The Dentist's Network #93

Chris J. Lampert, DMD
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Determining Endo Working Length

An accurate working length is one of the most important criteria for achieving successful endodontic results and minimizing post-operative discomfort. An erroneous working length, either long or short, can compromise the outcome of the case from the beginning. An erroneously short working length leaves un-cleaned and unfilled canal space in the apical region. An erroneously long working length will lead to over instrumentation and overextended obturation, causing significant post-operative discomfort. That being said, in my opinion, it is better to be slightly long than slightly short.

There are different opinions throughout endodontics on where the canal terminus is. Furthermore, there is also debate on how close to the canal terminus you should clean and shape. Do you work short of the canal terminus at the expense of leaving pulp tissue and debris in the canal? Do you achieve patency and clean the entire canal? I am definitely a proponent of achieving patency and cleaning the entire canal. Leaving tissue in the apical region is setting the case up for failure at a later date when the remaining tissue becomes necrotic.

The three currently accepted methods for determining root canal length are:

1. Radiographic Working Length
Radiographs are probably the most common method used for determining working length. I have learned that you get three pieces of information regarding working length from a radiograph; lies, lies, and damn lies. Although radiographs are important in endodontic treatment, primarily for assessing canal curvature, they have limitations regarding length determination. This is because the radiographic apex (the end of the root on the radiograph) and canal terminus (where the canal exits the root) often do not coincide. The one absolute that can be proven by a radiograph is when a file is out the apex. At that point there is no doubt you are patent. If the file is right at the radiographic apex you are usually patent. If the file is short of the apex on a radiograph you still might be patent. This is why radiographs can be used to confirm patency, but are not the most accurate method for determining working length.

2. Electronic Apex Locators
Currently, apex locators are the most accurate length determining method we have. All electronic apex locators work by the same method of measuring the multi-frequency impedance changes that occur when the file reaches the periodontal ligament. Electronic apex locators are really “patency detectors” and they are accurate at determining the point of patency. Apex locators are most accurate when the canal is dry and the file fits tightly in the canal. Even though the manufacturers state their apex locators can be used in wet canals, they work best in dry canals. Good electrical contact between the file and the canal wall produces a stable reading and is achieved when the file fits tightly in the canal terminus. The remedy for a jumpy reading is to use a larger file size.

3. Paper Point Method
The late Dr. David Rosenberg taught me and many other clinicians the paper point method. It is very accurate for determining the final canal length prior to obturation. This technique is used following cleaning and shaping and involves placing a feather tipped paper point through the terminus of a patent canal. The tip of the paper point becomes moist where it exits the canal and this moisture spot is the true working length for obturation. This method is perhaps the most accurate for post-shaping measurement, but it is also technique sensitive and requires a lot of practice to master. The paper point method requires a patent canal terminus and great care must be taken during instrumentation to prevent apical bleeding.

I often use this method to compare pre-shaping working length from an electronic apex locator to the post-shaping working length. In curved canals, the degree of curvature is usually less following instrumentation. This reduction in curvature means there is a straighter and shorter distance to the canal terminus resulting in a shortening of the true working length. I rely on and trust the electronic apex locator over all other length determining methods. Once you develop confidence in your electronic apex locator, it will shorten your treatment time by requiring fewer working films. Ultimately, it will produce better end results with less post-operative discomfort for your patients.

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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Louis Malcmacher
DDS MAGD
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The Secret To Success In Dentistry

Success in dentistry depends on the ability to properly manage both the clinical and practice management aspects of your practice. This synthesis is vital to your success, and it’s amazing to me how many dentists completely lose sight of it. Most dentists make the crucial mistake in their offices of focusing on only one of these aspects, while ignoring or minimizing the other.

I see many dentists who spend an incredible amount of time and money to improve their clinical skills, which is always important and necessary. These highly trained dentists come back to their offices able to offer incredible dentistry to patients, but with the same practice management problems that they left with they find there are no takers. Patients don’t respond to clinical skills alone. In fact, most patients cannot differentiate between a dentist who has taken 1000 hours of continuing education in the past year and a dentist who has taken only 20 hours. If you don’t equally advance your practice management skills along with your clinical training, your dental practice will not grow.

