What Do You Do if Your Bonded Ceramic Crown Falls Off?

“Can you re-glue my crown on doc?” your patient asks as he hands you a small wad of tissue paper.  Many times, we unwrap that tissue paper only to discover a crown filled with the build-up and fragments of a tooth fractured to the gingival margin.  Occasionally, however, an intact ceramic crown will be present with only some residual resin cement stuck to its intaglio surface.  In these cases, the clinician may rebond the de-bonded crown by following a protocol to remove the residual cement without damaging the underlying ceramic.

The first step is to determine the type of ceramic from which the crown is fabricated.  A radiograph can be taken of the crown to determine its composition based on radiopacity.  A crown that is as radiopaque as a coin is likely zirconia, whereas, a crown which is more radiolucent than a coin is likely a glass-based ceramic, such as porcelain or lithium disilicate.

Figure 1. A quarter (left) and lithium disilicate onlay (right)

Cleaning residual resin cement from zirconia can be achieved by sandblasting with 50 micron alumina at 2 bar (30 psi) pressure.  Sandblasting zirconia with alumina particles does not reduce its strength due to its ability to heal cracks through transformation toughening.  In fact, sandblasting zirconia with alumina particles is the laboratory procedure which is used to give zirconia surface texture for bonding.   

Cleaning residual cement from the intaglio surface of glass-based ceramics, however, must be performed with more care in order to prevent damage to the underlying ceramic.  If a glass-based ceramic, such as lithium disilicate, is sandblasted with 50 micron alumina at 2 bar pressure, it will lose 25% of its strength. Grinding the residual cement from lithium disilicate with a coarse diamond bur will reduce its strength and may affect the internal fit of the restoration.

One option to remove cement from lithium disilicate is to place it in a ceramic furnace in the following program: stand-by temperature (B) = 403°C, closing time (S) = 03:00, temperature increase (t) = 15°C, holding temperature (T) = 550°C, holding timer (H) = 05:00, vacuum on temperature (V1) = 403°C, vacuum off temperature (V2) = 550°C, and cool down gradient (L) = 0.  By keeping the holding temperature below 590°C (the nucleation temperature for lithium metasilicate crystals), the strength and translucency of the crown should not be affected. After the crown is removed from the furnace, small pieces of burned cement will be present that can be cleaned in an ultrasonic bath or with an alcohol wipe.

Another option to clean residual cement from lithium disilicate is to sandblast it with 50 micron glass beads.  Glass beads are an alternate sandblasting particle that are less abrasive than alumina particles.  Glass beads can be thought of as small tennis balls as they are round and soft, whereas alumina particles are like small rocks as they are hard and irregular in shape.  Glass beads used at 2-4 bar (30-60 psi) pressure are able to remove excess resin cement without affecting the strength of the underlying ceramic.

Figure 2. Sandblasting residual cement from a lithium disilicate onlay with 50 micron glass beads

Once the residual cement is removed from the internal surface of the glass-based ceramic materials, the surface needs to be re-etched because the etch pattern is dulled with cement removal. Lithium disilicate materials are etched between 20-30 seconds (depending on manufacturers recommendations) with 5% hydrofluoric acid and feldspathic porcelain is typically etched between 60-120 seconds with 5-10% hydrofluoric acid seconds (depending on manufacturers recommendations).  After etching residual salts may be removed by cleaning with 37% phosphoric acid.

Observation of debonded crowns may help us improve our bonding protocol.  If the resin cement is stuck to the intaglio of our crowns (as described in this article), the bond failed at the interface with the tooth.  Perhaps improvement is need in isolation, clean-up of the tooth, or the bonding protocol to the tooth.  If the resin cement is stuck predominantly to the tooth, perhaps the bonding protocol to the ceramic needs to be improved. 

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About the author:

Nathaniel Lawson, DMD, PhD

Dr. Lawson, is the Director of the Division of Biomaterials at the University of Alabama at Birmingham School of Dentistry and the program director of the Biomaterials residency program. He graduated from UAB School of Dentistry in 2011 and obtained his PhD in Biomedical Engineering in 2012. He has served as an investigator on over 50 clinical and laboratory research grants, and published over 150 peer reviewed articles, book chapters, and research abstracts. His research interests are the mechanical, optical, and biologic properties of dental materials and clinical evaluation of new dental materials. He was the 2016 recipient of the Stanford New Investigator Award and the 2017 3M Innovative Research Fellowship both from the American Dental Association. He serves on the American Dental Association Council of Scientific Affairs and is on the editorial board of The Journal of Adhesive Dentistry and Compendium. He has lectured nationally and internationally on the subject of dental materials. He also works as a general dentist in the UAB Faculty Practice.

The Importance of Your Practice's Digital Information & Consistency Across the Web

People are searching online to find specific answers and services near them. Google, Bing, and Yahoo are the most reliable and quickest sources for people to find your services near them. Studies show that almost 6 in 10 consumers use Google to find a local service or business. Over 7 in 10 of these searchers lay a lot of emphasis on the information provided by the search results. So, when it comes to getting your practice found online, you cannot ignore the importance of local listings and search engine optimization (SEO). Besides, practice's digital information is essential, and you must maintain data consistency across the web. NAP or "Name, Address, and Phone number" along with other specific factors are the most important digital information relevant to your practice that should be maintained consistently across all websites and platforms. 

