the patient as you cure, Dr. Barres said. Of course if you forget to charge the bluephase and need to plug it in you can, so Dr. Barres never has to worry about running out of power mid-cure. Are the batteries easy to replace? You’ll be using your curing light quite a lot throughout the day, making it important to invest in a light with easy-to-replace, rechargeable batteries, which is one of the key features of the VALO curing lights, Dr. Lowe said. Is the light from a reputable manufacturer? There are a lot of budget curing lights on the market these days, Forcucci said, and while they might save you money up front, they’ll likely cost you in the long run. “With budget lights, researchers have found inconsistent performance during use,” he said. “Light output at the end of the probe is often inhomogeneous. We want homogenous

distribution of light across the restorations. Low-cost lights don’t cover a large area so they’re not curing the entire restoration.” Another problem with these lights? The companies behind them typically don’t offer the customer support you need, Forcucci said. So if something goes wrong or you have questions, you’re likely on your own. How does it feel? Test different curing lights before making your final decision, Forcucci said. Think about how every light fits in your hand and how comfortable they are. Some lights are heavier and bulkier than others; you want something that’s lightweight, ergonomic and well balanced. There’s a lot to consider when investing in a curing light. The best advice? Do your research, Simmons said. Look at the science and find a high-quality light you can trust, from a manufacturer you know will provide you with customer support. This will give you peace of mind that your work is completely cured, and you won’t have to worry about patients coming back in with failed restorations because the light didn’t do its job. “If you look at the literature, you’ll see some researchers believe the average lifespan of a composite is only 5.7 years,” Dr. Lowe said. “One major reason restorations fail is inadequate cure, and it’s up to the dentist to eliminate as many of these variables as possible to ensure quality restorations for our patients.”

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What CareCredit is Doing for New Dentists By Sameer Bhasin, VP of Strategic Alliance

or new dentists looking to grow their practice and help more patients get care, accepting the CareCredit healthcare credit card can provide benefits and value that go beyond patient financing. In fact, one of the most unique and valuable resources dental providers who accept CareCredit have available is a dedicated Practice Development Manager. CareCredit Practice Development Managers visit thousands of practices each year to share and collect helpful tips and best practices for optimizing patient financing as well as many other practice management issues. Their sole focus is to work alongside the doctor and team to help them get the most out of the CareCredit program and relationship, which includes connecting them to proven ideas, insights and tools developed with input from today’s leading dental educators. CareCredit Practice Development Managers are available to meet with doctors and their team at the practice or over the phone — whichever is most effective and convenient — to share their industry experience and provide the support practices need. Practice Development Managers can help practices improve patient communication, empower the dental team to help patients access exceptional care, increase long-term patient loyalty, attract new patients and increase referrals, and help more patients receive recommended treatment. These dental and sales professionals can provide assistance starting at the most fundamental level, such as helping the team have great financial conversations and optimizing their free listing on CareCredit’s online Provider Locator. They can also provide comprehensive information that helps teams solve key practice issues, including: • Understanding patients’ decision-making process and how to provide the right information and advice • Team training on minimizing failed appointments • Audio programs on topics ranging from managing overhead to telephone skills • A referral kit that makes it easy for patients to know you appreciate and welcome referrals • Pre-coded digital assets to enhance the practice’s Web and social media sites Enrolled practices also can reach out to Practice Development Managers to gain access to valuable information like the Practice Performance Review and personalized practice reports that can help ensure practices get the most out of patient financing. The Practice Performance Review shares how other practices have success increasing treatment acceptance by offering patients promotional financing. Providers also can learn how much additional treatment they are receiving from cardholders who may have originated in another healthcare industry such as veterinary. And 12 THENEWDENTIST.NET S P R I NG 2 0 1 7

they can find out how many times their practice has appeared in searches on CareCredit’s online Provider Locator. The Practice Performance Review also can identify cardholders in the practice with available credit so dental teams can be more proactive in helping patients with incomplete care move forward with needed treatment. In addition to resources like a dedicated Practice Development Manager, there are many other ways adding CareCredit as a payment option benefits new dentists, including: 1. More patients get care. It may not be the total cost of treatment that makes patients delay or decline care; it’s fitting payments into their family’s lifestyle and budget. CareCredit can address these cost concerns and make it easier for patients to get the care they need and want.* 2. Practice cash flow improves. With CareCredit, the practice gets paid in two business days with no responsibility if the patient is slow to pay or defaults.** Hard-earned money isn’t sitting uncollected in accounts receivable. Instead, it’s available for practice business needs. 3. The cost and risk that comes with billing and collections is reduced. When patients use CareCredit to

finance care, the team no longer needs to make uncomfortable collection calls, but instead can focus on patient communications that strengthen relationships. CONTINUED ON PAGE 27 >>

Sameer Bhasin, VP of Strategic Alliance at CareCredit, is dedicated to working with dentistry’s key opinion leaders and leading educators. To help increase recommended patient care, Sameer shares best practices with CareCredit’s community of more than 110,000 enrolled dental providers. Prior to his current role, Sameer acquired more than a decade of front-line business practice experience in his position as Practice Development Manager and subsequently as Regional Sales Manager. Sameer earned his MBA from the University of the Incarnate Word, San Antonio, Texas, where he currently resides with his wife of 17 years.

She needs care. She wants care. But she’s going to delay care.