I’ve seen dentists make the opposite mistake as well. They will invest time and money in improving their practice management skills to motivate patients to accept treatment, they utilize marketing to bring in new patients and they work on their case presentation, but they do not put any focus on improving their clinical skills. Dentists will invest in trying to get hoards of new patients, but if you don’t have the clinical skills necessary to perform esthetic treatment or complex restorative and implant treatment, your practice will also not grow and not break out to the next level.

I frequently see both of these common mistakes as I consult with many dental offices around the country. It is this constant balance of clinical and practice management skills that you need to hone and improve that will dramatically enhance your ability to diagnose and treat patients while at the same time being able to motivate and lead patients to optimal dental health. Add to this the ability to effectively know what patients want from a dental office and what procedures they desire, and this is how we bring a dental practice that is under producing to its maximum potential.

You have to understand that every decision you make on a clinical product, technique, or piece of equipment has direct practice management ramifications in such things like patient satisfaction, efficiency, and overhead control. Similarly, every practice management decision that you make will have direct clinical applications as well.

Let me give you some quick examples:

A Laser In Every Practice
Laser dentistry has been growing and growing and as more patients find out that dentistry can be done without the dreaded shot. The consumer demands for minimally invasive techniques will push most dentists to incorporate some kind of laser into their practices.

Facial Esthetics and Dermal Filler Therapy
Over half of the state dental boards are now allowing dentists to enter the arena of total facial esthetics. This presents a unique opportunity for dentists to be able to expand their dental practice to really enhance and complete esthetic dental cases and adjunctively treat TMJ and bruxism. Approximately 8-10% of dentists in North America are already providing this service to their patients.

No Prep/Minimal Prep Veneers
Esthetic dentistry has had its ups and downs, but in this economic recovery it will grow quickly as so many patients are aware of the esthetic dental options that are available to them. New advances in veneers will continue to rapidly grow this market as most patients now look for conservative ways to permanently receive a great-looking smile.

Answer the Phone Correctly
Everybody wants to get new patients. What may surprise you is that new patients call your office all the time. One of the biggest secrets in dentistry in getting more new patients in your practice is to just answer the phone correctly. People call your front desk all day long, and if they are on hold for too long, if their questions are not answered correctly, or if they are not asked to make an appointment properly, they may go ahead and find a new dentist. You can do all the marketing in the world and get your phone ringing off the hook, but if the person up front does not have proper telephone skill training, then you are turning away more new patients than you can imagine.

Like anything else in your office and in dentistry, you need to get some education and training to become highly skilled. The proof of the pudding is how many more patients get scheduled as new patients when you finally learn the right way to do it.

Successful practice management and clinical systems are essential to every office. The most common mistakes we make are trying to isolate instead of synthesizing these two all encompassing aspects of your practice. Dentists can learn how to look at their practices differently and make smarter purchasing and hiring decisions based on both clinical applications and practice management needs. This results in a happier, more stress free and productive environment for the whole dental team and that is when you really reach success in dentistry.

Louis Malcmacher DDS MAGD is a practicing general dentist and an internationally known lecturer, author, and dental consultant known for his comprehensive and entertaining style. An evaluator for Clinicians Reports, Dr. Malcmacher is a consultant to the Council on Dental Practice of the ADA.

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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Dr. Ryan Swain
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Self-Awareness Is King

Do you know yourself? Think about it for a minute. Do you really know yourself? I’m a relatively young dentist but there is one thing I’ve learned early in my career that has paid enormous dividends for me in both my personal and my professional life. I’ve learned that self-awareness is king. Everyone thinks that they are self-aware. By this I mean that when asked, almost everyone would say that they believe that they know themselves. In my experience, this is far from the truth. Most people live their lives without gaining a true understanding of who they are and how they are perceived by others. It’s a strange phenomenon and I’m convinced that it is the single biggest characteristic that holds dentists (and all people) back from reaching their full potentials.