Search engines deliver the NAP data to your target audience, allowing them to contact and reach out to your dental office. So, what is NAP, why is NAP consistency important, and what are the underlying requirements? We want to shed valuable insights on this topic. We are sure that most dentists and other practitioners don't realize the importance of this information.

What is NAP?

NAP refers to location-based information about your practice. This includes name, address, and phone number . NAP consistency requires that this information should be accurately maintained across all web platforms, including websites, social media profiles, local directories, and business listings. It is an important local SEO ranking factor. Any mention of your NAP information is referred to as a citation.

Every dentist wants their practice to be found online on top of the search engines recommendations. NAP consistency is the foundation of your local SEO strategy. Whether your digital marketing strategy is managed in-house or by an external marketing agency, someone must ensure the accuracy and consistency of your practice's information. While this is the minimum requirement for playing the local search game, it is a necessary foundation for your digital presence.

Why is NAP Consistency important?

Google and other search engines use many types of factors to rank websites locally. As a dental practice, local search results are crucial for you because patients do not keep scrolling down when it comes to choosing a dentist. The first top 3 local business recommendations from Google or any other search engine are what patients decide when looking for a dentist, so it is important to be locally ranked on the top 3 results. Citations are among the most important signals for Google and other search engines to determine that your practice is authentic. They will also rely on the NAP consistency to ensure that accurate information is served to users. 

It is worth knowing that user experience (UX) is at the heart of Google search ranking algorithms. Search engines are committed to delivering accurate information to their searchers (users).

If your citations have inconsistencies, they will be de-merited in search engine ranking signals, thus adversely affecting your practice's search rankings. Practices having consistent NAP data across the web will be relatively ranked higher!

HOW DOES INCONSISTENCY AFFECT A PATIENT'S PERSPECTIVE?

Imagine a patient is trying to contact your dental office, only to be led astray by inconsistent online listings, old phone numbers, different names and addresses. The patient will likely think that you and your team can’t be bothered to update your contact details. It can be seen as an insight into the quality of services that you offer. 

Studies show that 73% of searchers will not trust a brand if the business listing consists of inaccurate data. So, you must make every effort to ensure your online information always stays up to date.

It may not just affect the patient psychologically, but the wrong information may be causing inconvenience for the patient when reaching your practice.

NAP Consistency & SEO

Correct information and a great user experience (UX) are the most important elements of a search engine. A search engine must trust that your website and/or practice will meet the needs of their users because search engines only want to deliver the best experience for users; by having the wrong information, you are failing to work with the search engine's primary purpose.

The key to building trust with Google or other search engines is to ensure that the search engine's algorithm understands who you are, what you do, and where you are located. Search engine crawlers can detect any variations in your dental practice's name, phone number, physical address, and website address, but having the same information is the best way to accomplish their mission.

Consider the following scenario:

Consider a dental office with the following name, physical address, and phone number. This is an official business registered name.

ABC Dentistry Inc
123, Wurzbach Rd,
San Antonio, TX 78258
(210) 292-0111 

Digitally, most offices would not list the "Inc," so this would be the ideal digital practice information on Google and other search engines. 

ABC Dentistry
123, Wurzbach Rd
San Antonio, TX 78258
(210) 292-0111

A few months later, you promote an online ad with a tracking number to keep track of the phone calls generated by the ad. The marketing company tells you they will use this tracking so you can have better "accountability." Still, the problem is that they list this number in organic places such as your Google listing, which means NAP information becomes incorrect. 

ABC Dentistry
123, Wurzbach, Rd 
San Antonio, TX 78258
(210) 292-3212

Then you recently verified your Facebook page, but you wanted to make it more personalized, so you decided to add your name to the practice name; mistakenly, you forgot to put the word "Rd" on the address.

ABC Dentistry by Dr. Smith
123, Wurzbach,
San Antonio, TX 78258
(210) 292-0111

Since you purchased the practice from another dentist, some old listings, such as Google, Yelp, Yellow Pages, etc., may have the old information. The phone number and address would be the same because they are given with the office, but the name is entirely different! Google does not know if there is a new practice or not; for the algorithm, this is just wrong information.  

Dr. Garcia Berg – Oral Surgery
123, Wurzbach Rd,
San Antonio, TX 78258
(210) 292-0111

You may also want to consider searching for your name and looking into all these specific listings under your name (not your practice name). Since you worked as an associate for other offices, you may have information all over the place. It is crucial to fix the data from another practice to your new one. 

Dr. Smith is working at
Extreme Smile Associates
567, Power Rd.
San Antonio, TX 78254
(210) 997-6852

Lastly, you build a website, and your website MUST have this NAP information correct. Just because you have a website, it does not mean Google and other search engines will know what to do with the information displayed when the website goes live. The data is read in different ways, and design may also affect how it is structured for search engines. A specific set of codes such as schema markup provides the correct information for search engines. This code is the foundation of Search Engine Optimization.

