The Dentist's Network #99

Michael Moore, Esq.
Director McKenzie
HR Solutions
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Cliques And Queen Bees Equal Loss Of Sleep
And Profits - Part II

In part one of this article, we discussed the various ways that things can go bad when the boss isn’t in control of the staff, and the impact this can have on the practice’s bottom line. I was discussing an associate’s case in which an office “queen bee” and her clique were actively obstructing and sabotaging the associate’s work, and the host doctor refused to step in. If we dig a little deeper, we will no doubt find that profits are down in this office because of the inefficiencies that result from such a situation.

I have not yet addressed the potential for a major legal claim if the associate is forced out because of the host doctor’s refusal to take action. There could be contract claims, discrimination claims, defamation charges, and a host of other legal theories a good litigator could bring to bear on the facts. Nor have I addressed the potential for patient complaints to the state dental board.

Without knowing any more about this practice, I already know that the host doctor neither has a written employment policy, nor has he ever taken steps to bring order to his office. His reaction – denial – is understandable. No one likes confrontation, and the host doctor either consciously or unconsciously recognizes that if he takes action, it is going to cause major headaches for him. What is happening is the result of years of neglect. And that is understandable as well, because in most situations, the doctor is the last one to learn that the environment has become toxic.

If the doctor is unaware of a deteriorating office environment, his potential exposure is growing each day. Some doctors have expressed to me that they haven’t any worries because they have never had a problem. But in today’s employment environment, nothing is as it has been. Employees are more and more conscious of the need to seek legal advice if they are fired or forced to quit. And if you consider that defending just one legal case will cost a minimum of $50,000.00, is that a risk that you want to take?

I have reiterated again and again that a written employment policy is the only way to reduce or eliminate the potential of the dysfunctional office that leads, at the least, to loss of profits. It is necessary to not only have this policy, but to ensure that it is consistently followed. But not just any policy will do. There are many policies available – some for a couple hundred bucks on the internet. But these are all punitive and paternalistic in form, and they do not accomplish the key goal – reducing the doctor’s anxiety level by increasing his or her knowledge of the office environment, and also by using non-threatening methods in discipline and separation of employees.

In writing the McKenzie Employment Practices Manual, I have drawn on twenty years of litigating employment claims. I’ve distilled the most effective procedures from hundreds of corporate manuals and policies – and I’ve created unique methods for the doctor to deal with problem employees in a manner that is neither confrontational nor disruptive. In doing so, the doctor creates a paper trail that effectively immunizes the practice against employment claims.

Here are the key elements of an effective policy:

The policy must be only as detailed as necessary, and must be understandable and useable by anyone. A multi-volume policy, or one written in legalese, will simply end up in the drawer.

The policy covers every contingency that you can conceive of – use of computers, dress, provision for ongoing education or certification, leaves of absence, reimbursement for dental work on staff and family members, etc.

Because it is concise, every employee gets a copy of the provisions and signs that it has been received and read. The receipt acknowledges that she was paid to read it.

The policy guides you in effectively hiring staff.

The policy provides employees with an anonymous means of bringing issues of concern to the doctor’s attention – simply stating that you have an “open door” doesn’t get it.

“Discipline” in the form of warnings and suspensions do not exist. You definitely counsel, and you document counseling. The policy provides for the employee to be the first to take responsibility for her own behavior by, among other things, providing the employee with a “decision day” to consider her situation if there have been ongoing issues.

Exit procedures are clearly set forth, and your protection is in the “exit evaluation” that every separating employee is asked to fill out upon leaving. This applies to everyone – including those who are terminated.

The key to effective management of staff performance is that – insofar as foreseeable – every contingency affecting an employee is known. It doesn’t require hundreds of pages, but it is the first critical step. Second, you consistently follow the policy. In most cases, there is no undo hardship for the doctor in this. Third, by following the policy, you – and the employee – create the documentation to establish that all employees are treated with fairness, consideration and respect.

Remember – queen bees and cliques didn’t work in high school, and they won’t work in a professional office. The consequences for the doctor if they go unchecked can be more costly than you can possibly imagine. So take action, institute a policy, and follow it. You will sleep better every night.

Mike Moore is ranked among the best in employment law and has been named one of the top 10 lawyers in Ohio. As Director of McKenzie's HR Solutions, Mike is the creator of the Employment Policy and Handbook, geared to providing dentists who are unsophisticated in the legal arena with a step-by-step policy manual.

Click here to hear Mike present “7 Elements of an Effective Employment Policy.” Email Mike at mike@thedentistsnetwork.net.

Interested in having Mike speak to your dental society or study club? Click here.

