The Dentist's Network #97

Louis Malcmacher
DDS MAGD
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It's All Semantics!

Most dentists that I know think that semantics do not matter at all. It really makes no difference if you tell the patient that they are getting a composite filling as opposed to a tooth colored filling. Many dentists still use that four-letter word - “pain” - instead of talking about slight discomfort. I have even heard dentists tell their patients, and this was with my own ears, “We are going to put a crown on this tooth and it is basically like putting your tooth into a coffin.” How is that for imagery?

Words do matter. Your patients are carefully listening to the words that are coming out of your mouth, both in terms of their context and the actual words themselves. Do you think for a moment that patients understand words like “composite resin,” “bite wing,” “periapical,” “Panorex,” “Cad Cam,” “inlay/onlay,” “interproximal,” “occlusal” or any of the other technical terms that we use? We understand these terms, but to the patients they don’t mean a darn thing.

How can you learn patients’ language? Do an Internet search about a dental topic and then go ahead and read the consumer magazines and see how they describe what we do in our offices to dental patients. I can’t tell you how valuable this lesson is going to be for you. Consumer magazines are written for the masses, and those masses do not speak in “Dental-Eze.” They speak common language that speaks to the ears of their audience.

Early in my career, I had the opportunity to go through media training and this was one of the best spiels that have stayed with me over the last 25 years. It was three days of training to learn how to speak the language of the audience so that every quote, sound bite, or saying that comes out of your mouth will connect with the people that are supposed to hear it. It is important to be concise, to the point, use terms that are commonly understood, and learn how to be a translator from Dental-Eze to everyday English.

Communication is the key to your success in the dental office. Of course, clinical skills are vitally important because if you don’t have them, you can’t deliver the dentistry that the patients need or want. Every dentist reading this article can learn any dental skill and technique that they would like and become proficient at it. If you can’t go ahead and explain it to patients, which then leads to treatment acceptance, then that skill and talent that you have acquired is pretty much worthless. If patients cannot understand you, chances are that treatment acceptance is going to lag way behind.

Let me also make clear that in the dental office, the dentist does not necessarily have to be the one that can explain treatment to patients in their language. In many offices, this is best left to a qualified assistant, hygienist, treatment coordinator or the office manager. Not all dentists have good communication skills and, like any smart business person, you know that you can either develop the skills that you need, or you can delegate it to someone who can do it better than you.

This is abundantly clear to us now that we are delivering total facial esthetic treatment of veneers and facial injectables to our patients. When talking to patients about their facial esthetics, I let the female team members discuss with the patient their goals. This peer to peer discussion helps the patient gain a much better understanding of what can be accomplished. Being that the female team members in our office have had Botox and dermal fillers, they can speak to the patient with first-hand experience, which is invaluable in treatment acceptance and speaking the patient’s language.

In both my clinical and practice management lectures, I routinely tell my audiences that when I talk about practice management, I get most of my material from consumer magazines. Practice management boiled down to one line is this: “Give people what they want.” How do you find out what people want? Instead of just ordering all of those nice magazines for your waiting room and then putting them out for the patients, why don’t you try reading or flipping through some of these magazines and reading about anything that has to do with dentistry and facial esthetics. This will immediately improve your communication skills with your patients by simply just using some of the terms mentioned in the articles, because they are written by professionals who know how to communicate with the consumer mass market who are also your patients.

How do you find out what your patients want? Watch what they watch, read what they read, and then learn to speak their language so that they will come to trust you, value your opinion, and accept your treatment plans that will improve their lives.

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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Chris J. Lampert, DMD
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Rotary Instrument Separation

Rotary nickel-titanium instrument separation is an event that can easily turn an otherwise ordinary appointment into an undesirable experience. Although many times the long-term prognosis for the tooth is unchanged, the event casts a negative light on the root canal procedure for both the patient and doctor. Understanding the physical and mechanical causes for rotary instrument separation is critical to preventing and limiting its occurrence.

Causes of rotary instrument failure can be divided into two main categories. The first is cyclic fatigue failure. The second is torque failure. Although these two causes are often discussed independently, torque failure is more likely to occur after an instrument has experienced cyclic fatigue. Therefore, cyclic fatigue and torque separation are not necessarily independent.