So, what is a schema markup or, in other words, microdata for search engines? Schema markup is code (semantic vocabulary) that you place on your website to help the search engines return more informative results for a user in specific ways. This gives you control of what to say to Google and other search engines for their users. 91% of dental offices do not have a schema markup placed on their websites.

So, as you can see, the inconsistency across the web becomes harder and harder to keep track of. Search engine crawlers are exceptionally detail-oriented, so having all this wrong information will affect the results of search engines, thus your practice not being recommended as a top result by Google or other search engines when patients are searching for your services.

How to Fix or See My Practice Information?

There are several ways to make a practice analysis of digital health. However, the first step you should take to ensure your practice's digital information is consistent is to conduct a Google search for your dental office's name.

Google your practice's name with your city name. You will most likely get your Google listing information which should look like the image attached.

Once you verify all the information on your Google listing is accurate and how you want it, you will have to go into every listing to see If you come across different addresses or phone numbers across the web (NAP Inaccuracy).

You can also use online tools such as GeekBoost™ to check citations consistency. Before you do this search tool, you need to make sure you write down the exact information. Do not miss a period or suite number sign.

Here is a local listing search to make your life easier: CHECK PRACTICE'S DIGITAL HEALTH

GeekBoost™ will only show around 70-90 local listings, but there are thousands of listings, so you may want to consider reaching out to an expert that knows about this type of search optimization. Keep in mind that 91% of offices do not have these placed; that means not everyone gets this right.

NAP data plays a significant role in driving foot traffic to your office, therefore you cannot take it lightly. If you are serious about growing the number of patients visiting your dental office, you must address this important factor in your local SEO strategy. 

Accuracy and consistency in NAP data will not only boost your number of new patients but can also increase your office's online visibility in your search engine results pages (SERP). Google and other search engines favor listings that provide rich and consistent information no matter the data source. When it comes to fixing inconsistent NAP, it is a time-consuming and cumbersome job. You will have to find and visit all the websites where your practice is listed, create accounts, and make the changes. It is best to seek professional help to ensure faster and proper steps are taken. 

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About the author:

Cesar Navarro
CEO at Geek Dental Marketing

Cesar Navarro, MS, is presently the Marketing Director & CEO of Geek Dental Marketing®, a marketing, development, and technology company for dental offices. With the vision to grow practices, improve management and visibility online, Cesar launched a full marketing company that focuses solely on dentistry to help dentists stand out from the crowd. Cesar holds over ten years of experience in the dental marketing field. He has also served as a group practice administrator and treatment coordinator, where he began his journey and passion for dentistry. Before dentistry, Cesar served as an NCO in the United States Army for several years, where he gathered many skills that most marketers lack. Combining all his skills like attention to detail and experiences, he has presented several CE courses to help dentists globally, such as “Leadership in a Dental Office,” “Branding Mastery Course,” “The How Much Patient? Converting & Selling”, “A New Era: Social Media Marketing,” and many more, and with it thousands of hours as a practice marketing consultant.

His strategy includes the GeekBoost™ program, which allows clients’ business information, including addresses and phone numbers, and online web presence to be distributed across multiple channels, such as landing pages, listings, and social media platforms from one single source – securing the accuracy of dental office information online.

Rekindling your Passion for Cosmetic Dentistry

Passion, both personal and professional, is a fuel that when paired with desire and hunger, can and will bring about the greatest results, achievements, and fulfillment in life. It’s not far-fetched for a dentist to feel burnt out, detached, or lose passion over time in their careers. I once lost the passion I carried for dentistry in my career, and it took a deep dive into my interests and the fundamentals to rekindle the fire that has driven my thirst to learn at every opportunity. If you feel as if you’ve begun to lose the spark that ignited your career in dentistry, let’s look at steps one can take to reignite that fire, and maintain it for years to come.

My passion for drawing is a trait that will never leave my soul. I still carry small sketchbooks around with me, so I can draw when the mood strikes. Being creative is what drew me to focus my career on the cosmetic aspect of dentistry for over 3 decades. This passion started when I realized I needed to learn the fundamentals of cosmetic dentistry.

If you believe that you know cosmetic dentistry fundamentals, and believe that you’re ready to graduate to more advanced topics, it may do you good to go back and review the fundamentals again. In the article “Gaining A Basic Understanding of the Subject” by Theall, Wager, and Svinicki on Idea.org, a nonprofit organization dedicated to improving student learning in higher education, they say that the “acquisition of basic information upon which more complex learning relies” is key before moving on to advanced studies. If the fundamentals are ingrained in us, we understand what is truly important and how to prioritize the advanced intricacies of our craft. A famous quote from one of my former art teachers is very applicable. He said, “One of the things masters have in common is they never tire of re-engaging the fundamentals.”

What lengths would you go to achieve your highest potential in cosmetic dentistry? I used to practice with a very famous and talented cosmetic dentist on the East Coast. One day we were talking (I always listened to hear any pearl of wisdom), and he told me in his younger years that he took a make-up class to learn facial form and aesthetics to achieve the desired appearance. He then applied this to tooth form and smile development. This taught me to never stop looking for ways to improve, especially outside of the infrastructure of traditional dental education.

