Clayton Davis, DMD 

Hint: It wasn’t because I was cold. 

A First Impression I Will Not Forget 

One of the activities my family enjoyed on our vacation to Ireland 25 years ago was visiting the famous McGee tweed factory in Donegal. They had a loom set up so visitors could pick out threads, weave with the shuttlecock, and make a pattern. My children were at an age when that was very entertaining. 

On our last day in Ireland, we walked the main street of Sligo and stopped in the Mullaney Brothers haberdashery. While my wife looked for a few things, I waited with no intention of buying. An elderly gentleman walked up behind me, and with a charming Irish brogue asked, “I say, sir, are those your children over there?” I said, “Yes.” And he said, “Oh, they’re fine looking  children. They are a credit to you, well behaved.”  

As the conversation proceeded, he introduced himself as Mr. Johnny Mullaney. He inquired about where I lived and what we had done while in Ireland. He mentioned how he enjoyed watching the Olympics in my hometown of Atlanta. He knew a lot about Markree Castle, our accommodation for the week, and Rosses Point, a golf course I played at. He enthusiastically shared his opinion of its famous 18th hole. He was immensely proud of the golf course. Then he mentioned the pride they had in their tweed jackets made from tweed from the McGee tweed factory.  

He pointed to the jackets and asked which of the tweeds I liked best. I pointed to one and he said I appeared to be size 41L (exactly right), and before I knew it, he had slipped the jacket over my shoulders. As he brushed his hands over my shoulders and down the sleeves and tugged at the cuffs and bottom of the jacket, it felt tailor-made for me. I told him I liked the way it fit, but our luggage would be tightly packed for our trip home. I expressed my concern the jacket would end up badly wrinkled. He said, “Oh, it’s tweed, sir. We can fold it very nicely and have it ready for you to pack and it will unfold without wrinkles when you get home.” 

I liked the look of the jacket, yes, and I appreciated the quality of McGee tweed. But ultimately, what I appreciated most, what made me want the jacket, was Johnny Mullaney, himself; the consummate haberdasher, a master at his craft, who won me over by becoming my friend in a mere five minutes.  

I thought, “I don’t have a memento of this trip. This jacket will always remind me of our wonderful trip, our day at McGee factory, and this endearing Irish businessman.” I said, “Mr. Mullaney, I will take the jacket.” 

What I Learned from that Lasting Impression 

There are four elements from meeting Johnny Mullaney that I apply to meeting every new patient in a preclinical interview: 

1. Make a friend. (How can you trust each other if you don’t become friends?) 

1. Make an invitation. (Accepting an offer to be examined makes co-discovery exams flow.) 

1. Make it easy. (Find out their concerns, and address them.) 

1. Connect the feeling to the choice. (People do business with people they like.) 

You see, we always make choices based on our feelings. The preclinical conversation allows the new patient to feel good about my desire to genuinely help them and understand their feelings and needs. This is how we can move forward toward optimal care.  

A Series of Invitations Lead to the Treatment “Yes” 

When dentists ask me how they can do more cosmetic and restorative cases, they are usually surprised when I tell them it begins with doing pre-clinical conversations at the first visit.  

• You can’t do comprehensive cosmetic and restorative treatment until you’ve presented a treatment plan.  

• You can’t produce a treatment plan until you’ve done a good diagnosis.  
• You can’t produce a diagnosis until you’ve done a thorough exam. 
• And that thorough exam is incomplete when it doesn’t start as a good preclinical conversation with the new patient. 

The preclinical conversation sets the tone for trust and healthy open communication. It is the essential first step in creating a lasting good impression that leads to the first “yes” in a series of invitations on the way to treatment.  

Laura Harkin, DMD, MAGD 

Let’s delve deeper into the preclinical interview! 

It’s helpful to understand a patient’s perception of their overall health and oral health, as well as what type of restorative dentistry they’re hoping to have and why they feel the way they currently do.  