Understanding Cyclic Fatigue Failure
Cyclic fatigue is defined as the accumulated strain that develops from repeated bending of an object at the same location. The repeated bending action cycles tension and compressive forces at the site of bending. An example of cyclic fatigue is demonstrated when a paper clip is repeatedly bent at the same location. With every bend the paper clip becomes more fragile (fatigued) and eventually breaks. In a canal, cyclic fatigue accumulates at the site of the canal curvature. The main factors affecting cyclic fatigue in rotary endodontic instruments are degree of canal curvature, speed of rotation, and instrument size (diameter).

Instrument size (tip diameter and taper) is the most important variable that influences cyclic fatigue failure because the clinician has control over this variable, where as canal curvature is a fixed variable that is beyond the clinician’s control. Smaller tip size and smaller tapered instruments are more resistant to cyclic fatigue because they are more flexible. The clinical relevance of this principle means that in curved canals, selecting an instrument with a .04 taper would be a safer choice than an .06 taper to prevent cyclic fatigue instrument separation.

Understanding Torque Failure
The second main cause of instrument separation is torsional load or torque failure. Torque failure occurs when the rotational torque load applied to the instrument exceeds the torque limits of the instrument. An example of torque failure occurs when an instrument is forced apically under too much pressure and the tip binds under rotational force. Multiple studies have pointed out that an instrument’s torsional strength is directly related to its metal mass, and therefore is again influenced by instrument tip size and taper. As the cross-sectional diameter of the instrument increases, its resistance to torque induced separation increases. An important point to remember is that as the instrument diameter increases, the instrument cross-sectional surface area increases exponentially. The difference in diameter between a size 20 instrument and a size 30 instrument is a 50% increase, but the cross-sectional surface area is a 129% increase. This geometric feature of instrument size shows that using a slightly larger instrument size will greatly increase metal mass and therefore torque strength.

Torque related instrument failure has partially been remedied by the introduction of torque controlled auto-reversing motors. Torque controlled electric motors can be pre-set with torque limits just below the instrument torque limit so that the motor automatically reverses when the torque sensor reaches a certain torque. Torque controlled motors, when set just below the limit of elasticity for each instrument, reduces the risk of fracture markedly. It is important to remember that the limit of elasticity is different for different types and sizes of rotary instruments; therefore the proper torque limit must be selected for the individual instrument.

Preventing Instrument Separation
Understanding the mechanical principles behind instrument separation aids the clinician in the prevention or reduction of its occurrence. For example, knowing when the canal possesses a significant curvature, which is more likely to cause cyclic fatigue failure, it would be appropriate to use an .04 tapered instrument. Less tapered, smaller diameter instruments are more resistant to cyclic fatigue failure. Creating straight-line canal access is another method to reduce cyclic fatigue. Removing high cervical bulges in the orifice region or impinging access walls will effectively create a straighter, less curved path for the instrument to follow and reduce cyclic fatigue.

Preventing torque-induced failure is a more difficult task. Utilizing a torque controlled electric motor, larger tip diameter instruments in straighter canals, and creating a glide path for the rotary instrument to follow are all techniques that reduce torque induced instrument failure. Perhaps the most important skill for preventing torque-induced separation is the utilization of mild apical pressure when advancing a rotary instrument down a canal.

Unquestionably, rotary nickel-titanium instruments have revolutionized endodontic treatment. Rotary nickel-titanium instrumentation has produced more efficient, predictable shapes than could be achieved by hand instrumentation. Nickel-titanium endodontic instruments also have a greater ability to negotiate curved canals, and reduce transportation, zipping, ledging, or perforation. They also allow larger apical preparations of curved root canals while maintaining the original canal path. Along with all the benefits of rotary nickel-titanium instrumentation there is an inherent risk of instrument separation. Being mindful of cyclic fatigue and torque failure will help prevent the dreaded instrument separation.

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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Dr. Ryan Swain
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Creating Value In A Recession - The Cosmetic Paradox

“Value” is a word that we hear so often, I think many of us have lost sight of what it really means. Dictionary.com defines value as “worth, merit or importance.” Value is subjective. We all apply different amounts of value to different items. A great piece of sushi may be extremely valuable to me (a sushi lover) but essentially worthless to someone with a strong aversion to raw fish. During this recession, we as dentists and business owners must think hard about the amount of value that we are creating for our patients. We must also clearly understand what aspects of our practices provide the most value to our patients. Is it the convenient location of our office? Is it our ability to provide painless dentistry? Is it the quality of our dental restorations? To be successful, we need to create significant value for the people in our communities or we are destined for mediocrity or in the worst-case scenario, failure.