As mentioned previously, drawing is one of my first loves. But did switching from analog (pencil and paper) and getting a digital tablet and stylus (iPad Pro and an Apple Pencil) make me a better artist? No, and it’s the same with dentistry. There are no shortcuts to true comprehension of a subject. No digital tool or app is going to make you better unless you grasp the fundamentals entirely. Having a digital scanner doesn’t result in better impressions if you can’t create smooth margins and manage soft tissue properly. The digital design of restoration doesn’t make it better if you don’t know the fundamentals of occlusion and functional movements. One of the first continuing education classes I attended in the early ’90s spoke to this idea of analog dentistry. The presenter said that if you really want to know how good or bad you are, you should pour your own impressions of your crown and bridge work for six months. Well, I did, and it was a humbling experience. Today, that is not necessary because of digital scanners that can provide us instant feedback on our preps and soft tissue retraction. This is an invaluable source for us to improve our skills because we can then correct our mistakes and take another scan within minutes.

Regarding skills, an often overlooked, yet imperative skill set, or fundamental for practitioners is the art of listening. I say art because you have to be able to keenly listen and read between the lines a lot of the time when trying to understand your patient. There is a reason why the words “listen” and “silent” are spelled using the same letters. Think about it, listening shows you care, and that develops trust with your patient. In Dr. Steffany Mohan’s article “ 5 Ways a Dentist Can Increase Patient Referrals'', she states that “referrals from existing patients account for two-thirds of dental practices’ new patients.” With that in mind, the rapport that you and your staff build with existing patients is a foundation of your practice. Gaining new patients means that you and your practice are consistently creating new smiles in your community. Impacting the lives of others is one of the most rewarding feelings we can experience as dentists, and we do it every day.

Passion exists when we are doing something meaningful for others and for ourselves. Cosmetic Dentistry can provide patients with passion, the fuel to smile again and change their overall personality and perspective, introducing them to the confidence they have so longed for. For the practitioners, it’s what we were made for, to serve others. That is our purpose and we should feel nothing but gratitude and an overflow of passion that we get to do this for a living.

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About the Author:

Dr. Christopher Pescatore is a national and international lecturer who has written articles for numerous publications, including Practical Periodontics and Aesthetic Dentistry, Profiles, Dentistry Today, Compendium, Dental Economics, and Inside Dentistry. He lectures on state-of-the-art aesthetic procedures, CAD/CAM techniques, and materials and holds a U.S. patent for a non-metallic post system to restore endodontically-treated teeth. Dr. Pescatore is a past member of the Board of Directors and the editorial team member of the American Academy of Cosmetic Dentistry (AACD), former Clinical Co-Director, and former featured lecturer at Las Vegas Institute for Advanced Dental Studies. He is also the past instructor of the Advanced Aesthetic Program at New York University - College of Dentistry, the Aesthetic Continuum at Baylor College of Dentistry, and the Aesthetic Program at the University of Kentucky. Dr. Pescatore is a graduate of the University of Medicine and Dentistry of New Jersey - New Jersey Dental School.

The Dentist vs. Implant Tissue Showdown: Just How Lucky Do You Feel?

You've got an implant patient in your chair, and the first thing you're thinking, "Do I feel lucky?" Well, do you, implant dentist? Does the patient present with all the required soft tissue health characteristics for successful implant treatment, or don't they? Considering that the patient's prior periodontal history and willingness to maintain superb oral hygiene habits are the most powerful determinants of success—or could blow your case out of the water—you make a bet and hope your pick lands on the wheel of luck.

In any case, you surrender to the fact that thorough soft tissue risk assessment and evaluation are significant to implant success and must be addressed before spinning the wheel and undertaking any procedures. If patients have or had advanced periodontitis, that—combined with poor hygiene—makes it a sure bet that they are not good candidates for implant treatment. And if patients express a desire to modify their poor oral hygiene habits, the smart wager is waiting some time to allow them to demonstrate a serious commitment because those habits absolutely correlate to long-term implant success.

Of course, there are other tells—such as smoking and uncontrolled diabetes—that could suggest the deck is stacked against long-term implant success. However, those are actually indicators, as opposed to direct causes, of implant periodontal problems. So to up the odds in you and your patient's favor, consider what makes for a safer bet (meaning, low risk) and one where the stakes are higher (meaning, high risk).

Low-risk implant patients have a healthy medical status, low esthetic expectations, and are non-smokers. They present with a low lip line, low scallop/thick biotype, and rectangular shape. The treatment site has no history of prior infection, intact soft tissue anatomy, and no deficient bone. The bone level of adjacent teeth is less than 5 mm to contact; adjacent restorative status is virgin, and; the width of the span is ≥ 7 mm.

Note that a thick tissue phenotype is found in more than two-thirds of patients. They are predominantly men with quadratic tooth anatomy, a broad zone of keratinized gingiva, and flat gingival contours.