When you introduce the CareCredit healthcare credit card to all patients as a financing solution, more patients will be able to get care. A recent study found: n

47% of patients who were not aware of CareCredit said they would have considered financing if it enabled them to get care immediately.* 39% of patients surveyed said they would have chosen not to get care if CareCredit had not been available.*

Request your FREE copy of the complete Let’s Talk – Tips for Great Patient Conversations. Already accept CareCredit? Call 800-859-9975, option 1, then 6. Yet to add CareCredit? Call 800-300-3046.

* Path to Purchase Research conducted by Rothstein Tauber Inc., 2014 for CareCredit. Copyright 2016 Synchrony Financial. All rights reserved. No reuse without express written consent from Synchrony Financial.

FREE!

NEWD1016DA

The Case for

How these systems can save you time while leading to better outcomes.

By Renee Knight, Editor

hen Dr. Hal Cohen first started practicing, he used Tofflemire Bands to complete Class II restorations. About six years ago, he decided he needed a better method for what he describes as a tedious process, which is how he discovered the Palodent V3 sectional matrix system from Dentsply. Dr. Cohen, who is a member of The New Dentist™ Magazine advisory board, said making the switch has decreased his finishing time, reduced the amount of flash he has to deal with, and has helped him prevent over-contouring. “This saves time over the Tofflemire Band and is less traumatic to the patient,” Dr. Cohen said. “It really helps with finishing and leads to better contouring. You end up with a much nicer looking restoration.” While many dentists aren’t exposed to sectional matrix systems much during dental school, Jason Phillips of Garrison Dental said they’re worth learning about. These systems can be great practice builders and time savers that lead to more predictable results and better outcomes.

How it works Traditional Tofflemire Bands cover the circumference of the tooth, Phillips said, and when the band wraps around 14 THENEWDENTIST.NET S P R I NG 2 0 1 7

The Composi-Tight 3D XR from Garrison Dental. the tooth, it creates a funnel effect, providing flat or thin contacts at the marginal ridge. The contact only touches the top of the tooth and doesn’t reach toward the middle, which tends to create a triangular space toward the gingiva known as a food trap—which could lead to recurrent caries and periodontal disease. Matrix systems like the Composi-Tight 3D XR from Garrison Dental eliminate this food trap by curving around the tooth, Phillips said, properly recreating the original contact of the tooth interproximally. Garrison also has wider non-stick bands for even more coverage so when dentists pack composite, they don’t get as much, if any, flash coming out of the sides, decreasing finishing time. “Direct restorations are most GPs’ bread and butter, but they don’t get paid a lot for them,” Phillips said. “The biggest difference with our product is the 3D XR matrix ring has a soft silicon face on it. When you place the band and the wedge to hold the band in place and then put the ring on interproximally, it actually hugs that band and seals it on the buccal and lingual side. That eliminates any of the composite coming out of the sides when the dentist is packing the composite in the prep.”

Common misconceptions One of the biggest misconceptions new dentists have about sectional matrix systems is that they’re too complicated, Phillips said. While the three-step process can be intimidating at first, (placing a band, placing the wedge and then placing a ring with forceps) after three or four restorations, most dentists become pretty comfortable with the process and see the benefits matrix systems have over traditional Tofflemire Bands. Often, new dentists are also concerned about price, Phillips said. Matrix systems do cost more than Tofflemire

PHOTOS COURTESY OF GARRISON DENTAL

Sectional Matrix Systems

Bands, but make up for that in time savings and enhanced outcomes. “You’re looking at less than $2 to have the restoration done the right way and to eliminate the need for retreatment. It’s hard to put a price on that,” Phillips said. “Dentistry is all about building and maintaining a customer base. You can’t do dentistry without patients, and keeping and getting new patients is one of the main struggles new dentists have. So doing this kind of routine dentistry will help you build a good reputation. Using a sectional matrix increases predictability and gives you an ideal clinical result.”

Choosing the right system There are a variety of sectional matrix systems on the market, and Dr. Aaron Layton, who uses the Garrison system and is a member of The New Dentist™ Magazine advisory board, suggests seeking out recommendations from

colleagues and then finding an easy-to use, proven system that works best for you and your practice. When first investing in a system, it’s also a good idea to buy a starter kit, Dr. Cohen said, because they give you everything you need. He also suggests looking for a system that offers a variety of matrices and wedges for different clinical situations, with rings that are resistant to fatigue and matrices that don’t adhere to the restoration. No matter which system you use, switching to a sectional matrix system should lead to more predictable results while also saving you time. “It’s a very common procedure and while it’s also a very simple procedure, there are a lot of little things you need to focus on to make sure it’s successful,” Dr. Cohen said. “These systems give you everything you need so you get the results you’re looking for.”

Garrison’s new wedge Garrison Dental recently came out with a plastic wedge, the Composi-Tight 3D Fusion, which makes it more rigid, Phillips said. It’s wrapped in silicone and has fins on each side for a better seal and more predictable results. The wedge gently molds itself to root irregularities when inserted. The fins along the gingival edges fold in smoothly during wedge insertion and spring back when clear of the interproximal space. “I like that Garrison’s wedge is shaped so it creates a good contact and eliminates flash,” Dr. Aaron Layton said. “This wedge shape makes the most anatomical sense.”

