The Dentist's Network #101

Ken Rubin
CPA, PFS
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Protect Yourself When You Sell Your Practice

1. Always Interview More Than One Broker
The sale of your dental practice is one of the biggest financial transactions of your life. Your decision will directly affect the quality of life that you will enjoy during retirement. Think about it! This should be a well thought out, logical decision based on facts and information. Don’t make a snap or emotional decision based on “a feeling,” a smooth talker or old information that is no longer valid. Like the dental profession, the brokerage profession has also experienced many changes over the past several years. All practice brokers have different methods, skills, experience, knowledge, marketing methods, buyer databases, ethics, business volume, personality, reputations, etc. Be careful and develop a list of important interview questions to ask.

2. Request a Broker’s Performance Report for the Past 12 Months
This is absolutely critical. Insist on getting the names of your colleagues in your immediate area (not 50 miles away - unless your practice is a very rural area) whose practices they have sold recently.

3. Get Proof of Broker’s Malpractice Insurance
Litigation is on the rise. Request a copy of the policy Declaration Page. Active brokers should have a minimum of $2,000,000 in coverage. Buyer failure rates and lawsuits have skyrocketed! Because good insurance is very expensive, many brokers have been “going bare” or are inadequately insured. Things don’t always go 100% as planned and if there’s a problem, you don’t want to find yourself solely left “holding the bag” and suffering a massive financial loss with no recourse.

4. Insist On Having A Protective Escape Clause In Your Listing Agreement
This will make it possible for you to get out of a listing early with a non-performing broker. Even though a broker may tell you initially that they’ll let you out of the listing agreement, insist that it appear in writing. If you’re not extremely impressed with the marketing campaign of the broker after the first 30 days, it’s time to move on to another broker. PERIOD! Even in today’s tough market it’s still possible to sell practices quickly (except in very rural areas). The results of a strong marketing campaign will be blatantly obvious. Don’t get sucked into detrimental excuses and continued false hopes that could string you along for a long, long time.

5. Make Sure The Broker Will Always Be Present To Show Your Practice
Showing the practice to prospective buyers is their job, not yours! It’s what you pay the broker for - their time, expertise and ability to facilitate a smooth transaction. You (and/or your spouse) shouldn’t be left alone to show your practice and try to function as a professional dental practice broker. The larger a geographic area that a broker covers, and the further away the broker is from your practice, the less likely it is that they’ll be involved in showing your practice or even meeting with the buyer.

6. The Listing Period is Negotiable
Even in today’s tougher marketplace, it doesn’t take a year to sell a practice. Protect yourself by demanding a listing term of no longer than 6 months. Better yet, start with a 3 month listing or even shorter. At the end of 3 months (assuming you’re satisfied that the broker is doing a good job) you can simply extend your listing agreement. This keeps you in control. It’s a dog-eat-dog world, and many dentists have found themselves stuck in long term listing agreements that they desperately wanted to get out of but were legally bound to the broker. With declining practice values in this current economic situation, the damage is amplified dramatically. Negotiate the listing period.

7. No “Multiple Listing Service”
Unlike selling a home, there is no Multiple Listing Service (“MLS”) for dental practices. It’s customary for practice brokers to sell their own listings and avoid having to split the commission with a buyer’s agent. Because dental practice brokers rarely “co-op” their listings with other brokers, your success in selling will solely be determined by the efforts, experience, resourcefulness and reputation of the broker you select. Like dentists, all brokers are not created equal, so choose wisely!

8. Don’t Be Fooled By A Broker’s Current Listings
To make it appear like they’re more active and successful than they really are (in order to help deceive sellers into listing with them), some brokers will actually include “false and fictitious” listings on their websites and display ads. They will include practices that they sold a long time ago; old expired listings that they were unable to sell; listings they expect or hope to get in the future; and in some cases fake listings that they completely made up. A long list of legitimate practices for sale can also be an indicator of the broker’s inability to actually get practices SOLD. (See #2 above)

9. The Commission Rate Is Negotiable
Although most brokers charge a 10% fee, some are willing to discount the rate, especially on very large practices. More importantly than the commission percentage charged, focus on the amount that you net in your pocket after paying the commission. Keep in mind that there is a huge difference in the sales price that different brokers are able to command for your practice, and although you may have saved 1-2% in commissions, it may end up costing much more in terms of reduced sales practice price than the discounted commission savings. You can’t get something that you don’t ask for, so it’s always worthwhile to at least ask for a discounted commission even if a confident broker won’t discount their fee. For example it would be better to pay a 10% commission to a broker that is able to sell your practice for $800,000, than to pay an 8% commission to a broker that is only capable of selling your practice for $750,000. Do the math!

10. Don’t Be Fooled By An Overstated Opinion Of Value
In order to capture a listing, some brokers will tell you they can sell your practice for an inflated price. It’s the oldest trick in the book. After a few months they’ll “reconsider” the price, or blame it on the market, and convince you to agree to a much lower asking price.