High-risk implant patients, on the other hand, have a reduced immune competence, high esthetic expectations, and are heavy smokers (i.e., more than 10 per day). They present with a high lip line, high scalloped/thin biotype, and triangular shape. The treatment site has acute infection, soft tissue defects, and vertical bone deficiency. Additionally, adjacent teeth are restored, with a bone level of 7 mm to contact, and the width of the span is two or more teeth.

Here, bear in mind that less than one-third of patients—predominately women with slender tooth anatomy and a narrow zone of keratinized tissue with high scalloping—present with a thin phenotype. Also, an estimated 11% of bicuspids, 24% of cuspids, 23% of lateral incisors, and 7% of central incisors are surrounded by thin phenotype tissue. Remember, too, that patients can have a thin phenotype but still have substantial bone (i.e., quantity and quality) underneath.

Not assessing periodontal tissues and a patient's risk factors are essentially testing their luck and your chances for achieving predictable outcomes. Fortunately, when tissue augmentation is necessary, current trends in soft tissue management demonstrate that subepithelial connective tissue grafts are the gold standard when a coronally advanced flap is created, and acellular dermal graft, enamel matrix derivative, or collagen matrix is placed. The riskier proposition is placing a free gingival graft, which has been shown to disappear from the esthetic zone and is very limited, even in esthetically irrelevant applications, unless the graft is de-epithelialized.

Another way to hedge your bet? Use healing abutments with the proper size, shape, and handling characteristics. Anatomic healing abutments protect soft and hard tissues and reduce crestal-bone resorption compared to concave/straight healing abutments.

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About the author

Dr. Jerry Hu
Founder, Smiles of Alaska

Jerry Hu, DDS, is triple board-certified in dental sleep medicine and holds masterships, fellowships, and accreditations in implant and cosmetic dentistry. He also has published numerous clinical studies in peer-reviewed, highly respected journals such as AACD's Journal of Cosmetic Dentistry and AADSM's Journal of Dental Sleep Medicine. Dr. Hu also teaches for Modern Dental Group both nationally and internationally and for Sleep Group Solutions, VIVOS growth guidance appliance group, and Prosomnus Sleep Technologies. He also has won numerous awards in cosmetic and implant dentistry from Macstudio Model Search by MicroDental, and the IAPA Aesthetic Eye competition. He is currently working on a patent for dental sleep medicine and looking to help the US military out in dental sleep medicine.

Improving Case Acceptance; The Patient’s Journey

Helping patients have healthier mouths, doing more of the dentistry that is fulfilling and making more money as a result, are admirable goals that most practices have.  I have written a couple times about techniques that help us improve case acceptance; creating curiosity and co-discovery, listening, the learning ladder and more.  This brief construct is an attempt to see the process as a journey for the patient and to take their perspective.

Patient’s Journey; Eighteen Inches at a Time

I sat in church a few months ago and listened to an excellent sermon on faith.  It would apply to any religion, but my mind drifted to the ‘Business Case’ this construct offered for dentistry.  As Father Mike spoke about a faith journey, I envisioned parallels in dentistry with case acceptance.  I kept out a keen eye for a bolt of lightning.

It Starts in the Head

Patients first listen to the facts about dental care, their need and wants, issues or diseases that they have and potential treatment solutions.  Sadly, facts are not enough.  We all acknowledge that developing great listening skills, caring and trust help patients come to see you as their health advisor. This requires an eighteen-inch Journey to the Heart! It is there that caring and trust live. The emotional connection is very important in case acceptance and to ignore it, is to minimize your success. But that too is not enough.

The patient must schedule, keep appointments and pay for the recommended treatment. This Journey to the Wallet is the next eighteen-inch trip the patient must take.  It is the execution of the plan from their perspective.  Valuing dental care and oral health are demonstrated by their checkbook and what they spend time and money on.  Still not done?

The next eighteen-inches take us to a knee.  Appreciation helps fulfill us as caregivers.  Most rewards are best when they are balanced, financial and behavioral, money and warm fuzzies, you get the idea.  Money alone does not buy happiness (but it does help you enjoy your misery in some mighty fine places!). This is when I really kept guard for that bolt of lightning for drifting from the faith focus of the story.  I prayed for forgiveness as I created this metaphor and took out my phone to type some notes.

The final journey takes us eighteen inches to the patient’s feet.  Like a missionary, when patients tell others about your practice and refer their friends, you have come full circle.  This trust display is the ultimate compliment to you and your team.

Keep the Patients Perspective in Mind

Ask yourself the following and seek answers with your team to enhance patient’s health, your fulfillment and rewards.

• Have you helped nurture the movement to the heart?

• Did the patients accept and schedule treatment? If not, why not?

• Were they able to pay with gratitude and appreciation? (borrowed from Dr. Pankey)

• Did you ask for and receive referrals of their friends and family?

Remember, it is a journey not a destination.  Enjoy the trip and check the map along the way. You, your team and your patients will all be the better for it.

“A Journey is best measured in friends, rather than miles.”

Tim Cahill

Better Case Acceptance with F.A.B.

Getting patients to ‘YES’ is a challenge, sometimes because we are so forward with telling them what they ‘NEED’ instead of waiting until they ‘WANT’. One technique I have personally used and coached hundreds of others with remarkable success is, to “play hard to get”.

