Dr. William G. Dickerson discusses how to do esthetic restorations properly.
William G. Dickerson, DDS
Editor`s Note: Most dentists come back from a cosmetic dentistry course all charged up and ready to make the changes necessary to transform their practice. On Monday morning, reality sets in with a full schedule of patients and, as the days go by, the initial enthusiasm begins to wane and nothing is changed. Dental Economics went to the top and asked Dr. Bill Dickerson to discuss questions most often asked on how to do esthetic restorations properly.
Most dentists still use amalgam on most fillings. Why should they change?
Let`s look at that in two ways. First, the reason that they use amalgam on most fillings is because that`s all they know. When you`re a hammer, everything looks like a nail. If all they are taught in dental school is plugging amalgams, then that`s all they will do when they get out. But it goes even deeper than that. Part of the problem is that we have devalued the human mouth and patients don`t put the appropriate value on it. We, as dentists, feel guilty about charging a decent fee for anything and, since this is a material we can plug in and make a little money on if we room-hop like crazy, it`s what we use. It`s pretty sad that an hour in the beauty shop is more expensive than an hour in the dental office. The real sad part is the beauty shop doesn`t loan its patrons the money to have it done like we do by accepting insurance as payment.
Why should they stop? Personally, I think it`s a disgusting restoration that I wouldn`t put in anyone`s mouth that I cared about. They leak like a sieve from day one and then expand as they age. Many studies have shown that, after seven years, 50 percent of the teeth filled with amalgam have fractured. Over 40 percent of the amalgams deemed in good clinical shape had caries under them. This does not even include the discussion about the mercury. I do believe that the days of amalgam approval are limited. Unfortunately, it won`t be dentistry that polices it`s own, but the government stepping in, as has happened in so many other countries.
The esthetic restorations are much more conservative and they prevent eventual fracturing as they restore the teeth to their original healthy strength. Probably the biggest advantage is that they maintain the integrity of the tissue by eliminating the need to bury the margins below the tissue for esthetic reasons, since the margins are invisible.
The good news is that you won`t suffer a financial setback if you stop doing amalgams. At seminars, I ask attendees how many no longer do amalgam restorations. The hands going up are getting more numerous. Then, I ask how many suffered a financial set-back when they stopped. No hands go up. Then, I ask how many experienced an increase in income and all hands go up again. This move is a no-brainer and has to do with the fact that business is not a game of volume, but of margins. Most dentists rate their practice on how many charts they have or how many people they see in a day. When someone brags to me that he/she sees 45 patients a day, I say, "What, are you nuts? My ideal day is one in the morning and one in the afternoon!"
OK, you`ve convinced me. What steps do I take to change?
Probably the most important is to take an intensive program where you will learn how to do esthetic restorations properly. Since they are technique-sensitive, if you don`t know what you are doing, you will have major sensitivity problems. A one-day program is a good start, but something like the posterior weekend program we offer at The Las Vegas Institute is even better, as you actually work on live patients and prepare and seat a case during the program. This is coupled with the detailed science behind it all, so you understand why you are doing the particular steps. Regardless of where you are trained, you can`t apply the knowledge you`ve learned for amalgam or gold for these restorations. They are a different animal and need a totally different protocol. Don`t misunderstand me; they are not difficult, just different.
Once you`ve acquired the skills to create these beautiful, natural, tooth-strengthening restorations, then just stop diagnosing amalgams. People have them done because you just put them in. I`ve never had anyone come in and ask for a "black, ugly, mercury filling!"
I can do an amalgam fast. How can I get my speed up on composites?
Why can you do amalgams fast? Because you`ve done so many. Your speed on composites will also improve as it also becomes second nature to you. But the truth is, you don`t want to or need to do them as fast as you do amalgams. Because of the fact that we are basically giving away the amalgam restorations by letting the insurance companies dictate our fees, we have to room-hop to make a profit. Since you can charge more for composites, you are not forced to run from room to room, plugging the holes like some speed demon. When you take your time and charge appropriately for it, you will also start to enjoy your profession. I mean really enjoy your profession, and that`s what it`s all about.
Should I start doing one thing or just jump in all at once?
Boy, this is a good question. It kind of depends on where you are right now. It might be easiest to start doing posterior esthetic restorations, then work your way to anterior esthetics, but I know some who have done it the other way. You need to understand the limitations of direct composites and the indications for indirect composites. But if you don`t know how to do a good direct, or why you can successfully do one without sensitivity, then you won`t know how to do a good indirect. By understanding the inherent problems and quirks with esthetic restorations, you will be able to avoid potential problems.
However, I think your commitment to excellence should be immediate. Decide from this day forward you will do nothing less than excellent dentistry. You then spend the rest of your life maintaining that commitment. You do that by continuing to learn and keeping up-to-date with the radical changes that are taking place. For example, there is a new composite material available that may virtually eliminate the need for metal in dentistry. It is called the Targis System (Ivoclar) and it is twice as strong as Inceram. In fact, the porcelain breaks off the metal before this material fractures. It is truly revolutionary.
How do I get my staff enthused about esthetic procedures?