11. Ask Active Current Buyers Which Broker They Would Use
This is a great source of unbiased information. Since there has been very little inventory of practices for sale, many buyers have now been looking for a long time, and are very familiar with many of the brokers. They know firsthand which brokers do the best job and you can ask them who they would use if they had a practice to sell today.

Please note: This list is NOT all inclusive! It’s just a starting point.

Ken Rubin is the President and CEO of Ken Rubin & Company, Dental CPA's - www.kenrubincpa.com, and Ken Rubin Practice Sales - www.krpracticesales.com

Ken can be reached at Ken@kenrubincpa.com

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Louis Malcmacher
DDS MAGD
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New Directions

This is perhaps one of the most interesting times in dentistry that I ever remember. It really does seem that we are at a crossroads and we, as professionals, have to decide once and for all if we are simply “tooth mechanics” or if we are real healthcare professionals. What prompted this article was a conversation I had with the head of a state dental association a few weeks ago. State dental associations as well as state dental boards are now being forced to look at dentistry in a totally new light because, as a dental profession, we are finally realizing that what we do in the mouth has far reaching effects in systemic and oral health, well being, and overall facial esthetics.

Let’s take a look together at some of the new directions that dentistry is taking.

1. Nutrition
There is no question that dentists are frontline healthcare professionals, much like general physicians, and we interact with patients in a very personal way. Nutrition is generally something that dentists do not have formal training in, but certainly there are basics to be learned and there are major ramifications with good nutrition and good oral/systemic health. With periodontal disease still being so prevalent, maybe it behooves us as dental professionals to take a new look at nutrition recommendations for our patients. There are nutritional systems that are now specifically available for dental offices. Certainly, this requires some training, or at least interaction with dieticians and patients’ physicians.

2. The Oral-Systemic Health Link
There is a tremendous amount of lip service given to the fact that the mouth is the gateway to the rest of the body and is a reflection of what is going on with the patient’s systemic health. While just about all dentists agree that is important, very few dentists are truly involved in this oral-systemic link beyond a regular prophylaxis, some periodontal treatment, and elimination of infections so that the oral environment is healthy. Some dental practitioners have taken this up a few notches and provide screening of systemic diseases in their practice with DNA testing, blood samples from the patient for testing, and the use of other commercial devices to pre-screen patients. This would then directly tie in with the above discussion about nutrition, where then specific recommendations could be made to patients about their nutritional needs. There have even been anecdotal reports of dentists who have literally saved lives based on this early testing.

3. Soft Tissue Facial Esthetics
Botox and dermal fillers in dentistry are one of the fastest growing aspects of many dental practices. It is now estimated that up to 16% of dentists perform these procedures. This would seem to be a natural addition to every dental practice, certainly substantiated by those dentists who are already providing these treatments. Botox and dermal fillers are simply soft tissue esthetic enhancement procedures that are done to complete and enhance the teeth esthetics by developing esthetic smile lines and lip lines. Dentists have the basic skill set to provide these services very successfully with proper training.

4. Sleep Apnea
Sleep apnea is an interesting area for dentists to be involved in. There have been oral devices for sleep apnea in dentistry for a long time, but there are dental practitioners who really raise the bar in this area by being involved with sleep studies and investing in very sophisticated equipment to measure and then treat sleep apnea. Most of the time, these treatments can only be provided either with or under a physician’s direction. The investment of equipment and the need for a physician’s guidance has held back many dentists from getting into this field, but it certainly has attracted the attention of some dental practitioners.

What’s interesting is that this cycle is repeated in dentistry every so often. A number of years ago, the concept of conscious sedation dentistry and neuromuscular dentistry were new and almost outlandish concepts that many dentists rallied against because, for whatever reason, they were of the opinion that conscious sedation and neuromuscular concepts were medical treatments and we were “trying to be physicians.” Today, these two areas are very well established and are part of our everyday lexicon. It is natural for dentistry to expand as our knowledge and understanding of what we do evolves and integrates with other healthcare professionals.

Certainly, any of the items discussed above or anything new that comes into dentistry requires intensive training before any dentist gets involved in these new concepts. Let me say this as strongly as possible - it is abhorrent when dentists think that they can take an online course or a half day lecture in some new concept, where the bulk of the time talks about how to make more money without any real benefits to the patient.

Dentistry is expanding rapidly into areas that can really complement our current practices. One of the nice things about dentistry is that individual dentists can choose which areas they like and practice accordingly. If the above concepts don’t interest you, keep doing what you know and like to do in dentistry. If any of the above concepts do appeal to you, get some good solid training and add them to your practice – new concepts such as the ones described above look like they will be a part of many dental practices for years to come.

Dr. Louis Malcmacher is a practicing general dentist in Bay Village, Ohio, an internationally known lecturer, dental consultant and author, and is President of the American Academy of Facial Esthetics. Interested in knowing more about how to truly enjoy dentistry? Click here.