Sometimes, an integral family member has influenced the timing of care. For instance, you may hear, “My grandchildren are making fun of my teeth” or “My wife asked me to get my teeth fixed.” From this response, I know that I will need to be sure my patient personally desires treatment before rendering it. I’m also anxious to understand what type of restorative dentistry a patient is considering. For example, are they open to removable prosthetics, fixed crown and bridgework, or implantology? 

Recently a new patient came to my office with an emergency. Tooth #5 presented with the buccal wall broken to the gumline and a moderate-sized, retained, amalgam filling. He immediately said, “I do not want bridgework.” I listened quietly until he elaborated by saying, “When I had this front tooth replaced by my other dentist, I had to take it in and out, and I just found that so irritating.”  

I finally understood that he was referring to a flipper but calling it bridgework. So, it’s important to listen and ask questions when someone seems close-minded about having a certain modality of treatment. Delve deeper into the conversation because it may simply be confusion surrounding dental terminology. 

For the grandparents who ask for a better smile, I’d like to understand their thoughts on the scope of treatment and their expectations. Are they looking for a white, straight, Hollywood smile or a more natural appearance with a little bit of play in the lateral incisors? Are they mainly concerned about stains, gaps, or a missing tooth? Are there other problems they’re aware of such as tooth sensitivity, inflamed gums, or the need for a crown? This input is very important as we continue conversation with co-discovery throughout the clinical exam, diagnostic records, and treatment planning phase. 

Learn to count on your chairside for pertinent information. 

I’m fortunate to always have my assistant, Cindy, beside me for preclinical conversations, comprehensive examinations, and restorative procedures. Sometimes, Cindy interprets a patient’s statement or component of conversation differently than me. She may hear a message that I missed or read body language of which I wasn’t aware. Sometimes, auxiliary conversations between patient and assistant take place after I’ve left the room to complete a hygiene check.  

At the end of the day or in the morning huddle, we always take time to discuss interactions with our patients. Together as a team, we’re more efficient at acquiring accurate information so that we may approach the road to health most effectively for each individual. 

Determine if trust is present. 

As I’m getting to know a patient and before I choose to begin restorative treatment, I seek to understand if trust is present in our doctor/patient relationship. New patients often share past dental experiences, and, unfortunately, some have lost trust in dentistry itself. This may be warranted due to improper care, but it may also be due to a lack of understanding or unclarified expectations regarding a given procedure or material choice.  

It’s not unusual, particularly when a patient is considering a large scope of treatment, to serve as a second or third opinion. Building trust and waiting to be asked for our skills are key necessities before moving forward in irreversible therapy.  

The comprehensive examination, periodontal therapy, splint therapy, and gathering of records are all appointments during which opportunities exist to get to know our patients. True trust often takes time to establish, but the reward reaped is frequently one of empathy, friendship, and the ability to do our best work. 

Explaining Dentistry in a Way Patients Understand 

Clayton Davis, DMD 

Here are some of the ways I communicate with patients to help them understand dentistry. I hope some of these will be helpful to you in enabling your patients to make good decisions about their treatment.  

Occlusal Disease: In helping patients understand occlusal disease and the destruction it can cause, I have long said to them, “The human masticatory system is designed to chew things up. When it is out of alignment, it will chew itself up.” I tell them, “Your teeth are aging at an accelerated rate. We need to see if we can find a way to slow down the aging process of your teeth.” The idea of slowing down aging is very attractive to patients, and if you relate it to their teeth, they get it.  

Occlusal Equilibration: Typically, I come at this from the standpoint of helping them understand that teeth are sensors for the muscles, and when the brain becomes aware our back teeth are rubbing against each other, it sends the same response to the muscles as when there’s food between our teeth. In other words, the brain tells the muscles it’s time to chew, and this accelerates wear rates on the teeth. Equilibration is really a conservative treatment to reduce force and destruction of the teeth.  

Diseases of the Jaw Joints: Regarding jaw joints and adaptive changes and breakdown, patients understand that joints have cartilage associated with them. Saying there has been cartilage damage in your jaw joint gets the message across simply. 

Treatment Presentation: When patients say, “I know you want to do a crown on that tooth,” I jokingly say, “Oh, don’t do it for me. Do it for yourself.” I never say, “You need to get this work done.” Instead, I say, “I think you are going to want to have this work done.” 