Let me explain. If we remain patient and refrain from telling them the answer, the path is easier. By asking questions about what they see or think about the problem we engage their curiosity and co-discovery.

These are natural tendencies in patients that are often squelched by our well-intentioned urge to tell them what they need right away. Talk about the problem, ask them questions, show them images using the intra-oral camera and hold off moving to the solutions discussion until they…wait for it…ASK YOU what you think. If we stay in the question with them, they will eventually ask us what we think they should do. Their curiosity gets the best of them and they truly want to know. That is when I play hard to get.

After successfully engaging them about the image of a failing MODBL, showing them the open margins, describing the decay process, asking about percentages of tooth versus material and advising them about the inevitability of this tooth needing a root canal if left untreated, they succumb to their curiosity and ask the inevitable question, “what do you recommend?” This is where it gets fun. Instead of simply answering them, I put on my sales and marketing hat and FAB (features, advantages and benefits) the crown they need. Marketing 101 reminds us to never sell the thing, rather sell the Features, Advantages and Benefits of the thing.

I explain that there are several different clinically acceptable ways to fix that tooth, but I need some information from them to make the recommendation. First, would they prefer a solution/material that will last several years or one that with some luck, might even last the rest of their life? Most folks go for longevity. Then I ask if they prefer the material we use to be tooth colored, silver or gold metal?

Most choose the esthetic alternative. Without ever saying they NEED a crown, I simply asked them what features, advantages and benefits they WANT! This improves the odds of completing their treatment significantly, but not to 100%.

One more crown per week or bite splint, or periodontal treatment or implant etc. can have a significant impact on production. Just think, at $1,200 per unit, and 50 weeks you would increase production $60,000 and help fill your schedule.

The same can be said for chair time in hygiene as well. No communication skill, script or technique is foolproof, but by shifting the odds in our favor we will get more yesses, fill our schedule and help patients have healthier mouths.

We’re in this Together

Dear Dental Community,

Our highest priority at this time is the health and safety of our teams, our valued customers, and your patients. As the global challenges continue to evolve, we would like to share some information regarding  steps we are taking to minimize the risk of exposure to our employees, our customers, and the community.

The challenges we are currently facing are real, and we can assure you that our laboratories are operating to support your immediate and essential restorative needs. As a precaution, we have invoked a mandatory work from home rule for our Customer Experience and Solutions Teams, restricted all business travel, CE Events, and all scheduled face to face meetings. These additional steps are precautionary and a necessary measure given the evolving circumstances.

We are paying close attention to guidance from the Centers for Disease Control and Prevention (CDC), World Health Organization (WHO), and our internal teams meet daily to stay abreast of the situation and adjust as needed with any new information. While we carefully review and navigate the daily challenges faced by our communities, we will continue to support you to the best of our abilities. Here you have a brief list of measures we are taking to support everyone’s health and safety:

• All of our laboratories follow strict OSHA disinfecting protocols to ensure that our facilities are clean and sanitized at all times, and we have increased the frequency of our sanitation efforts.

• As a precautionary measure, all delivery personnel wears masks and gloves.

• Visitor access to our facilities is temporarily restricted to employees only.

• Our upcoming CE Events are being rescheduled, and several will soon be delivered via webinars. We are notifying registered attendees via email or phone and are looking forward to connecting with you soon.

• Our Technical, Customer Experience, and Customer Solutions Teams are available to communicate with you via phone, email, and video conferencing.

• A 24/7 live answering phone service is in place to provide you with an immediate point of contact, and extended hours of services to meet your needs.

As we continue to navigate through this situation, we will keep you informed as to any developments and important updates. If you have any questions, concerns, or immediate needs, we invite you to contact us at any time. Our technical and service teams will continue to be available and are looking forward to hearing from you. We appreciate your support, friendship, and loyalty.

Stay healthy, stay connected, and together we will get through these challenging times. If I can be of any assistance please feel free to contact me directly. (laurakelly@microdental.com).

Laura Kelly, AAACD
Chief Executive Officer

Special Forces Dentistry?

When it’s easy, complacency can set in. When success is everywhere, we often just celebrate. But what about those challenging days, weeks and months? When reimbursements decline, patients cancel or a key team member leaves for seemingly no reason at all what should we do? Call in the Special Forces!

Recently I have been helping a friend of mine who is a Navy Seal. He wanted to transition from his ‘regular’ job to coaching, consulting and public speaking. I am pretty sure I have learned at least as much as I taught him.  His perseverance and unwavering focus on a goal is a trademark of the Seals. Never Quit, there is always a way to get it done, improvise, innovate, plan B, C or whatever it takes. Here are a few Navy Sealisms I have taken away from being around him. When the going gets tough in practice, think like a Seal. Persevere.

“The Only Easy Day was Yesterday”

This is the motto of the US Navy Seals, it means don’t sit around too long complaining or celebrating about whatever just happened. Instead, get ready for what’s next to come. Dentistry is tough. Patients, procedures, striving for excellence and our own OCD personalities make this profession tough. Each day, take a moment to find what went right yesterday, celebrate and get ready for today. There will be new challenges and obstacles to overcome. The preparation that got us here is unlikely to be enough to get us to the next level.

