I practiced general dentistry in Keokuk, Iowa, population 10,000 and declining pretty steadily, and there I did a bit of everything, including pedodontics (using N2O without local anesthetic for all primary restorations), most routine extractions (When did dentists quit removing teeth? Some won’t even pull a baby tooth!), and amalgams. Now’s not the time to start a debate, but for those noble souls who refuse to besmirch themselves by placing amalgam restorations I have two requests: 1. Look at the literature. 2. If you’ve practiced ten or more years, start paying attention to the longevity, or lack of same, of your posterior composites.
I was financially independent and able to retire at age 53, and while I believe the quality of my work was acceptable, I certainly was not blessed with any extraordinary clinical gifts. The hallmark of my practice was gentleness, especially being able to consistently and predictably provide painless anesthesia, and rigorous honesty. I never placed my need (or greed) above that of the patient by doing work I wouldn’t perform on a family member or loved one. But three services I offered were a bit unusual, and in my humble opinion presented great value to patients, were stimulating for me to learn (It has to get mind-numbingly boring doing only operative, crowns, and anterior endo), and possessing these additional skills proved to be a marvelous way to differentiate and elevate my practice in patients’ minds from all the other guys down the street, thus enhancing busyness and profitability.
A simple way to distinguish your office is to be on time. If I was ten minutes behind schedule I was unhappy, as my tardiness led to unhappy patients, which creates a stressed and unhappy team; yet at my age I see way too many physicians, and some are even significantly late for their day’s first appointment. I feel – know – this shows a lack of regard and respect for me as a person, and I question why they are not accomplished enough to know how long procedures they preform DAILY take.
Many years ago I initiated a process which allowed us to see patients precisely when they were appointed, assured we had a full lunch hour, and that we exited the office on time; two things which will delight your staff who, a) Like to eat, and b) Have a life outside the office they’d greatly appreciate getting to in a timely and predictable manner.
We used a stop watch and 3 X 5 cards to time ten examples of all of our procedures, then averaged each and scheduled to the closest ten minute unit beyond that average. I.e. if our typical time was 26 minutes, we scheduled 30. Our first timed appointment happened to be for a root canal on a maxillary central incisor which, for no particular reason, we’d scheduled 60 minutes. Not counting anesthesia or restoration, it took twelve minutes. Bit of an epiphany. Not everything is hard or complex, but often a matter of mindfulness and will.
Treating TMD
For decades I’d insert some type of orthotic (many work) that separated teeth, then see my patient every week to adjust the appliance, wait until their head, neck, and joints were completely comfortable and had regained a fully range of motion (which usually took around a month), and then do a full mouth bite adjustment for which I scheduled an hour.
Preforming a definitive equilibration is challenging, and if you mess up, you can’t put the enamel you ground off back. A simple alternative is to place an NTI appliance (maybe the only thing in my practice that was FDA approved). Pain relief to TMJ suffers is often almost instantaneous, and I also used an NTI to control the damage (wear and fractures) caused by heavy bruxism, as they are easier to fabricate, less expensive, and much more comfortable to wear than a full-arch mouth guard. Many of my patients, including myself, reported that when wearing the NTI their snoring ceased. My chairsides fabricated these by adding Jet Acrylic to the NTI’s pre-formed shells.
Diagnosis was part of either a new patient or emergency exam (which is billed separately), so my time involved was close to zero. There were few patient we couldn’t help, and for TMD sufferers, relieving pain they’d endured, sometimes for years, seemed a miracle. Dental marvels are unicorn-rare, and being able to routinely pull one off will get your office discussed in glowing terms. As to profitability, the suggested fee is $600 – $700; a Lower Incisal Guidance NTI (my favorite) sells at 11 for $319, or $29 each. Add $.50 for acrylic and 30 minutes assistant pay you get ($600 – $29 -$10 = $561.)
Six month Smiles
This was the particular system I chose to realign adults’ anterior teeth. There is no attempt to correct the bite, only to achieve ideal cosmetics, and this is carefully explained and document to patients. While not a perfect solution, I believe this choice of care is an option adult patients should be afforded.
The company offers a fine text, training is a two-day course, and consultation help is available once you began to treat patients. I completed around 20 cases in two years before I retired, and all went well. Treatment time ranged from three to eight months. The company’s lab prepares each case individually from models and records you send, so there’s no need to purchase $5,000 in bands and brackets, and one seats a quadrant of brackets at a time using a custom formed device that resembles a bleaching tray, so placing the fixed appliance is easy and accurate. Ceramic brackets and toothshaded arch wires makes the braces virtually unnoticeable. Fixed lingual retainers are placed for post-care stability, tooth whitening is included, and for many this is a truly life-changing service.
I saw a gentlemen of about 40 years who had a severe class III bite and teeth that appeared to have been thrown at him from across the room. I believe an orthodontist had estimate a 5-year plan including resection of the mandible, for which the fee was… formidable. We achieved an ideal cosmetic result in eight months, and created an effusively appreciative patient. Believe me, EVERYBODY noticed the change in his appearance.)
orthopedics
I may have buried the lead, because of all the treatment I offered, I was never more proud of any than this. Orthopedics involves moving bone with removable appliances, and has been around since 1950 or so, which I believe means it’s been tested. I provided this service for about 30 years, including for two of my four kids, and most recently on two of my grandchildren who presented with full blown class III bites. When they turned seven, we changed this to a class I with a four mm overjet in around eight months. The eldest just had his eleventh birthday, and everything has remained copasetic.
This is only my observation and opinion, but after a career of trying to help TMD sufferers, I think extractions for orthodontics is often a mistake. Cosmetically I much prefer a full, Julie Robert’s type smile to the retracted straight teeth which a patient of mine once referred to as a “rat smile,” and I believe that pulling maxillary anteriors to the lingual, thus driving the condyle back into the joint is a possible source of chronically painful distress that is often difficult to set aright. If one corrects a division II bite (Maxillary anteriors tipped to lingual), and observes the mandible continuing to move forward as you make room for it to decompress, I think my point will be made. Also, expanding the maxilla flattens it, thus enlarging nasal passages, which makes breathing easier, and many if not most constricted maxillas result from mouth breathing, often due to the epidemic of allergies that exist.
Orthopedics can correct cross-bites, crowding, class II and III jaw relationships, and is an interceptive procedure best done on mixed dentition cases starting as soon as the six-year-old molars and maxillary central incisors erupt, which is salutary, as it means a child doesn’t have to wait to be eighteen to have a great smile. Make no mistake here, while I believe the service to be wonderful, doing it well will require a commitment to a lifetime of learning; but didn’t we already make such a vow? If you choose not to do this, please consider referring to someone who does.
It seems to me that many dentists graduate, then suddenly become too timorous to continue to learn and grow professionally to any significant degree (Switching to a new impression material des NOT count). If you survived dental school without a crippling case of posttraumatic stress disorder, you are capable of all the things I’ve mentioned (even being on time!). I believe every dentist wishes to provide quality care, but until one fully understands occlusion and TMJ’s, he or she cannot achieve excellence in our field, if that is defined as restoring mouths to states of complete beauty, health, and function. Please recall that our profession’s patriarch, Dr. G.V. Black, admonished dentists to be committed to a lifetime of perpetual learning. We owe that to our patients; and it will make a lengthy career much more interesting, fun, and rewarding.
Dr. John A. Wilde has published over two-hundred articles and six dental books, including his most recent, “A Dentist’s Guide to Financial Freedom,” a primer to achieving wealth written specifically to address the unique situation of practicing dentists, and which is available on the TPD website.