Conservative Treatment: I have always enjoyed John Kois’s saying that no dentistry is better than no dentistry, so when talking about conservative dentistry, I’ll tell patients, “No dentistry is better than no dentistry. We certainly don’t intend to do any dentistry that doesn’t need to be done.” Another way I speak about conservative dentistry is to say, “Conservative dentistry is dentistry that minimizes treatment. In the case of a cracked tooth, a crown is actually more conservative than a filling because it minimizes risk.” 

Moving Forward with Treatment: I love Mary Osborne’s leading question for patients after they’ve been shown their issues and treatment possibilities have been discussed. The question is “Where would you like to go from here?” With amazing regularity, the patients choose a really good starting point for their next steps toward improved health, steps that feel right to them. Always remember, people tend to support that which they help create. 

Dental Insurance: I typically speak of dental insurance as a coupon that can be applied to their dental bills. I’ll say, “Every plan sets limits on how much it pays. The way dental insurance works, it’s as if your employer has provided a coupon to go toward your dental bills.” 

Presenting Optimal Care: If I want to present optimal care to a patient who is ready to hear it, I ask permission by saying, “Mrs. Jones, if I were the patient and a doctor did not tell me what optimal treatment would be for my problems because the doctor was concerned that I couldn’t afford it or that I would not want it, I would think, ‘How dare you make that judgment for me. You tell me what optimal care would be, and I’ll decide for myself if I want it.’ So, with that in mind, Mrs. Jones, would it be okay with you if I presented you with the optimal solutions for your problems?” 

Another dentist asked me, “What temporary cement do you use so your temporary crowns actually stay on?”

The cement I like is TempoCem from DMG America. It is easy to utilize and clean. But there is a more important question than what type of material I like to use. It is: “What is going on with the tooth before the prep is begun?”

I have found that the reason temporaries come off is because something in the functional movement of the patient’s mouth is interfering with the tooth. Before prepping a tooth for a temporary, I anticipate I may need to re-design the tooth first.

Before prepping the tooth, I take an intraoral photo of the bite marks to understand what is going on functionally. I explain to the patient what I am looking for and show the patient the evidence of excursive interferences on the tooth. My goal is to design the provisional and the crown to decrease the forces and increase the functionality of the tooth. I then modify the tooth and take another intraoral photo of the bite marks to show the patient the changes before making the impression of the natural tooth.

I realize many dentists check the bite marks and modify the tooth prior to making an impression without the added step of photography and patient education. But I suggest you try using before and after photo images chairside to educate your patients. This process engages the patient in understanding how their teeth function and why there has been damage to the tooth. I’ve learned it also “opens their eyes” and increases their appreciation for the additional dentistry I recommend based on my comprehensive examination of their mouth and diagnosis.

Here are three tips that have helped me in organizing my practice so we can best manage same-day emergency patients and not disrupt the quality time we spend with already scheduled patients. Each of these tips enlist the help of the dental team.

Tip 1

At the morning huddle, we sit around the table, and it is the responsibility of the assistants and front desk to identify and clarify where the best spot in the schedule would be for an emergency patient. It could be a patient of record or someone who is new who has a great referral. If it is someone new without a great referral, appointing that person depends on whether it makes sense for the patients already scheduled that day.

Tip 2

Over the phone, we make sure the conversation with the emergency patient includes an important question – “How can we help you today?” In the case of a patient of record, we look at their chart and plan to address their concern that day but not over address it. Oftentimes a patient will say, “I don’t have a lot of time today. I just want to drop in and get the chipped edge smoothed and get scheduled for the restoration.” This provides us with an opportunity to slip in a short appointment to help the emergency patient and not interrupt how we are scheduled to best help our other patients that day.

Tip 3

When I walk in the operatory, I have a 3-way conversation with the dental assistant and patient. The assistant and I no longer have a conversation in the hallway that takes time, and I no longer walk into the room and have a separate conversation with the patient. In front of patient, the assistant describes the information that has been collected and the concerns of the patient. The patient can agree with, add to, or clarify what the assistant tells me. This has made us more efficient. It also spares me from walking into the room and taking over, thinking I have all the information. The 3-way conversation accelerates our ability to help the patient.