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Subject to credit approval; some restrictions may apply. Bank of America may prohibit use of an account to pay off or pay down another Bank of America account. Bank of America Practice Solutions is a division of Bank of America Corporation. Bank of America is a registered trademark of Bank of America Corporation. ©2017 Bank of America Corporation

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THENEWDENTIST.NET

ADVERTORIAL By Marya (Vaysburg) Polan, DDS

Five Tips to Find a “Slam Dunk” CAD/CAM Case The Golden State Warriors have changed the game of basketball. Slam dunks used to be the greatest thing to watch as a spectator. Now, most fans at Oracle Arena get more excited when Steph Curry or Clay Thompson sinks a three pointer. Just as the Warriors have changed the way we appreciate basketball, CAD/CAM technology is changing dentistry. We can now deliver same-day indirect restorations, and patients are taking notice. Steph Curry was not always the MVP we know and love today. It took many years of hard work and dedication to get to his caliber. To become great, one has to know which shots to take and when to take risks. Steph was never the biggest athlete on the court, but always found a way to be successful. He is levelheaded, consistent and takes immaculate care to perfect even the smallest fundamental detail of the game. Mastering CAD/CAM has similar challenges, and to be successful dentists must learn many things along the way. When first starting the transition to CAD/CAM dentistry, case selection plays a vital role in achieving successful outcomes. Advanced CAD/CAM users have one advantage over beginners: They have experienced a wide variety of cases and learned the hard way that some cases are more difficult than others. Choosing “slam dunk” cases can help dentists build confidence with CAD/CAM dentistry. Through my experience, I’ve learned five simple tips that can help dentists select the best cases when first using CAD/CAM technology. These tips may seem like common sense, but can drain you of your confidence if not applied.

1. Begin with Posterior Teeth Anterior teeth are for more advanced users, and require more training and understanding of the materials and software. Until one gets a firm grip on the dental anatomy and design process, it is easier to get away with a few minor flaws esthetically on a posterior tooth. It may help to try visualizing the restoration before preparing the tooth. Most of us find we can set ourselves up for success and build our confidence when we begin with the end in mind. 2. Start with a Courtesy Case This can help reduce the pressure to deliver the restoration the same day, and the patient will be thrilled to benefit from the technology. The verbiage should sound like this, “Mrs. Jones, I want to tell you about this wonderful new technology we are integrating into our practice. With this technology we can make you a beautiful, metal-free crown that we may be able to 16 THENEWDENTIST.NET S P R I NG 2 0 1 7

deliver today to help avoid you having to wear a temporary. If it is okay with you, I would love to make a CAD/CAM crown as a courtesy for you today since you are one of the first patients in my practice to benefit from this technology.”

3. Focus on Continuing Care Patients Whenever incorporating something new into the practice, it is wise to start with patients we have an existing relationship with. If we have worked with patients before, we know how easily they become numb, if they have a severe gag reflex, or if they have time constraints. Whenever we try new things we are forced out of our comfort zone. By trying to foresee as much of the appointment as possible, we may feel more relaxed, making us more likely to be successful. 4. Embrace Root Canal Treated Teeth A tooth that has had a root canal eliminates one main stress for the dentist: post-operative sensitivity. Patients absolutely love getting same-day crowns; however, the sparkle may be dulled if they have a very sensitive tooth after the procedure. CAD/CAM crowns are commonly cemented using bonding cement, and the cement process may cause sensitivity. If patients are not used to having bonded crowns, they may equate the pain with the CAD/ CAM technology—making case acceptance more challenging in the future. 5. Leave Occlusal Clearance Challenges to Advanced Users Teeth affected by heavy wear with limited occlusal clearance are not ideal for CAD/CAM beginners. Preparing a crown restored with CAD/CAM technology requires smooth edges and very rounded angles. If the prep is not perfectly smooth, the software will over mill the porcelain and may end up creating a thin restoration that can fracture. Until one becomes confident with his or her CAD/CAM preparations, it is likely best to avoid these cases. As dentists, we all recognize some cases will be easier than others. Until we feel confident with a new technology, we need to find cases that set us up for success. Don’t be afraid to try new things, but stay focused and humble while learning the skill. Start at the three point line before trying a long range shot from half court. By keeping these five tips in mind, you can gain the experience and confidence you need to provide quality CAD/ CAM restorations for your patients. Marya (Vaysburg) Polan, DDS, is a 2013 graduate of University of the Pacific Arthur A. Dugoni School of Dentistry. Dr. Polan is an owner dentist at Alameda Landing Dentistry, a practice supported by Pacific Dental Services® in Alameda, CA.

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What’s Your Perio Protocol? How to establish a perio protocol that helps ensure your patients get the care they need while you grow your practice.

ou want to provide patients with the best care possible and for them to trust you when you recommend treatment. This is vital to practice growth, and is one of the many reasons you should consider establishing a periodontal protocol. Focusing on perio from the beginning, which includes knowing how to correctly code treatment, educating patients and training team members to make it a priority, will help new dentists, like you, increase production and might even lead to referrals from happy patients who understand the importance of maintaining periodontal health.

18 THENEWDENTIST.NET S P R I NG 2 0 1 7

By Renee Knight, Editor

“When you establish a periodontal protocol, people with perio disease don’t fall through the cracks. They receive the treatment they need,” said Carol Tekavec, RDH, a consultant for McKenzie Management. “It’s also economically good for the practice. Just focusing on standard prophies is a disservice to the patients and the practice.” Not sure how to get started? Follow these tips to establish a periodontal protocol in your practice.

