In the year 1958, Dr. L. D. Pankey asked one of his most devout students to join him and teach the Pankey philosophy about dentistry and life to dentists around the world. And that’s precisely what they did. F. Harold Wirth, DDS, was one of the most dynamic speakers in all of dentistry. He rivaled Drs. L. D. Pankey and Bob Barkley in his ability to engage an audience and make his points clear using real (often funny) stories from his practice and life experiences.

Harold understood people on a very deep level—physically and emotionally. For this, he gave Dr. Pankey most of the credit. He had a very successful restorative practice in downtown New Orleans prior to meeting Dr. Pankey, but always felt that something was missing. L.D. Pankey showed him what that was, which turned Harold Wirth into a missionary for whole-person dentistry from that point forward:

“Give the case presentation to the person who makes the decisions,” Dr. Wirth said. “If I ever get to the point where I’m explaining what I’d like to do…If I’m not already about 90% into gaining their agreement, then I have messed up! Because I should have already won them over with the interview, the aura of my office, the literature that I’ve given them to read, and whatever else I’ve done before that time.”

Dr. Wirth said, “The case is constantly being presented: Every time the patient comes in, you’re doing a presentation. As a matter of fact, I think the interview is forever ongoing. It might only be one word, but every time the patient comes into your office, you should be interviewing them. Are you comfortable? Does your bite feel good? Are your teeth sensitive?”

These are questions that have to do with how the person FEELS. A case history is exploring what happened, but an interview is about how they feel! You need to understand the difference! How do you feel about your restorations? Are you comfortable? Are you satisfied with the appearance of your smile? Can you chew everything you want to chew?

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.

How long does a dental crown last? The answer is, “It depends.” In this blog, I will review how I manage answering this question for my own peace of mind and to reduce disappointment for my patients.

All of us can think about crowns that are currently in our patients’ mouths that have been in four decades or more…crowns that are doing fine. Sometimes, we look at a bite wing of one of these restored teeth and see space enough “to drive a truck” between the margin and the natural tooth structure. Yet, the crowned tooth is fine with no caries.

We also can think about crowns in our patients’ mouths that needed to be or now need to be replaced within five years or under…perhaps, even within two years. Some of these crowns were carefully and beautifully done.

We have a habit of thinking: The better our skill is, the greater is the longevity of the crown. We need to get away from this generalization because there are numerous factors that impact longevity.

Yes, the dentist’s skill is a factor as are the amount of time and energy we put into making it exquisite, the quality of the laboratory, and the materials. But the other part of the equation is that we put dentistry into the mouths of human beings, and human beings come with risk factors. The most common reason we replace a crown or filling is recurring caries. We see some patients who have new carious lesions every time we see them in the dental chair. They are at high risk. At the other end of the spectrum, we have patients who have not had a carious lesion in multiple decades. The functional risk of the patient is the second primary risk factor. We have patients who can break any type of crown, and we have other patients who have no evidence of functional risk.

What do I say to my patients? I tell them dentistry does not last forever, and there are challenges in predicting the lifespan of their restorations. I do not say, “When your crown fails at some point in the future, it will need dental treatment again.” Instead, I say, “We’re going to treat this tooth with a crown. At some time in the future, it will need treatment again.” Then I say, “The most common reason why a crown needs to be replaced is dental decay around and under the crown, and what we know about you is that you tend to get cavities [or not get cavities]. The second most common reason we replace crowns is that they break. The materials cannot withstand the forces. And what we know about you is that you are tougher on your teeth [or not as tough on your teeth] compared to many other people. “

This type of conversation makes most dentists nervous. They fear the patient will not want to do the crown if the patient knows they will eventually need to retreat the tooth. That has not been my experience. The reality that cars do not run forever does not stop us from buying a new car. The knowledge that your roof will last 10 to 14 years does not stop us from replacing the roof. The reality that the tooth will need retreatment in the future does not stop us from having it treated now.

Setting realistic expectations results in less patient frustration, sadness, and disappointment. It also lessens conflict between the dentist and patients. I want my patients to understand the reality that dentistry does not last forever. It all has a lifespan, just like a car or washing machine. Any tooth we treat will need to be treated again. I also want them to know their risk factors for decay or breakage relative to other patients. Is it high? Is it low? Is it somewhere in between? We can then have a conversation about what they can do and what we can do together to minimize those risk factors.