When I think of the small things my practice does on an everyday basis that have a big impact on patient relationships, patient satisfaction, and case acceptance, the first thing that comes to mind is what we call check-in and debrief.

Early in my practice years, way back when I was practicing corporate dentistry, when I walked into the operatory, the patient already had topical in place and my job was to get them numb. There wasn’t much of an opportunity to have a conversation. Over time, I learned the concept of check-in and debrief, which is really about how you can use the time at the beginning and end of the appointment to influence the relationship you have with the patient.

These are ideal times to build value for what the patient has agreed to do at that appointment and to tie the goals of the patient to the value of the treatment the patient is receiving, or you hope the patient will accept.

Usually, the check-in and debrief each take about two minutes. My assistants participate in this process with me, so they have increased understanding as well.

Previous Conversations Inform Me

I can be mindful and successful with my conversations if previous conversations with the patient were documented. My assistants take notes for me during my conversations with patients. I need to know:

• What is important to them,
• What they are hoping for, and
• What could get in the way of accomplishing what they believe is best for themselves?

My Check-in Conversation

During the check-in, I aim to converse about what we have planned to do and how this fits the overall goals of the patient. Usually, I enter the room and there is a little chit-chat. Then I ask, “What is your understanding of what we are going to do today?” The response helps me gauge the patient’s awareness. Following this conversation, I may ask, “What is your understanding of how this is part of your long-term health plan?” Or, if the patient has a stated a good understanding of what we are going to do, I say, “Yes, and this is how it fits into your long-term goals for your teeth.” They should now have a good sense of why the appointment time is of benefit to them.

My Debrief Conversation

During the end-of-the-appointment conversation, I aim to thank the patient for being cooperative, talk about what they can expect as a result of today’s appointment, and what they can expect as we move towards their preferred future. No matter what happened during the appointment, I want my patients to hear how much we appreciate them being our patients and being there today. When we talk about what to expect from today’s appointment, we can go over any post-op instructions, which are also presented in written form. Lastly, I want to give them hope that we are accomplishing steps on the road to their preferred future and that we can get there with their continued cooperation. I want to see the rays of hope register on their faces.

I believe all of this is of high value to the patient personally and in building value for the practice. It is well worth the time, and for me, it is a standard part of every patient visit.

In a previous blog, I wrote about how we use multiple flavors of topical in my dental practice and the positive patient experience this creates. In this article, we will look at the topical application technique we use to create maximum patient comfort.

I have often debated in my mind whether topical actually makes patients feel more comfortable when anesthetic will be injected. The scientific literature confirms it works great on the surface of mucosa, but it does not reach nerves under the gums or in teeth. From working with my patients, I know it makes a difference to them in how they perceive the injection feels. And there are studies in which patients overwhelmingly self-report that the initial pinch feeling of the needle entering the tissue is reduced after topical.

Before applying topical, thoroughly dry the area so the topical goes directly on the tissue you want to numb. If topical is applied to saliva, its effectiveness is greatly reduced. Ideally, let the topical work for 60 seconds but minimally 30 seconds prior to beginning the injection. My technique is to thoroughly dry the mucosa, swab the dry area with topical, leave the cotton tip applicator in place against the mucosa, cover it with a 2×2, and have the patient close to hold it in place while I watch the clock for 60 seconds to make sure I am not rushing.

To deliver anesthetic I use The Wand computer-assisted anesthetic delivery technology. While I am waiting for the 60 seconds, I explain to the patient that the anesthetic delivery may be different than they have experienced before and how the anesthetic will be delivered.

In my last blog, I wrote about the value of offering patients a choice of topical flavors. I can also fill some of the 60 seconds by asking the patient if the topical administered tastes like the flavor of topical they selected. As soon as the 60 seconds have passed, I immediately remove the 2×2 and cotton tip applicator and begin delivering the anesthetic.

There is good science behind some types of topical acting faster than 60 seconds, so you may want to do some research and select one of these types.