When possible, conduct new patient exams before the first cleaning. This will help establish trust, Tekavec said, and gives you the opportunity to talk with new patients about any problems they’re experiencing as well as their oral health goals. Ask open-ended questions about their primary concerns and then take the time to address those concerns before you talk about any periodontal problems you discover. During this exam, use intraoral photographs, a perio probe and digital x-rays to evaluate the tissue. If you spot a problem, talk to patients about coming back for scaling and root planing with the hygienist (two different appointments, two quadrants each). Explain why a regular cleaning won’t work and exactly what scaling and root planing entails, Tekavec said. This helps patients build trust and a connection with you and the practice. Hygienists also know what to expect before the appointment begins, and can go over what will happen during the visit and answer any remaining questions patients have when they arrive. While these initial exams are ideal, they typically don’t happen, Tekavec said, because most patients want to combine their exam and cleaning into one appointment. “Patients call the office and say I’d like a cleaning and a

check-up. The problem is, you don’t know exactly what their cleaning is going to be,” Tekavec said. “They can come in and just need a standard cleaning or they might have advanced periodontal disease. When they have advanced periodontal disease it’s a problem. Instead of just having a very minor procedure they’re now dealing with something serious. Patients don’t know enough about you to trust you so they think ‘I don’t need all that, why are they telling me I have periodontal disease?’ If the dentist sees the patient first it’s different because they’ve established a relationship before they even see the hygienist.” If scheduling that initial exam isn’t an option, introduce yourself to new patients at the beginning of their hygiene appointments, Tekavec said. Take a look at their mouth before you leave and let them know that to get an overview of their teeth, bone and gums, you’re going to need x-rays that the hygienist will take. Once it’s clear patients have periodontal disease, whether you’re working on new or current patients, the hygienist can offer to start scaling and root planing that day or schedule their first appointment.

Discuss insurance with your patients. Whenever you talk with patients about treatment, they want to know what their insurance covers. While most insurance covers perio treatment, Tekavec said, it typically doesn’t cover as much as patients would like—which could present a barrier to care. Make sure you talk with patients about what insurance will and will not pay for from the beginning so there aren’t any surprises down the road. It’s also a good idea to provide third party financing to help ease the financial burden of treatment, McKenzie Management Hygiene Consultant Jean Gallienne said. Companies like CareCredit enable patients to pay their portion in small monthly amounts rather than

For more information on treating periodontal disease, visit perio.org.

writing one large check, making it easier for them to say yes to the periodontal treatment they need.

Provide the necessary education. When patients are educated about their condition and why they need treatment, they’re more likely to accept that

PERIO PROBES Every exam set-up should include a perio probe—an explorer, a mirror and a camera aren’t enough, Tekavec said. While she doesn’t have any particular brands she likes, Tekavec prefers probes that come in 3 mm graduations rather than 1 mm. While 6 point probing might not be necessary during every exam, there should be a probe available for the hygienist to look at inflamed areas. Remember to educate patients about the probe and the measurements being taken. Tekavec shows the probe to her patients and describes it as a tiny ruler that helps her measure around the tissue to see how the foundation is doing. When selecting a probe, Gallienne suggests trying different types to get a feel for what’s most comfortable. She prefers a rounded tip over a pointed tip, she said, but everyone has their own personal preferences. Here’s a list of some of the perio probes available today: •

PerioWise Periodontal probes from Premiere Dental, periowise.com

•

DE Perio Probes from American Eagle Instruments, am-eagle.com

•

Colorvue probes from Hu-Friedy, hu-friedy.com

•

PDT Sensor Probes from DenMat, denmat.com

•

Florida Probe GoProbe System, a charting system that works with any manual probe, floridaprobe.com

treatment—even if they have to pay more out of pocket than they’d like, Gallienne said. Most of this education comes from the hygienist and should start at the beginning of the appointment, Gallienne said. Before the hygienist starts probing and calling out numbers, she should tell patients what she’s doing and what the different pocket depths mean. If patients hear numbers that are 4 mm or greater, they know right away there’s a problem. This enables patients to co-diagnose rather than just listen to the hygienist call out numbers that have no meaning. And instead of just telling patients they need to come in every three or four months for regular periodontal maintenance once the initial scaling and root planing is done, explain to them why those visits are so important, Tekavec said. Educate patients about the oral-systemic link and how periodontal disease affects their overall health and they’ll make these appointments a priority. “Once you need scaling and root planing it’s a fight,” Tekavec said. “They can’t ignore how they got this way in the first place. But once they get through those first appointments they’re usually motivated and want to stay healthy.”

Get your team on board. When you’re ready to establish a periodontal protocol, your team members should be excited about what it means for your patients and your practice, Gallienne said. They’ll help provide that all-important education, which should start from the time the doctor and hygienist are chairside and continue until patients are on their way out the door. This also helps keep messaging consistent, which is a key component of case acceptance. “You want continuity amongst the staff,” Gallienne said. “Providing some kind of training for the staff is important.” CONTINUED ON PAGE 27 >>

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THENEWDENTIST.NET

Do NOT

Try This at HOME How to get the training you need to successfully place implants. By Danny Domingue, DDS, FAAID, DABOI/ID