In times of disruption, small changes can have a large impact. Follow the 5 P’s and see where Proper Planning to Prevent Poor Performance leads you.

Those of you who experienced the joys of boot camp may remember the 5P’s: Proper Planning Prevents Poor Performance. Since we are all stuck waiting to get back to the office, now is a great time to work on plans for a preferred future.

Although we will be opening in a disrupted world and the market we left has been transformed by forces outside our control, good business principles and practices remain valid. Here are some key performance indicators adapted from Roger Levin’s 2019 article about the KPI’s every dentist should know.

Production, Collections and Profit

Review your production, collections and profit for the last 12 months. Levin points out that the trend on each of these items should be up. Sounds simple but it is not. Dig in and analyze deeper. Start with monthly figures and look for trends, then weekly and daily. What are your most productive procedures, days, time of days? When was your last fee increase? Analyze your outstanding accounts. You should be collecting 98% with only a small percentage over 60 days outstanding. How much are you writing off due to insurance mandates? How profitable are you? Have you set any goals? Understand that any item in your practice that is not true overhead is profit. Now you are ready to start working “on” your business.

What percentage of your active patients is currently scheduled? Nobody should every leave your office without another appointment. Your goal should be 98% of active patients are scheduled for some form of care. What is your case acceptance rate? Are you tracking patients with planned treatment that is not scheduled? What is your average production per patient? What is your average production per new patient? It should be at least two times greater than existing patients. What is your hygiene cancellation rate? If you are not happy with what you are learning, now is the time to be planning for better outcomes.

Overhead

Now is the time to carefully assess every item included in your overhead. If you have a practice generating a million dollars, a 2% decrease in overhead is $20,000 directly to profit. Levin Group tells us that general dental practices should have overhead at 59%. Very few practices meet that goal. It is very likely that new mandates from the government will be coming for PPE and testing. Now is the time to get lean and mean in this area.

Patients

Are you tracking your monthly new patient growth and your patient attrition? With all the media attention to aerosol spreading of Covid-19, it is likely there will be resistance to treatment and dentistry in general. Knowing your current situation is important. It is imperative that you use every means available to help your current and new clients understand that you are concerned for their health and safety as well as to emphasize that deferring treatment will only lead to future more difficult and expensive problems.

Staff Costs

The elephant in the room…staff costs in a general dental practice should be 25% of collected production. Your team members are the most expensive and most important part of your business. You may want to share your homework with your team – or even involve your team in the exercises above.

Three-quarters of human brain growth takes place in the first three years of life.

And that represents almost everything except the prefrontal cortex, which does not fully mature until around the age of twenty-five. This means that our ability to cognitively process…our ability to understand and respond appropriately to lower brain functioning, and particularly our emotional system, is quite limited early-on. Yet that is exactly when most of our beliefs about the world and how it works are formed and rarely challenged. So, when a person comes into the office claiming that “When I was a kid, the dentist put both feet on my chest to extract the tooth. It was horrible. I hate going to the dentist,” we are actually dealing with a belief and not a fact.

Responding to “When I was a kid…”

It is counterproductive to begin a new relationship with a person by telling them that they are wrong and don’t know what they are talking about. So, we have to begin someplace else, with the goal of facilitating a change in belief over time, and not with a goal of convincing others how much we know and that they should surrender to our intellectual prowess. Start with the understanding that we humans don’t like to be challenged as wrong. Also understand that we’d often rather be wrong than right, simply because it feels better to our ego.

It turns out that the only way beliefs change is through an inside-out process of self-reflection, re-assessment, new realizations, and new assumptions repeatedly confirmed by new experience. Before there is a commitment to action, your patient with negative beliefs about dentistry must go through this. And, I’ll bet you weren’t thinking all of that was going on in your patients’ brains, but it is…every single day. That is why relationship-based dentistry holds so much power and potential.

Truly helping relationships are the only vehicle through which significant personal change occurs in dentistry. L.D. Pankey said, “Know your patient,” not because you can use the knowledge strategically to defeat them on an intellectual level, but rather to help pave the way toward significant change and therefore better decision-making.

We can’t manipulate our patients toward becoming healthier.

In fact, the more we try to manipulate people, the more their lower brain recognizes something is wrong. It doesn’t know what, but at least it’s smart enough to stop listening, and focus on self-preservation—like staying away from people who will likely put “both feet on their chest.”