Even if you think topical is not effective, think about the placebo effect topical has on the patient. We are doing something to improve their comfort. We are actively doing something to make the procedure more comfortable and to help them through the process. I believe this act of caring has value to the patient that even exceeds the value of the numbing effectiveness reported in clinical trials.

I wrote this article 20 years ago for The PankeyGram, and it is still relevant today.  

As I walked into the room, the nurse was applying medication to a hand wound my grandmother had received from a fall a week earlier. My eight-year-old son, Tim, and I had traveled a thousand miles to say goodbye to my grandmother. At 89 years of age, her body was finally ready to give in to breast cancer, and her mind had fallen victim to Alzheimer’s disease over previous several years. 

I knew she would hardly know who I was, and if she did remember, the memory would be gone moments after I left. However, my father was an only child, and it was important to help him through these difficult times. My son also needed to learn about his roots. 

It was sad to see her unable to hold herself up in a chair, and she seemed so frail and weak. I said hello to her, and she opened her eyes enough to gaze at me. Her air-filled voice repeated, “I’m so tired. I’m so tired.” I held her hand and comforted her the best I knew how. I showed Tim to her, and she struggled out a sincere smile towards him. I told her stories about my family, my job, my tree we planted in honor of my grandfather, and how full and complete our lives were. It was as if I was trying to justify her life through the one, I was able to live now. 

We had brought some cinnamon cookies with us, and I offered one to her. Her dry frail hand reached for a cookie. She slowly nibbled on it.  

As you spend time with someone who is close to death and appears to have lost everything, one naturally thinks about how unimportant much of one’s life can be. I thought about the worldly parts of my life: the cars, the boat, my home, or ability to travel. I thought about the simple function of life: walking, running, feeding ourselves, dressing ourselves…. We have so much when we are healthy. Being a dentist, I reflected on how trivial teeth seem at a moment such as this. I pondered these thoughts as the first cookie disappeared, then another. 

My grandmother’s exhausted manner seemed to temporarily dissipate. She had found pleasure in nibbling the cookies. With her eyes closed and body relaxed, my attention focused on a collage of colorful photographs hanging next to her bed. Looking down at me was a picture of my grandfather, almost as if he approved that I had come. 

My grandfather was a righteous man who always felt it was important to do things the correct way. His home was not large, but it was perfect. Every part of it was neat, crisp, and clean. The saying “everything has a place and every place has a thing” describes how well he took care of his belongings. In the same manner, his and my grandmother’s health had been important to them, including their teeth. They both had most, if not all their teeth until the end. Even at the time of my grandfather’s death at the age of 84, he was scheduled to have some major dental work completed. My grandfather had been comprehensive about caring for his health and life. 

My grandmother was now working on a fifth cookie. I watched as she gently grasped it, lifted it to her mouth, bit and sighed with pleasure at its wonderful taste. Suddenly, I realized that because she had her own teeth at age 89, she was able to find some pleasure in what most would consider horrible existence. She could still eat and experience the pleasure of taste! What had seemed small in the scheme of things a moment ago had renewed importance. 

Many patients judge the competence of a dentist based on whether they are free of pain. However, a dentist’s true competence is measured by whether patients still have the ability to eat at the end of their lives. This can only be achieved with a comprehensive long-term approach to dentistry and helping people understand the importance of this type of care.  

No matter what you do in this world, you need to treat people in a personalized, comprehensive fashion. Now I look at every patient with the hope that when they have lost everything else, including their mind and most body functions, they might enjoy the ability to eat and the sense of taste. 

As her hand reached out, her fragile voice whispered to me, “May I please have another cookie?” 

L.D. Pankey, when talking about the assimilation of knowledge would say, “First you get it in your hands, then your head, and finally in your heart,” meaning objective understanding and competence was only a step in becoming a complete dentist. 
 
This, of course, was a hard message to hear as a young clinician, because after rapidly proceeding through Pete Dawson’s curriculum, purchasing three Denar articulators, and then going on to The Pankey Institute, I felt that I was ready to start practicing as a “comprehensive dentist.” 
 