Editor’s Note: This is the second article of a three-part series about how to add implants to your practice. o you remember the first time you had to drill and fill a cavity on a real patient back in dental school? I sure do. My hands were shaking. I was worried I would use too much pressure with the drill or maybe not enough. What if I was too slow and the anesthetic wore off? Now, think of those concerns as you look to add implant placement to your practice. As you’re drilling into the bone, you hope you achieve the correct depth. You also hope you’ve chosen the right treatment plan, and that you’ve placed the implant with the exact precision to comfortably and esthetically support the crown. Through education and training, I overcame those concerns and developed the skills I needed to be more confident in placing implants. High quality, implantplacement focused education, taught in a continuum rather than a series of one-time courses, helped me understand what to do and, more importantly, what I didn’t know. After completing a one-year general practice residency, I was lucky enough to complete a two-year implant fellowship. Mentors also proved to be invaluable as I developed my skills as an implant dentist. I have been privileged to work with and, literally, look over the shoulder of many mentors who have allowed me to spend time in their offices. Not all dentists seeking to add implants to their practices are in a position to drop everything and complete a two-year implant program. The good news is, there are a number of other avenues available to learn implant placement surgery and restoration, including continuums, conferences and online learning. 20 THENEWDENTIST.NET S P R I NG 2 0 1 7

THE CONTINUUM APPROACH A number of organizations provide excellent, non-biased, implant education in a continuum format. These courses tend to be presented over several months and have a curriculum that provides the fundamentals through didactic courses, hands-on learning and experience. Dentists can attend these courses one weekend a month over a nine-month period or over a one-week time frame with intensive learning. For a list of courses I recommend, see “Continuum Programs” on page 21. TOPIC-SPECIFIC COURSES There are many topic-specific courses offered by a variety of providers throughout the country. If you google “implant dentistry courses,” you’ll get 366,000 results. Google “dental implant courses” and you’ll find 627,000 results. These courses tend to cover a specific aspect of implant dentistry in-depth and are usually offered as one-day or weekend classes. Some take the form of a “study club,” typically held once a month with an evening event. Virtually anyone can offer implant education, including universities, individual dentists and manufacturers. Topics offered cover the waterfront as well. Many are only peripherally related to implants.

Implant programs Interested in a list of one- and two-year implant programs in the U.S.? The AAID can help. Find it here: aaid.com/uploads/cms/documents/advanced_programs_2015.pdf

• •

•

• •

Here’s how you can decide which courses to attend: Make certain the course provider is an approved ADA CERP and/or AGD PACE provider. Check out the speakers’ credentials. Are they experts in implant dentistry? Just because someone is a specialist in perio or oral surgery does not necessarily mean they have expertise as an implant dentist. Are they a Diplomate of the American Board of Oral Implantology/ Implant Dentistry, which is the only independent certifying board in implant dentistry in the U.S.? Is the program manufacturer-specific? While there’s nothing wrong with education provided by manufacturers, it’s important to realize what you learn may only be applicable to that manufacturer’s system or product. Are there any hands-on experiences? If so, will you learn on models, pig jaws, cadavers or live patients? If the course involves working on live patients, do you need to obtain a temporary license? What arrangements are made for follow-up? What is your potential involvement/liability? Will you be made aware of any complications? May you bring your own patients?

CONFERENCES Every professional association holds at least one conference each year—and a variety of implant-related topics are covered during these conferences. Many organizations with a specific focus, such as cosmetic dentistry or ADArecognized specialty organizations, typically have implant sessions, tracks or even implant-specific conferences. In addition to earning 20 or more implant-specific hours of CE, these conferences also give dentists the opportunity to expand their network through interactions with colleagues and vendors. ONLINE LEARNING The most cost-effective way to obtain implant education is through online learning. Many videos are available at no charge—sometimes as a loss leader for the provider or simply posted on YouTube or Slideshare by individual dentists. The teaching methods can include webinars (both live and archived), streaming video from a program presented at a conference, and podcasts. Other online offerings provide students with a series of videos to watch, but students usually must answer questions about each module before proceeding. Some are designed as interactive learning. For example, AAID’s Clinical Classroom (free for AAID members), powered by Dental Campus, presents a case that includes patient history and complaint. Students develop the treatment plan, carry it out virtually and then compare what they did with others online or with the expert who developed the case.

Continuum Programs • American Academy of Implant Dentistry MaxiCourses, aaidmaxicourse.org • The Misch Implant Institute, misch.com • Midwest Implant Institute, midwestimplantinstitute.com • California Implant Institute, implanteducation.net • Smile USA Study Club Mini-Residency, smileusa.com/mini-residency-usa • Dental Implant Learning Center Mini-Residency, dentalimplantlearningcenter.com/ce-courses

Regardless of what education you have the time and money to pursue, do not attempt to surgically place implants without training. The more training you can get, the better. The success rate for implants is reported to be as high as 98%, but not knowing what you are doing and, more importantly, not knowing what you don’t know, can lead to complications that are devastating for the patient and potentially ruinous for your reputation as a dentist. The third and final article of this series, which will appear in the Summer issue, will focus on how to prepare your practice for implants, including staffing and equipment.

Conferences • American Academy of Implant Dentistry, October, aaid.com • Academy of Osseointegration, March, osseo.org • International Congress of Oral Implantology, February, icoi.org • American Academy of Periodontology, September, perio.org • American College of Prosthodontists, October/November, prosthodontics.org • American Association of Oral and Maxillofacial Surgeons, December, aaoms.org

Dr. Domingue is a Fellow of the American Academy of Implant Dentistry and a Diplomate of the American Board of Oral Implantology. He was recognized as the youngest recipient of this certification in the world. He is the Founder and President of Acadian Southern Society, serves as Chair of AAID’s Membership Committee and is co-host of AAID’s Podcast.

