May 16, 1986: Over 30 years ago, the quote from Maverick and Goose in Top Gun was: “I have the need for speed”. A little corny, but it hits nail on the head for dentistry today. We have to deliver services and products at least 25%-35% faster with as good or better quality than we are doing right now if we ever expect to compete in an insurance driven economy. This is the second in a series of articles about how to improve our services by increasing our speed. I will try to keep this short and sweet, and your job is to act on each one the day they arrive. Yes, you will need “speed” of commitment to act on each of these, too. I see enough offices and dentistry to know that few doctors are pushing the bar upward. It seems like that “just OK” is the standard of care. I would argue that even an average practice is way behind the quality mark that our patients demand. The well-appointed offices, great locations, consumer hours, in-network with their insurance, never running behind, never having sensitivity or temps that come off are just the very basic level or entry point of what it takes to do well in dentistry. This new age of educated consumers will no longer frequent an average office. Why should they? There are 6 more offices on the block they can choose from. L.D. Pankey said that “average is either the best of the worst or the worst of the best”. This is a pretty damning statement in the light of this year graduating more doctors than ever before. If history is any indication of the future, these graduates will also end up being average. No one wants or needs another average dental office. So, let’s fix this.
Tip 1: Teach your staff to take good impressions for making crown temps. Right away, I’m assuming you, the doctor, could do this yourself. Maybe. A great impression means no bubbles or pulls. This is especially important with an assistant that is going to be making a temporary following your preps. If the margins of the unprepped tooth are not captured perfectly, you can bet that the assistant will struggle to trim the temp as the consequence of having bubbles and pulls at the margins. This can easily add another 10 minutes with the patient sitting there using up chair time and you being without an assistant until they get through. The remedy is to use a heavy body material like Blue Mousse, dry the tooth, then take a squirt or two of the impression material on the assistant’s index finger and smear the buccal and lingual with excess material forcing it into the proximal areas margins and then loading the tray and taking the impression. Doing this will forever eliminate any bubbles or pulls and result in a perfect impression for the final temp mold. BONUS: Doing this will also prevent short temporary margins, micro leakage, sensitivity, and probably long-term negative results just due to a poor temp.
Tip 2: If you are using triple bite trays, always use the same type of tray for the impression of the temp and the final impression for the crown. I find most doctors using a cheap tray for the temp and another more expensive one for the final impression. The error here is that by using the same type of tray, you will know if it fits well by looking at the temp copy, and this allows you to adjust its position or using an entirely different tray for the final if you find it is too narrow or you need to push it further back, or the patient struggles to be able to close completely. This saves you time when you catch problems before the final impression. Failure to do this can be the number one reason your crowns don’t fit perfectly.
Tip 3: Always have X-tip or Stabident in your office for those times when it is difficult to get profound anesthesia. This is your ace in the hole when the tooth isn’t all the way numb and the clock is ticking. It takes seconds to work and you can go right back to work with the confidence that they can’t feel a thing. I am so surprised that anyone would not have these in his or her office. This can save at least ten minutes. I even got where I would use ½ to 1 carpule for a block or infiltration, wait a couple of minutes and hit them with the Stabident, pick up the high speed and whip out the prep. No more waiting 10 minutes for profound anesthesia. Along with this, imagine the decrease in stress knowing that the patient will always be completely numb. BONUS: Save 5-10 minutes on the initial numbing while eliminating any possibility for delays in the unlikely event that you find a tooth that did not actually have profound anesthesia. Cost is little less than a dollar an application.
Tip 4: For crown and bridge, consider the Reverse Prep made famous by Michael DiTolla, DDS, FAGD, with videos on the Glidewell lab site (2 cord reverse prep video). I was a lab tech in high school through college and helped pay my way through dental school doing all my professors crown and bridge lab work. From a lab technician’s perspective, margins are a “make it, or break it” situation. In the Reverse prep protocol, you will be using a number 6 high speed diamond to create the finish lines on the buccal and lingual as a starting point. It turns out that if you lay the axis of a #6 diamond parallel to the buccal or lingual of the tooth. As it happens, ½ of a number 6, which is about what would engage with the tooth, is 1.3 to 1.5 mm. That happens to be the exact depth that Ivoclar Vivadent suggests for buccal reduction for Zirconium and E-Max crowns. Google them and take a look at their videos and prep guides. The ripple effect for speed here is quick, perfect preps. Rarely do you have any soft tissue bleeding. Temporaries don’t come off and don’t break because of poor underprepared teeth. Remakes and failure eat up hours of our time. This is the direct result of dentists not understanding what a great prep should look like. In addition to the time savings, you avoid the disdain of patients when they continue to have problems with temporaries, over contoured crowns as a result of poor reduction, and terrible cosmetics because we lab techs are not miracle workers. I love the sign in Golds Gym by the free weights: Pick up you own weights; your mother doesn’t work here. Labs can’t turn out great work if you don’t take the responsibility of giving them an admirable prep.
Tip 5: Use cord every time and consider using a dual cord technique. Time savings here is not having to redo an impression due to poor margin capture. Secondly, the cord can actually be placed prior to numbing or prepping further ensuring that you will not clip the gums or fail to be able to see to create a perfect prep. NOTE: Labs need to see one millimeter below your finish line to create the proper emergence profile and contour for a life-like restoration. The ripple effect is few, if ever, any redoes. That should save at least 10 minutes. NOTE: There always seems to be enough time to redo inferior work, yet not enough time to do it correctly the first time.
Tip 6: Always have the assistant take the shade first thing on a wet tooth before anything else is done. You can check it, but let her do it first. To make sure you are actually getting a great shade, grind off all the necks of the shade guide. Failure to do this will cause at least a ½ shade error. Never use anything other than a blue bib and color corrected lights in the ops. Walls should never be any color other than a light blue or off white. Any other color will alter your shade selection. Speed: Patient satisfaction, no redoes, perfect shade.
Tip 7: Never finish a prep without cleaning and disinfecting it with Chlorohexidine and placing Gluma after that. The Chlorohexidine will remove any crud from the tooth and disinfect it. The Gluma (two coats, 20-30 seconds apart, no air drying, just use vacuum and allow it to dry) will seal the dentinal tubules and actually increase bonding strength with any product you decide to use.
We will continue next week with more quick and easy tips to increase speed with better results. This is how you Summit.
Michael Abernathy, DDS
PS. Just an early heads-up announcement of a meeting next spring that you might want to get on your calendar and make plans to attend. This will be a group of very entrepreneurial dentists that are working hard right now to position themselves and their practices for future success, regardless of what the Corporations do or don’t do. Check it out! www.dentalwinwin.com