“Get Comfortable Being Uncomfortable”

The selection training for Navy Seals eliminates over 75% of the well qualified candidates because they cannot endure the discomfort of the training. Not physically, rather the mental discomfort can be so great that they just quit. In practice, our challenges can pile up in such a way to create unbelievable discomfort. How well we endure often depends on whether we quit mentally.  I have coached so many dentists who have given up on their dreams in dentistry because it got so tough. Some people quit just before they would have experienced success. Edison failed dozens of times to create a commercially successful light bulb. Lincoln lost elections for Congress, Senate and the Vice Presidency before becoming one of our greatest presidents.

“In the Absence of Clear Orders, I will Take Charge and Lead my Team “

The structure of dentistry and the current milieu is far from ideal as a platform that supports comprehensive care.  Declining reimbursements, maintenance benefits that masquerade as insurance, patient perceptions, and more are the “orders” of the day.  If your practice vision is on a tangent from your vision, you must innovate, find a way and improvise. In the absence of a clear path, make one! Practices that are thriving today have figured out a different path to take their team on to a promised land. Creating a value proposition that resonates with the right patients and collecting a fair fee is a worthy goal. Like a sailboat, set your sails and go where you will. The journey may be longer and slower, but also, far more rewarding.

Mark T. Murphy, DDS, FAGD Mark is the Principal of funktionaltracker.com and Lead Faculty for Clinical Education at MicroDental Laboratories and ProSomnus Sleep Technologies. He also serves on the Adjunct Faculty at the University of Detroit Mercy and oversees the Practice and Financial Management Curriculum at the Pankey Institute. He lectures internationally on Leadership, Practice Management, Communication, Case Acceptance, Planning, Occlusion, TMD and Obstructive Sleep Apnea. Mark has been involved in Sleep Dentistry for over 25 years, is an AADSM member, and has trained with several of the leading sleep dentists and training institutes. He is an informative and entertaining speaker, blending a stand-up style of humor and anecdotes with current evidence based research that you can take home and use in your practice right away.

Essential Laboratory Needs Support

While current challenges continue to evolve, the health and safety of our employees, customers, and your patients remain our primary focus. Our teams meet daily to assess how to comply with guidance from the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO).

We are also taking additional and necessary measures to support everyone’s well-being responsibly. Furthermore, we want to inform our dental community that our Modern Dental USA Centers remain operational for your emergency and essential needs.

For your convenience, below is a list of Modern Dental USA Centers that are available to assist you:

MDC Boston, MA / 888.659.5913

MDC Chicago, IL / 866.963.6856

MDC Savannah, GA / 844.886.6337

MDC Seattle, GA / 800.860.5006

MDC Troy, MI / 810.534.9273

MDC Wilmington, DE / 844.872.6633

Shelter-in-Place Orders Have Been Lifted

We are pleased to inform you that where the “shelter-in-place orders” have been lifted, our labs are ready to accept all of your dental laboratory cases. Our team wants to remind you that we are here to support you and your patients’ restorative needs. We are prepared and excited to collaborate with you and look forward to connecting with your team soon.

Our commitment to you remains the same; to deliver restorative based solutions at the highest functional and aesthetic requirements, fabricated with your specifications and your patient’s satisfaction top of mind. In addition, we have enhanced our safety and disinfection guidelines within our lab and during pick-up and delivery trips—adjusting to new safety, health, and compliance standards. Our goal is to be abreast and adhere to new industry regulations continually. More than ever, we are devoted to the well-being of our customers, employees, and the community as we focus on supporting your success.

As an additional safety measure, we ask that you continue to disinfect all impressions and place them in biohazard bags before sending them to our lab. We would also ask that the RX’s are placed in a separate biohazard bag to avoid cross-contamination.

We understand that our dental community is adapting to our “new normal” and are optimistic about the opportunities ahead of us. Please feel free to contact us to discuss case planning, material recommendation, digital files, or shipping supplies. We miss you and

Navigating Tough Times

The Navy Seals have a unique way of surviving the most difficult situations, conditions, and experiences. They train at the highest level, prepare for contingencies and have the best equipment known to mankind. At this time in our history, dentistry is faced with so many challenges that would have been impossible to predict; incredible educational debt, reimbursement declines, manpower shortages and now, COVID-19.

Nonetheless, we must persevere, survive and then rise from the abyss and grow our practices again. Dentists and their teams are like entrepreneurial small business navy seals.  We are well trained, tough and we will survive this evolution. COVID-19 presents challenges that grow each day; offices are sheltered, teams are temporarily unemployed, revenues curtailed, expenses amplified, and we face the risk of a pandemic affecting ourselves and our families. Give up? No way!

Think like a Navy Seal. Work the problem. Ask for and openly take help when offered. Communicate well. Don’t panic, but don’t bury your head in the sand either. Embrace the challenges. Our government and the ADA will help, but they will not solve all our issues. Our teams, families, and patients will suffer alongside us. They will look for us to lead. Hold our head up high, always look to the future and inspire others to see the way forward. This too shall pass. We may not know when, but if we take it One Day at a Time and move forward together, we will thrive.