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THENEWDENTIST.NET

The Must-Know Rules for

Occlusal Health

Editor’s note: This is the first article of a two-part series on occlusion.

By Jose-Luis Ruiz, DDS

Proper occlusal management is indispensable for all dental procedures and for any specialty. How we manage the patient’s occlusion will greatly influence the outcome of most dental procedures, including simple and complex restorative procedures, as well as endodontic, implant, orthodontic and periodontal procedures. Good working knowledge of occlusion will greatly aid dentists during differential diagnosis procedures of dento-facial pain, which often is related to occlusal problems.

PHOTO COURTESY OF DR. JOSE-LUIS RUIZ

arly, easy and predictable diagnosis along with early minimally invasive management is key to successful occlusion management. Occlusion is indispensable and fundamental to dentistry and although it is often made to appear extremely complicated, it doesn’t have to be difficult. To properly manage occlusion, dentists must be able to easily identify patients whose occlusal condition puts them, and their work, at risk, as well as understand some “must-know” rules. This article is part 1 of a 2 part series on occlusion and will present a very simple and methodical system to implementing occlusal management, which includes early diagnosis and understanding the 7 signs and symptoms of occlusal disease. Part 2 will focus on minimally invasive management and understanding the 3 golden rules of occlusion.

Fig 1. This is a risky patient who has a history of breaking restorations and teeth.

The Occlusal Disease Diagnosis System Identifying patients who place your treatment at risk because of their compromised occlusal condition is key to a happy dental life (Figure 1). I developed the “Occlusal Disease Management System” to implement early, simple diagnosis and patient education, followed by minimally invasive management. This allows even busy dentists to perform occlusal diagnosis and therapy on all patients.1 A brief “dental history form” that identifies occlusion related signs, such as morning headaches, tooth sensitivity, grinding or clenching and jaw pain, helps dentists educate patients that “OD is much more than just wear.” You can download the form for free at RuizDentalSeminars.com. Once patients begin to understand occlusal disease has multiple signs and symptoms, acceptance rates increase, 22 THENEWDENTIST.NET S P R I NG 2 0 1 7

especially as we identify and educate them on the 7 signs and symptoms of occlusal disease.

The 7 Signs and Symptoms of Occlusal Disease Assessing if a patient has occlusal disease is much simpler than most people think. If the patient presents with one or more of the 7 signs and symptoms of occlusal disease, then we know the patient has a traumatic and pathological condition that is causing damage to the masticatory system (teeth, periodontium, muscles and joint). If the patient does not have any of these signs, then we can assume the patient is well adapted to his or her occlusion, has no pathology and is not in need of any occlusal management.

The 7 signs and symptoms of occlusal disease are: 1. Pathological occlusal wear and fractures of teeth/ restorations. Although controversial, most occlusal wear

PHOTO COURTESY OF DR. JOSE-LUIS RUIZ

is multifactorial, a combination of attrition, erosion and abrasion, and toothpaste abuse.2,3 Nevertheless, whenever we see excessive (pathological) occlusal wear, we know there is something outside the norm going on. If we see multiple chips on teeth or small and large fractures of teeth and

restorations during our observations, this should also make us suspect a pathological occlusion. Upon assessing the severity of the pathological wear, (incipient, moderate or severe), the patient should be educated that although wear is normal, his or her condition is at a pathological level. Occlusal disease is not a disease of the old, thus early management is crucial (Figure 2). 2. Cervical dentin hypersensitivity (CDH). It is absolutely eye opening to understand that most cervical dentin hypersensitivity is caused by occlusal trauma and the most reliable modality of treatment to eliminate sensitivity is occlusal management.4 A high percentage of our patients CONTINUED ON PAGE 24 >>

Fig 2. A 23-year-old female with severe wear, headaches, tooth sensitivity and two teeth with fractures syndrome.

Dr. Ruiz is the Director of the Los Angeles Institute of Clinical Dentistry and Course Director of numerous CE Courses at University of Southern California (USC). He is Honorary Clinical Professor at Warwick University in England and member of the editorial board for Dentistry Today. He is also an Associate Instructor at Dr. Gordon Christensen PCC in Utah and an independent evaluator of dental products for CR (CRA). Dr. Ruiz has been named as one of the â&#x20AC;&#x153;Leaders in CE 2006-2017â&#x20AC;? by Dentistry Today.

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3. Tooth hypermobility. During our

comprehensive exams, how often do we find molars, specifically second molars, that have tremendous mobility even though they appear to have sufficient bone support when we look at the radiographs? This is caused by occlusal trauma and is a clear sign of unbalanced occlusion, which is overloading some teeth. How sad would it be if we consider extracting these teeth because of this mobility, when proper occlusal therapy will most likely give them proper stability? 4. Fremitus. This is the vibration we feel on teeth when patients chop chop on their natural bite or MIP. In anterior teeth this is usually caused by a pathological occlusion, which is often an envelope of function violation. Like hypermobility it is another sign of a pathological bite. 5. Abfractions. These very controversial noncarious lesions are usually caused by pathological lateral forces but, like most disease processes, the lesions are multifactorial. They can’t occur without the presence of an acidic environment but, of course, the teeth are often attacked by acidic substances like sodas, energy drinks, fruit juices and coffee. Whenever I see this lesion, I immediately look for the occlusal etiology. In most cases it is easy to find. 5,6,7

6. Vertical bone loss or localized bone destruction (secondary to periodontal disease).8,9 It is well

established in the literature that tooth mobility accelerates bone loss on periodontally compromised patients. So whenever I see a radiographic series that shows generalized periodontal disease as well as teeth with accelerated bone loss, it is usually traceable to teeth with occlusal trauma, which is one more sign of OD.