But unfortunately, most of my patients and the citizens of my berg didn’t get the memo. Most of them just looked at me suspiciously, while others left. Fortunately, a few of them allowed me to perform my “complete exam,” collect study models and take 35mm slide photography. And then, I’d spend hours waxing up cases, and preparing a thorough written report containing all of my findings and recommendations. Finally, I’d make  a “case presentation” appointment and unveil the brilliance of my understanding of complete dentistry–about which I was sure the patient would be impressed and then have no alternative but to say “yes” to my plan for them.

From there, it was easy for me to visualize a completely organized schedule full of people who had said “yes,” and a projected level of income of my choice based upon how hard I wanted to work, and the number of hours I was willing to commit to being at the office. It all sounded so perfectly logical, and it all fits quite well with my left brain driven in the world view of dentistry.

But things didn’t work out that way very often. And since that time, I’ve have spoken and consulted with literally hundreds of dentists who’ve experienced similar frustrations. Many of them told me that they eventually gave up on their effort to try and practice comprehensive dentistry. Others took their practice to near bankruptcy via their determination.

You see, most of us missed Dr. Pankey’s message the first time we heard it, or even after the next two or three times.

We failed to recognize that the concept of complete care also hinged on how each patient felt, what they wanted for themselves, and what the solution would mean to them on an emotional level.

It was only after this difficult realization that things began to improve for me and my practice. The work of Carl Rogers, Bob Barkley, Lynn Carlisle, Avrom King, Sandy Roth, Mary Osborne, and many others, helped me to make some critical adjustments regarding how I was communicating with my patients–and perhaps even more critically– when.

Patient-centered dentistry is just that, patient-centered, not treatment centered.

This means we must first come to appreciate each person without imposing our beliefs and expectations upon them. This is a process that involves feelings first (their feelings not ours) before cognition–and before the discussion of any solutions. We must first be able to grasp the contextual meaning of the dentistry in each person’s life, and by so doing, better appreciate their perspective.

When we become better at doing this, we’ll feel that our knowledge has finally reached our hearts and the hearts of our patients as well. And it’s only at that moment that things will start to become easier and our patient’s behavior more predictable. It’s only at that moment that the “yes” to comprehensive dentistry will happen on a regular basis. 

How many of us have had a patient call who was really upset with us or our office?

The other day, my office manager came to me and said, “Mrs. Jones called and is super upset.” We had just completed an upper and lower reconstruction. Due to the complexity of the case, I opted to place the lowers in permanently, but I placed the upper in with temporary cement, in case there were any modifications that she wanted made prior to finalizing the case with permanent cement.

My office manager continued, “her new bridge is loose, and she said she is going to get an attorney because she paid a lot of money for this and it is already failing.” I told my office manager it was in with temporary cement, and the patient must have forgotten that I told her this, which in fact was the case.

I asked my office manager to bring her in immediately, and I would take care of it. Mrs. Jones presented, and I greeted her with a smile. I said, “I will take care of you immediately.” I proceeded to remind her that the upper arch was in with temporary cement, and she said, “Oh yeah! I forgot about that.”

After allaying her concerns and asking her if she had any difficulties over the last month, to which she said no, I opted to place the restoration on with permanent cement.

I reminded her that there was one other section, which still needed to be put in permanently, but I would do this in the future, since I was unable to tap it off at the time. (Sometimes, when the seal is really excellent, even temporary cement will hold very well.) I reassured her that all should be well and to always remember that “We’re here for you!”

This can be one of the greatest statements you can make to a patient. So often they feel “discarded” once their work is completed, and you “have their money.” Or they feel like they are being bothersome if they contact you to make any adjustments. They feel that any issues they are having will work themselves out, or they will just get used to it.

I remind them that we are always there for them and want to make any needed adjustments or corrections to the work we’ve done before any other problems arise. We want to be proactive in taking care of their issues and not be reactive. Often it is a very simple correction.

Letting a patient know “We’re there for you” can go a long way to creating a patient missionary and can be one of your greatest practice builders. “We’re there for you” is one of my favorite messages to convey to my patients, and I repeat it often.