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Dr. Ryan Swain
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Moving Beyond "Occlusion Confusion"

Over the last five years I’ve been on a pursuit to understand occlusion and simplify the topic in a new and insightful manner. As is oftentimes the case, taking a big step back and looking at this complicated subject in a simple and pragmatic fashion will allow us to see some basic truths that perhaps were previously hidden from us.

I’d like to start by stating two easily observable and scientifically proven facts about occlusion:

Teeth do not touch with any significant force during normal mastication
Canine guidance and protrusive guidance are never used during normal mastication

When I state these ideas during my lectures, I can feel the skepticism in the room. It’s an interesting moment. Based on what I understand, many of the dentists are thinking “those statements aren’t true” and others are thinking “I’ve never thought of that before.” I pause for a few seconds and savor the awkward atmosphere before moving on to an effective little exercise. We pass out a hard piece of candy to all of the attendees and ask them to eat the candy. As the room fills with the sound of crunching candy, I ask the attendees to follow my instructions. “Raise your hand when your teeth touch or when you are utilizing canine or protrusive guidances.” In four years, I have never had a single attendee raise their hand.

Many studies over the years such as those by Gibbs and Lundeen have shown clearly that our teeth do not touch during the normal chewing process. But, unlike most scientific studies, we can very easily test these findings by observing what happens in our own mouths. I’m continually amazed at how few of us actually use our own personal chewing experiences to think critically about the topic of occlusion. In many ways, this is quite ironic. We are highly trained dental professionals; we analyze and repair teeth on a daily basis but many of us haven’t taken the time to consider how or when our own teeth, muscles and oral structures actually function. I encourage you to take my “when do teeth touch?” challenge the next time you enjoy a meal. You’ll notice that your muscles of mastication pull your mandible towards your maxilla so that your upper and lower teeth can pulverize the bolus of food. This pattern continues until the bolus is broken down to a certain point. At this point, when upper and lower teeth are just about to touch, you stop chewing and you swallow the bolus. As you swallow you may notice that there is some light tooth contact but what you should also notice is that the force with which this contact occurs is extremely light.

If teeth do not touch during normal mastication, then it is important ask “when do they touch?” The answer is relatively simple. The only time that teeth touch with significant force is during parafunctional events. During these events, food is not present in the mouth. So, although teeth are primarily used to aid in our nourishment, they are essentially only damaged significantly through parafunction and trauma. When we understand this clearly, our treatment becomes more focused and effective.

Many dentists wonder why they can place a restoration in one patient’s mouth and it will endure for years while a similar restoration in a different patient’s mouth fails in just a few months. Dr. Frank Spear has described two categories of patients: high responders and low responders. High responders are the patients we see who seem to wear, crack and break anything that is placed in their mouths. These are also the patients who have extreme sensitivity to occlusal disharmonies that can be created when new restorations are placed. Low responders are the patients that rarely have dental problems and seem to adapt to just about any kind of dentistry that is performed in their mouths. What it boils down to is that the high responders are the only people who are actually putting their teeth together with any significant force. They are the clenchers and bruxers.

When we understand these relatively simple concepts we are able to cut through much of the fog that seems to hang around the area of occlusion and hone in on the most important aspects of helping our patients protect their teeth and restorations. Recognizing the signs associated with parafunction becomes a primary focus for us as clinicians. Educating the patients whom demonstrate these signs about their parafunctional habits becomes a significant part of our patient communication. Understanding the best methods and materials for parafunctional control also becomes imperative.

There are many types of guards and splints that can be used to help soften the blow of bruxing events. My personal choice for effective parafunctional control is the NTI-TSS device. The NTI-TSS (Neuro-Trigeminal Inhibition Tension Suppression System) provides a remarkably effective and easy way for dentists to help their patients protect their teeth and joints. The NTI device is a small and robust guard that is usually made to be worn on the lower incisors. The NTI provides for incisor-only contact which minimizes maximum biting force and muscle activity by approximately 65%. When patients cannot contact with canines or posterior teeth in any excursive movements, the masseter and temporalis muscles can only fire with a minimal amount of force. This provides many benefits for our patients including muscle tension suppression and decreased load to the TMJ’s. Since there is no tooth-to-tooth contact while wearing the NTI, there is no opportunity for tooth abrasion to occur as the result of bruxism.

Full arch nightguards have been fabricated and used successfully for many years. However, because of the size of a full arch splint, patient compliance is extremely poor. Additionally, adjusting a full arch splint can be quite cumbersome if any muscle relaxation and compensatory condylar seating occurs. Another negative characteristic of a full arch nightguard that many dentists haven’t considered is that a patient can still clench with 100% bite force while wearing even the most accurately adjusted full mouth orthotic.