Navy Seals often share quotes that inspire and explain. Here are 7 that inspire me right now.

1. The only easy day was yesterday.

2. Get comfortable being uncomfortable.

3. Don’t run to your death.

4. Have a shared sense of purpose.

5. No plan survives first contact with the enemy.

6. Have a plan B, C, D and maybe even a plan E.

7. Plan for the worst and hope for the best.

I hope this analogy helps you gather the strength to carry on. Many of us live through the great recession of 2008-2009. It was tough for sure. The media made it sound like the end was near. Until a few weeks ago, the market was up over 300% and we were enjoying the longest bull market in history. Let’s all get together in 6 months and share our war stories.  We will all have plenty!

Preventing Cross-contamination with Clinical Procedures

With “Returning-to-Work” presented to us, the primary concern then turns to implementation of infection control protocols to prevent cross-contamination between Dental Health Care Personnel and from operatory to laboratory. We must understand CDC Universal Precautions in our unique dental settings along with updated OSHA and CDC COVID-19 guidelines that were established in May of 2020.

The objective of this blog is to discuss preventing cross-contamination with clinical procedures such as impressions and prosthetic procedures between the dental office and laboratory.

Read ahead for helpful links and resources for each topic.

History of Infection Control in Dental Settings

In 1986 the CDC published guidelines in their Morbidity and Mortality Weekly Report (MMWR) Recommended Infection Control Practices for Dentistry. This weekly report published on April 18, 1986, changed dentistry by creating mandatory Universal Precaution guidelines for Dental Health Care Personnel (DHCP) within the dental setting. These Infection Control Guidelines have been a part of clinical and technical dental care for the last 34 years. Link to 1986 CDC MMWR: https://www.cdc.gov/mmwr/preview/mmwrhtml/00033634.htm

Updated CDC Guidance in Dental Settings

On May 19, 2020 the CDC provided guidance to prevent cross-contamination in dental settings of suspected COVID-19 patients and how to limit exposure.
https://www.cdc.gov/coronavirus/2019-ncov/hcp/dental-settings.html

Updated OSHA Guidance for COVID-19

The Occupational Safety and Health Administration (OSHA) has updated its guidance for DHCP with a COVID-19 Risk Chart. Click on the link to review OSHA guidance.https://www.osha.gov/SLTC/covid-19/dentistry.html

Tip for Oral Rinse before taking impressions or working on prosthetics.

The use of a bactericidal mouthwash or rinse can significantly reduce the oral flora and number of microorganisms in dental aerosols. Mouth rinses have been shown to reduce oral flora by 76% to 96% and the number of bacteria in aerosols by 89%. One new mouth rinse formulated for the Coronavirus or COVID-19 using Molecular Iodine is called ioRinse RTU Ready to Use Mouth Rinse. https://www.iotechinternational.com/products

Disinfection recommendations for different impression materials.

Preventing cross-contamination of pathogenic bacteria between dental operatory and laboratory with dental impressions is an essential part of infection control procedures.

Impressions for dental prosthetics should be double-checked during the disinfection procedure for any blood on the surface or around any implant component. If blood is present on the impression it must be removed then disinfected before pouring, scanning, or sending to the dental laboratory. To better understand proper disinfection with different impression materials, click on the link.
https://www.dentaleconomics.com/macro-op-ed/article/16393662/impression-disinfection

Tip for pumicing and polishing old dentures and appliances in the dental office.

When adjusting or pumicing dentures in the dental office pumice can quickly become contaminated when prosthetic appliances are removed directly from the mouth and pumiced or polished without disinfection protocols. After the denture or appliance is disinfected to avoid contaminating the pumice pan area while limiting aerosols use a small amount of fresh pumice to be used for each procedure. Pumice can be set up in advance in the stretch to fit plastic bags that can be fitted around pumice pan. Click on the link for an example of a stretch to fit bags. Elastic Closure Plastic Bag Example

After each use, the pumice must be discarded then replaced with fresh pumice from a plastic fitted bag set-up. The rag wheels and brushes should be disinfected or sterilized after they are used on a denture or appliance that has been in the mouth. The buff wheels and brushes used for pumicing should be stored in a sterilized bag or pouch until needed. After pumicing and polishing the denture or appliance the prosthesis is then disinfected again before being inserted into the mouth. I’m not well versed in what the Dr may use for this process, but in my document, I mention any tools used to repair an old denture need to be cleaned and disinfected. Also, if they use a pressure pot it needs to be disinfected unless they place the appliance in a sealed bag to isolate it from the pot.

Glossary of Infection Control Terms

To improve communication and collaboration with infection control practices it’s essential that we understand the proper terminology for infection control practices in the dental setting. Link to CDC infection control glossary.
https://www.cdc.gov/oralhealth/infectioncontrol/glossary.htm

As the practice of dentistry enters this new era of infection control, we are prepared with 34 years of experience and knowledge in preventing cross-contamination of pathogenic bacteria. With the updated 2020 guidance from CDC and OSHA dental offices and laboratories will be providing optimal infection control care for patients seeking prosthetic treatment.