PHOTO COURTESY OF DR. JOSE-LUIS RUIZ

suffer from CDH and are completely unaware their occlusion is the primary cause of the problem. In my private practice, I treat all CDH patients with occlusal therapy and am absolutely certain of success. I’ve also found most post-operative sensitivity is caused by induced occlusal trauma, and proper occlusal adjustment after a restoration eliminates that postoperative sensitivity. Fig 3. Four-year post occlusal equilibration with composite. All signs and symptoms have dramatically improved. well worth the time spent as it helps us identify patients who have occlusal conditions that place our dental work at high risk. Once initial diagnosis has taken place, the severity of the occlusal condition must be ascertained and recorded, from incipient to severe. From there, the doctor should educate patients about their condition. The goal is to manage our patients’ occlusion. Using a minimally invasive approach, this could range from a simple night guard to additive or subtractive equilibration, based on severity. Part 2 of this series will explain the “must-know” mechanical principles that guide a physiologically healthy bite and the 3 golden rules of occlusion. References 1. Ruiz JL. Coleman TA. Occlusal Disease Management System: The Diagnosis Process. Compendium 2008 Vol. 29 No. 3 2. Grippo JO, Simring M, Schreiner S. Attrition, abrasion, corrosion and abfraction revisited; a new perspective on tooth surface lesions. J Am Dent Assoc2204: 135;1109-1118 3. Abrahamsen TC. Worn dentition, pathognomonic patterns of abrasion and erosion. Int Dent Journal 2005:4;268-276 4. Coleman TA, Grippo JO, Kinderknecht KE. Cervical dentin hypersensitivity. Part III: Resolution following occlusal equilibration. Quint Int 2003:34:427-434. 5. Telles D, Pegoraro LF et al. Incidence of Non carious cervical lesion… wear facets. J Esthet Rest Dent 2006; 18(4) 6. Grippo JO. Abfractions: A new classification of hard tissue lesions of teeth. J Esthet Dent 1991 Jan-Feb;3[1]:14-18.

7. Pain and tired facial and masticatory muscles or TMJ pain.10 Pain is the most common symptom

7. Ichim I, Schmidlin PR et al. Mechanical Evaluation of Cervical GI Rest…Finite Element. J Dent 2007; 35 Jan:28-35

dentists associate with OD. But when patients are actually asked about their symptoms, one of their most common complaints is sore and tired facial and masticatory muscles, which can often trigger headaches. Patients rarely report these symptoms because they are often unaware OD is the cause (Figure 3). The 3 to 4 minutes invested in occlusal diagnosis is

9. Greenstein G, Grenstein B, Cavallaro J. Prerequisite for treatment planning implant dentistry: Periodontal prognostication of compromised teeth. 2007 Compendium 28(8):436-447

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8. Harrel SK, Nunn MP, Hallmon WW. Is there an association between occlusion and periodontal destruction? Yes-occlusal forces can contribute to periodontal destruction. J Am Dent Assoc 2006;137[10:1380-1392

10. Gremillion HA The relationship between occlusion and TMD: An evidence-based discussion. J Evid Dent Pract 2006;6:43-47.

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BEEN THERE, Done That

Key Opinion Leader Dr. Gordon Christensen on recognizing and overcoming challenges.

s a new dentist, there are many challenges to overcome before you can find success—many that weren’t even an issue as recently as 10 years ago. But, as the industry changes new dentists must adapt and find ways to stand apart from the competition. Dr. Gordon Christensen has counseled thousands of dentists over his nearly 60-year career and said many of them express similar frustrations. Here, he offers advice to help you find direction, overcome common challenges and ultimately grow your practice. Make a plan. Dr. Christensen recommends thinking about what direction you want to take your career as early as the first or second year of dental school. Do you want to pursue a specialty? Would you like to join a corporate practice, which is becoming more common, or would you prefer to branch out on your own and have more control, and thus responsibility, for the practice? Are you interested in going into public health or becoming an educator? Once you answer these questions and determine where you want to end up, which you can even do as a more established dentist, develop a long-term plan to help you get there. Address your weaknesses. Whether you’re getting ready to graduate or have already been practicing for a few years, think about what your weaknesses are as a clinician and then address them. Attend CE classes to help you hone your skills as well as to learn about new techniques and products. Dr. Christensen also recommends taking courses on services patients are most interested in pursuing, such as cosmetic dentistry. “Take as many courses as you possibly can in this area, including tooth colored restorations, veneers, Botox and adult orthodontics,” he said. “And involve yourself with technology. You need that immediately because that’s what attracts patients.”