Interested in having Dr. Malcmacher speak to your dental society or study club? Click here. To reach Dr. Malcmacher, email him at DrMalcmacher@thedentistsnetwork.net or call 1.800.952.0521.

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Chris J. Lampert, DMD
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Endodontic Irrigation

While there is ongoing debate and disagreement in endodontics about important questions such as apical size, where the canal ends, obturation material, single versus multiple visit treatment, and many others, one fact that is generally agreed upon is the importance of irrigation. When considering all of the detailed and intricate steps involved in endodontic treatment, irrigation is the easiest, most important, and sometimes the most neglected. Using rotary and hand shaping files to create a space for gutta-percha that goes to length and looks good on a radiograph does not mean the canal was clean. As an endodontist I see many cases that were recently treated and look very good on the radiograph, but are still symptomatic or failing. Retreatment with proper irrigation usually corrects the patient’s symptoms.

The complex anatomy that exists in the apical region of nearly all root canals cannot be entirely debrided with round shaping instruments (rotary and hand files). Files simply create a shape within the canal for irrigation to be effective. Cleaning the canal involves dissolving residual pulp tissue, removing the smear layer, opening dentin tubules, and reducing bacteria to the lowest achievable level. As the saying goes, “files shape the canal, but irrigation cleans the canal.”

Creating Good Apical Shape For Irrigation Delivery
Irrigating the apical third of the canal is the most important step in endodontic treatment. Negotiating and cleaning the apical third is the difference between consistent, predictable endodontic success and failure. Creating a good, deep apical canal shape with adequate taper is necessary for effective irrigation exchange. The table below shows the volume space that different apical shapes create. The greater the funnel volume in the apical 4 mm, the more effective irrigation delivery is to this area. As shown in the table, tip size and taper are the two factors that affect the funnel volume in the apical 4 mm. The rank order shows that a final apical file of size 20/.04 provides less than half the irrigation space than a size 35/.04.

Apical file size (Tip/Taper)	Volume of apical 4 mm³
20/.04	.253 mm³
20/.06	.337 mm³
25/.04	.349 mm³
20/.08	.434 mm³
25/.06	.447 mm³
30/.04	.460 mm³
25/.08	.555 mm³
30/.06	.569 mm³
35/.04	.587 mm³
30/.08	.691 mm³
35/.06	.709 mm³
35/.08	.843 mm³

Because sodium hypochlorite kills bacteria only when it contacts bacteria, the sodium hypochlorite must be delivered to the apex for it to be effective. Simply irrigating the pulp chamber and the coronal half of the canal does not work.

Removing The Smear Layer
The use of rotary instrumentation creates a surface layer on the canal wall known as a smear layer. The smear layer is a combination of organic and inorganic debris that is burnished into the dentin tubules by rotating instruments (nickel-titanium rotary files and gates-glidden drills). Prior to the advent of rotary canal shaping, smear layer formation did not occur in the apical portion of the canal because hand files do not create a smear layer.

Complete removal of the smear layer following canal shaping is necessary to allow sodium hypochlorite to penetrate small lateral canals and dentin tubules. Two different solutions are required to dissolve and remove both the organic and inorganic components of the smear layer. First, 17% EDTA (ethylenediaminetetraacetic acid) is used to remove the inorganic component of the smear layer. EDTA is followed by 5.25% sodium hypochlorite to remove the organic component of the smear layer. The order of use is very important, the inorganic component must be removed first, and then the organic component is removed more effectively.

Ultrasonic Activated Irrigation
Following the removal of the smear layer, which opens the dentin tubules and lateral canal orifices, the effectiveness of the sodium hypochlorite is greatly enhanced by ultrasonic activation. Over the last five years ultrasonic activated irrigation has been a widely studied topic by both researchers and dental product developers. There are now many commercially available products to deliver ultrasonic energy to the irrigation solution. All of them improve the effectiveness of sodium hypochlorite. The ultrasonic energy agitates the sodium hypochlorite and dislodges debris and pulp tissue remnants. The ultrasonic activity is most beneficial at removing pulp tissue from uninstrumented surfaces such as fins and canal isthmuses. A secondary benefit of ultrasonic activated irrigation is the heating effect that occurs to the irrigation solution. When sodium hypochlorite is heated, the time needed for it to dissolve tissue and kill bacteria is reduced making it more effective.

In summary, creating adequate apical canal shape for irrigation delivery, removing the smear layer, and using ultrasonic energy will greatly improve your endodontic irrigation and subsequently, your endodontic success.

Chris J. Lampert, DMD maintains a fulltime Endodontic practice in Portland, Oregon, and is involved with research, testing, and development of new endodontic products. Dr. Lampert received his DMD from Oregon Health and Sciences University and his Endodontic post-graduate degree from Boston University.

Dr. Lampert can be reached at drlampert@thedentistsnetwork.net

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