A recession is an interesting phenomenon. Billions of dollars of wealth literally disappears in a very short period of time. Although they can be very painful, recessions do a great job of separating the wheat from the chaff and exposing businesses that aren’t bringing sufficient value to their customers. When money becomes scarce, consumers start treating each dollar with more care and spending their money with more scrutiny. Whether we like it or not, our job as business owners is to provide products and services that are worth more to our patients than the money they have in their pockets. When we do this, they will decide to give us some of their money in exchange for our services. Garrett Gunderson, author of Killing Sacred Cows, sums this up by saying “We only give up something in an exchange when we value what we’re receiving more than we value what we’re giving up.” It sounds simple, right? Let’s investigate this a bit further.

Why is it that during this recession, some practices continue to thrive while other practices are hurting badly? Why do some dentists increase their marketing budgets during the recession while others make cuts? It all boils down to value creation. The dentists that continue to provide services and experiences that are truly valuable to their patients will always have cash flowing into their practices. These dentists realize that when times are tough and consumers are clinging more tightly to their dollars, an increase in marketing will help convince more people to come into their offices for dental services. However, an increase in marketing will only yield results if there are aspects of the practice that are truly marketable. In other words, we must have something valuable to market to our patients!

The common myth is that cosmetic dentistry should be “put on the backburner” during a recession. The misconception is that cosmetic dentistry is “elective” and therefore is not something that people will purchase when money is tight. This brings us back to our concept of value creation. What do you think is more valuable to a patient - having a crown placed on their cracked but asymptomatic second molar or having the unsightly diastema closed between their upper centrals? Which will provide a more tangible result for the patient? Which procedure will help improve self-confidence and self-esteem and therefore create a significant amount of value for the patient?

The unavoidable truth is that most people care a lot more about their appearance than they do about their health. This is especially true when it comes to dental health. As dental professionals, we understand how important dental health is but sometimes the most frustrating part for us is trying to convince our patients to feel the same way. The trend towards insurance-based practices is a symptom of the discrepancy between the consumers’ perceived value of restorative dental work and the costs that are associated with these services. Many practices simply aren’t able to convince enough patients to spend the fruits of their labor (their money) on dental services, and therefore these practices opt to participate with insurance plans. When participating with an insurance plan, a practice can generate more patients and no longer has to work as hard to create value for the patients. Value for these patients exists because the dental office participates with their plan and they don’t have to spend as much of their own money in exchange for the dental services provided. Since they are spending less of their own money they don’t require as much value during the exchange.

Don’t get me wrong. I am neither praising nor denigrating dental practices that participate with insurance companies. There is nothing wrong with dental insurance participation and for many dentists it is a smart move. I’m highlighting the idea that there are various ways that dentists can appeal to patients and when times are tough it doesn’t have to be by signing up for more insurance plans.

We have to fully understand what patients want, and then provide it. In my office I’ve seen that affordable cosmetic dentistry can be an enormous boon to a practice. There is tremendous value in conservative dentistry that dramatically improves the smiles of our patients. Sure, those big $30,000 porcelain cases become rarer during a recession, but more practical forms of cosmetic dentistry can be very attractive to patients. Many dentists that I speak with on a weekly basis are actually growing their practices by ensuring that they are offering services that patients will say yes to and then creating the exposure needed to make patients aware of these services (both internally and externally). Many of these services are conservative cosmetic procedures such as: botox and dermal fillers (www.FacialEsthetics.org), strategic cosmetic bonding (www.BioclearMatrix.com), short term orthodontics (www.6MonthSmiles.com), teeth whitening (www.KorWhitening.com) and ‘minimal prep’ veneers such as Cristal veneers from Aurum Laboratories.

Along with great restorative dentistry it is important to have a vast service mix available to our patients. The products and procedures I’ve mentioned here can all be added to a practice with minimal amounts of time and money, but with significant return on investment. Allow me to conclude by stating very clearly what my “take home” message is. Businesses succeed in any economic environment when they continue to create value for their customers. As dentists, we must be honest about what our patients want and be willing to cater to them on their terms. We are highly trained dental professionals and we must be able to diagnose and treat dental disease at a high level. But, as business owners we should also recognize that it is our responsibility to understand our customers and cater to them. We must create value for our patients.

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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