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Stand out from the competition. Right now, there’s an over saturation of dentists in almost every area of the country, Dr. Christensen said, so if you’re going to succeed, you have to provide services other nearby dentists don’t. Let’s say no one offers TMJ treatment in the community you’d like to practice in, for example. Learn how to provide this treatment, incorporate it into your practice and let patients know it’s available. “If you go in with the same techniques you have little or no competitive advantage,” Dr. Christensen said. “Over saturation is severe. New dentists need to recognize this challenge and be different from the rest of the clinicians in their area.” Get involved. As a young dentist, it’s important to get out and network. Sitting by yourself in your office day after day won’t help you improve your skills or grow your practice. Get politically involved with local and regional societies as well as the American Dental Association. Do your part to influence the future of the profession, whether that means voicing concerns about mid-level practitioners or other challenges facing the profession. While that will keep you busy, it’s also important to take on leadership roles in community clubs and organizations, Dr. Christensen said. This will help you get to know people in the area while allowing you to give back to your community at the same time. Invest in products that will help your practice grow. Last year alone, Clinicians Report Foundation evaluated 717 new products—so it’s clear there’s plenty of innovation going on in the industry. To attract patients, you need to invest in the right products, and Dr. Christensen suggests purchasing technologies such as digital radiography, cone beam systems and clinical scanners. If you can’t afford these technologies now, find other ways to access them, such as working with Gordon J. Christensen is Founder and CEO of Practical Clinical Courses (PCC), Co-Founder and CEO of Clinicians Report Foundation (CR), and a Practicing Prosthodontist in Provo, Utah. Gordon and Dr. Rella Christensen are co-founders of the non-profit CLINICIANS REPORT FOUNDATION (previously named CRA). Since 1976, they have conducted research in all areas of dentistry and published the findings in the wellknown CRA Newsletter now called CLINICIANS REPORT. Dr. Christensen’s degrees include: DDS, University of Southern California; MSD, University of Washington; PhD, University of Denver; and two honorary doctorates. Early in his career, Gordon helped initiate the University of Kentucky and University of Colorado dental schools and taught at the University of Washington. Currently, he is an adjunct professor at the University of Utah, School of Dentistry.

Find the right words Perio continued from page 19 Know the codes. radiographic labs in your area. Get involved with implants right away, Dr. Christensen said, because they represent a huge opportunity for your practice. “Most patients have missing teeth,” he said. “A dentist who only knows conventional techniques to restore teeth is at a handicap.” Remember why you became a dentist. Most dentists got into the field because they wanted to help people achieve healthy, beautiful smiles. Don’t lose sight of that as you grow your practice. Continue to learn and stay passionate about what you do. “There’s too much financial orientation in dentistry today. Money should be a secondary factor,” Dr. Christensen said. “If you treat patients like you’d treat yourself, with conservative dentistry, you’ll excel. You’ll have financial success and the feeling you are actually serving.”

To ensure you get paid, it’s important for the team member handling insurance to know the codes and how to properly submit claims, Gallienne said. This includes providing the proper documentation such as perio probe depths, intraoral photographs and radiographs. Adding a periodontal protocol is a great way to grow your practice, Gallienne said. Not only do you get paid more for these appointments than cleanings, perio patients come in more often for care, increasing productivity and your bottom line. And, most importantly, these patients receive the treatment they need. “It all goes back to the quality of care

For more product information, including access to the Clinicians Report annual buyers guide with hundreds of products evaluated by 450 evaluators in 100 countries, visit cliniciansreport.org. If you’re interested in taking in some education, visit pccdental.com. Here you can find videos and join an international study club headed by Dr. Christensen.

you provide your patients,” Gallienne said. “They’re being treated as they need to be treated.”

It starts at the front desk Train your front desk employees to offer all patients both an educational brochure on periodontal disease and a questionnaire to fill out as they wait for their appointment to begin. Responses to the questionnaire will tell you what perio symptoms patients have experienced—opening the door for a conversation chairside.

CareCredit

continued from page 12 4. New patient flow increases.

Want more advice from Dr. Christensen and his team?

If you recently took over an existing practice or joined as an associate, you’re likely going to treat patients who have periodontal disease their previous dentist didn’t diagnose. This could be a tricky situation. Here’s what Tekavec suggests you say: “I know Dr. Jones and his hygienist have been taking good care of you for all these years, but something new has happened. We’re going to have to address a condition I see in your mouth that looks like it could lead to trouble in the future.”

Once practices add CareCredit as a financing option, they receive a free listing on CareCredit’s online Provider Locator, a resource that is searched on average 600,000 times a month by visitors looking for a provider who accepts CareCredit. For nearly 30 years, CareCredit has been focused exclusively on healthcare financing and has helped millions of patients receive needed and desired care. CareCredit can be used as a financing option for certain expenses not covered by insurance or to bridge payment when desired care exceeds insurance coverage. It is accepted at more than 200,000 healthcare practices and select merchant locations— including over 100,000 dental practices nationwide. Currently there are over 10 million CareCredit cardholders and an average of 6,200 new CareCredit

accounts approved every day. In a recent survey, 96% of cardholders rated CareCredit as a good, very good or excellent value and 92% said they would recommend CareCredit to a friend.*** For more information about how CareCredit can benefit your practice and patients, call 800-300-3046 or visit carecredit.com. * Subject to credit approval. Minimum monthly payments apply. ** Subject to representations and warranties in the CareCredit Acceptance Agreement for Participating Providers, including but not limited to only charging for services that have been completed or that will be completed within 30 days of the initial charge, always obtaining the patient’s signature on in-office applications and the cardholders’ signature on the printed receipt. *** Cardholder Engagement Study, Q4 2014, conducted for CareCredit by Chadwick Martin Bailey.

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