The NTI can be easily fabricated chairside by a dental auxillary and adjustments are relatively easy because the incisors are the only teeth that come in contact with the guard. After making our NTI’s chairside for many years, we now submit these cases to Keller Laboratories for laboratory NTI-TSS fabrication. There is a slight increase in expense but the saved chairtime and increased quality in the finished device provide plenty of value for me, my staff and my patients.

I encourage you to consider some of the ideas that I have presented here. As dental professionals, our desire is to be experts in our field and use that expertise to benefit our patients. Occlusion poses an obstacle for many dentists because of the wide variety of opinions and conflicting evidence. I’m certain that if we take a step back and try to see the big picture, some of the topics within occlusion can become less complicated. If we stay focused on the science and also utilize our own experiences and pragmatism, we can move forward and progress beyond a state of “occlusion confusion.”

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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Chris J. Lampert, DMD
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Evaluating Endodontic Treatment

Does the obturation material go to the end of the root on the final radiograph? Usually, the first thing we look at when evaluating endodontic treatment, and often all we have to go on, is whether or not the obturation material goes to the end of the root on the final radiograph. It is difficult to evaluate how well the most important steps of the endodontic procedure were performed, because they do not show up on the final radiograph. Was patency achieved? Was all of the pulp tissue removed? Was the canal thoroughly irrigated? Were all of the canals located and treated? Was the canal obturated in three dimensions? Was the apex clean and free of debris before being obturated? Was the smear layer removed? Most importantly, was the canal clean? Final radiographs do not answer any of these important questions.

Endodontic treatment is one of the few procedures in dentistry where key steps important for long-term success can be done poorly, yet the final result (radiograph) will still look good. Said another way, the clinician can cut corners and hide sloppy work. Obturating an unclean canal space with remaining diseased pulp tissue is the equivalent of leaving decay under a new restoration. In the short-term there may not be any signs of a problem, but as time progresses the problem always comes to the surface. The following is a discussion of some important aspects of evaluating endodontic treatment.

Evaluating Shape
The continuous tapered canal preparation is the desired shape for obturation with a warm gutta-percha technique or carrier based obturation. As the name implies, the preparation has a continuous taper from orifice to apex. The tapered shape in the apical region is important for warm gutta-percha obturation because it provides the needed resistance form for compacting the warm gutta-percha against. Another benefit of the continuous tapered shape is that it allows for deep irrigation into the apical region. Nickel-Titanium rotary instrumentation has allowed for consistent predictable tapered canal shapes. These same shapes, when carved with hand instruments, are a painstakingly long and laborious process and often take multiple appointments to accomplish.

When evaluating canal shape, the following five rules apply:

There should not be any parallel canal walls
There should not be any abrupt changes in canal size
There should be adequate deep canal shape for irrigation to be effective
There should be a smooth consistent flowing taper from orifice to apex
The finished canal shape must also maintain the original fidelity of the canal curvature without straightening or transporting the canal path.

Evaluating Length
Evaluating length on a radiograph is difficult at best. We all know that radiographs are the least accurate technique for determining canal length because the canal terminus rarely ends at the radiographic apex. I am a strong advocate of using an apex locator to determine working length because it is the most accurate. The final radiograph can show the more common obvious short-fills or the less common obvious over-fills, but is not very good at determining if the obturation length is accurate.

Evaluating Obturation
The objective of canal obturation is to fill and seal the entire canal system, including all lateral anatomy and portals of exit. The most successful technique for accomplishing this objective employs the use of warm gutta-percha. Warm gutta-percha obturation includes centered compaction of a heated master cone with a heat source such as a System-B (SybronEndo, Orange, CA), vertical compaction of warm gutta-percha, and heated carrier systems such as Thermafil (Tulsa Dental Specialties, Tulsa, OK).

The benefits of warm gutta-percha include consistent density without voids, excellent adaptation to the internal canal anatomy, and hydraulic forces that fill lateral canals with sealer and gutta-percha. Sealer may be extruded through the apical foramen forming what is known as a “sealer puff” which confirms canal patency and good apical obturation. When done correctly, the final film should demonstrate a dense, flowing obturation with a small puff of sealer out the apex.

Evaluating the Unknown
As previously mentioned, certain key elements of an endodontic procedure cannot be evaluated on the final radiograph. Complete tissue removal from all canals and thorough irrigation and cleanliness of the canals prior to obturation is the most significant. That being said, if the finished treatment has a beautiful tapered flowing shape, a small puff of sealer out the apex, and a dense obturation that exhibits good length control, then I would give the clinician the benefit of assuming the same careful attention was placed on the other key steps that cannot be evaluated on the final radiograph.

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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Cliques And Queen Bees Equal Loss Of Sleep And Profits - Part II

Moving Beyond "Occlusion Confusion"

Evaluating Endodontic Treatment

Cliques And Queen Bees Equal Loss Of Sleep
And Profits - Part II