Anyone who is truly excellent at something usually has a way in which they obtain valuable feedback about their performance. Professional athletes have coaches that scrutinize their technique and provide insight regarding how they can improve. Baseball players, for example, spend hours watching video footage with their coaches so they can recognize their flaws and discuss options for improvement. Golfers spend countless hours perfecting their games by analyzing each minute aspect of their swing and getting feedback from coaches. Ultimately, continual improvement and excellence only comes from honest investigation and a choice to work toward improvement through intentional and gradual changes.

I think most people would agree with my sentiments here. However, very few dentists actually apply these ideas to their own lives and this prevents personal growth. Pride, fear and laziness seem to blind us and prevent us from being honest with ourselves about who we truly are and how we are perceived by those around us. It’s much easier to ignore our own character flaws and focus on the flaws of others. Personal change can be quite challenging and therefore many of us don’t even crack that door open. We deflect criticism and make excuses for the way that we are. It’s a common pattern of behavior but there is tremendous freedom and success available for the few who can break the cycle.

Socrates once poignantly said, “The uninspected life is not worth living.” This idea really resonates with me. I believe we all want to reach our potential and be the best people we can be… the best dentists, spouses, fathers, employers, mothers, friends etc. This can’t happen unless we truly open ourselves up to scrutiny and criticism. We can only improve aspects of who we are if we clearly understand the areas that need improvement.

Let’s apply this idea more specifically to our roles as dentists. Most of us work very hard to become excellent in our clinical skills. We take many hours of CE and we spend a lot of time trying to figure out what tools, supplies and pieces of technology will help us to be clinically excellent. However, most of us realize that clinical ability is a very small part of what makes a successful and respected dentist/employer. Our patients and our employees are much more affected by our ability to: listen, be compassionate, lead with strength, show integrity, be humble, and respect those around us.

Some dentists are at their wits end, trying to figure out why their careers aren’t as successful as they’d like them to be. They are looking for a magic formula that will allow them to reach the success that they hope for. They ask questions such as “Do I need to learn a new procedure?” or “Am I missing a vital piece of technology in the office?” or “Should I switch to a different type of composite material?” Unfortunately, this way of thinking leads directly into a brick wall. It’s a dead end. Success and personal fulfillment doesn’t come in a simple formula. Happiness isn’t created by purchasing the right equipment or even hiring the right staff. It begins by taking an honest look in the mirror and performing a sincere inspection of the person looking back at us.

Ask yourself, how much time do you spend working on YOU? Do you even have a clear picture of how others would describe you? Do you wonder why you have a hard time retaining staff and getting good case acceptance from your patients? Do you find yourself blaming your mediocrity on “the economy” or the “more aggressive” dentists in your area? These are tell-tale signs of a person who is not self-aware. I’m imploring you to be honest with yourself and consider for one moment that maybe you fit into this category.

Running is easier than changing. If you are someone who is running, I’m inviting you to stop. You can achieve tremendous personal and professional fulfillment if you do. Here is “The Swain Plan” for getting out of the rut and getting on the road to self-awareness and ultimately a better life/career.

Write down what you believe are the three weakest areas of your character.
Ask those around you (spouse, children, employees, friends) if they agree with your list (if you have a hard time sharing this list with others, this confirms your predicament).
Make the following phrase a regular part of your dialogue with others - how can I be better? If we continually ask this question and honestly seek the answers, we can make a huge step towards growth.

Imagine the amount of useful feedback you can get when asking a simple question such as “How can I be better for you?” This phrase is simple but extremely potent. Use it regularly with your patients and your employees and be open to the responses you receive. Your life will change will because of it… ask me how, I know!

Dr. Ryan Swain is a graduate of the University of Florida College of Dentistry. He practices in Rochester, NY and focuses on Short Term Ortho and other conservative cosmetic dental procedures. He is president and chief clinical instructor for Six Month Smiles. Dr. Swain is a pioneer in the field of Short Term Ortho and constantly on the forefront of GP orthodontics. He has trained dentists internationally and prides himself on de-mystifying orthodontics for GPs.

Dr. Swain can be reached at Drswain@thedentistsnetwork.net

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