This is so easy, but it`s also the most ignored advice I give. Take your staff to courses on esthetics. Dentists can be so cheap that they don`t want to spend the registration fee on their staff, yet if their staff had been there, it would have resulted in such enthusiasm from them that they would have paid for the registration fee the first hour they got back to the office. It`s very hard for a doctor to create enthusiasm in his own staff. Trust me, I can get everyone else`s staff excited about dentistry, but struggle with my own. I have the best luck when I bring them to one of my seminars, then tell them to just sit and listen. It`s something about the energy in a room filled with excited people. It`s infectious.
I just recently had a staff member in attendance at our Baylor program get up and tell everyone that they made a big mistake if they didn`t bring their staff. She went on to talk about how excited she was and what she was going to do when she got home. The next session, the lecture hall was packed as almost everyone brought their staff. Why this is important is that some doctors need pushing from the staff. One of our assistant clinical instructors in the program was literally pushed into making the changes necessary by the two staff members who attended the program with him.
How do I get my hygienist to tell people about esthetics?
Great question. Three ways. The first way is discussed in my first book, The Exceptional Dental Practice, and has to do with compensating the hygienist on total-office collections, not just the hygiene department. If hygienists felt more connected to the total team, they would be more apt to recommend elective or even necessary treatment. This philosophy of team compensation applies to every team member.
The second way is discussed in my second book, In Search of the Ultimate Practice. It involves rewarding behavior you want to occur. If you want your hygienist to recommend esthetic treatment, keep track and reward her for cases sold. For example, in our office, we give our hygienists $125 for every veneer case she sells. Is it worth the $125 for a $10,000 case? You bet it is!
The third way is to veneer your hygienist`s teeth if she needs it and do it for free (as long as you think the individual will be there a while). Nothing creates enthusiasm in someone like having the work done on themselves. Doing this will not only create so much enthusiasm that your hygienist will begin to talk about that type of work, but it provides your office with a living model of what esthetic dentistry can provide. There is no single better marketing tool than to practice what you preach. Patients can sense if you are committed.
The problem is that many dentists often do it before they are properly trained or have their own teeth done by a friend who isn`t really that good. The result of showing a bad case is worse than not having your teeth done at all! Make sure you either have your work done by someone who knows what he or she is dong and wait to do your staff`s until you know what you are doing. We usually advise the doctors taking the esthetic programs at the Institute to use their staffs as patients in the program.
Will I have to hassle with insurance companies?
As long as insurance company administrators are in control of your practice, yes. But, adopting a new and practical insurance policy is all part of the transition. Understand that you should not be letting them determine what restoration should be put in the patient`s mouth. That is up to you and the patient. I will tell you that this broadening of paradigms might be the most difficult thing for most dentists to handle. Many have taken the information I`ve given them from either my seminar or my books and obtained control of the insurance monster. Others have not been able to do so.
Because of this, we`ve developed a "Vision of Success" seminar at the institute that literally monitors your actions and steers you into the proper course for your own individual situation. Imtiaz Manji has joined forces with me to take those dentists comfortably and successfully to that next level. He will analyze your practice as it is, then monitor you for one year by tracking data monthly. It is an incredible value, all rolled up into one weekend. I can`t tell you how excited I am about this program. I believe it might be the missing link to the puzzle I have been trying to solve on why some dentists can make this transition to an esthetic practice and others cannot.
What do you see as an ideal integration?
If you mean by this the type of dentistry performed in a practice, then that depends on a lot of things. A practice in New York City might be able to eventually do nothing but esthetic dentistry. There are some doctors who do nothing more than anterior teeth in their practices. But, if you live in YaHoo Arkansas, then you might not be able to develop a strictly esthetic practice. You probably will get to only do a cosmetic case a month, but for many dentists, that may be all they want to do.
I don`t think anyone should have to do amalgams because of his/her location, but it may restrict the amount of anterior esthetics that is done. But let me say one more thing. I don`t care where you are from, there is a whole lot more out there than you think. The basic problem is your patients don`t know about it, and if you, doctor, wait for them to ask you for it, then you`ll be waiting a long time.
The truth is most dentists would get excited about doing one veneer or cosmetic case every other week. Well, there are very few places in North America that it wouldn`t be possible to do that many. I really mean that! I`ve seen too many dentists go through our Institute programs from little towns all over America and Canada and implement what they have learned with dramatic results. Just because of that, I have a regular section in our Institute newsletter called "Metamorphosis," relating stories about people from all over making dramatic changes in their practices. It`s to stop the whining about "It can`t be done in my practice" that I hear all the time. If you think it can`t, it can`t. But you`ll never know until you try.
What`s the learning curve? How long does it take?
The learning curve is there, but it depends on your level of commitment. Take a one-day program and your learning curve will be longer, probably littered with problems along the way. Don`t get me wrong; you can learn to do these procedures in a one-day program and should always start there; but for the average dentist, it is a huge jump. The amount of material necessary to understand this type of dentistry is sometimes overwhelming. You never absorb everything at a program anyway.
Now, if you are taking part in a more intensive program that involves lectures, as well as hands-on treatment, it is much, much shorter. There is no substitute for actually doing a procedure after you`ve just learned about it, and seeing so many other cases being done as well. Certainly, with anterior cases, each one is uniquely different. At the Institute, we see what would amount to a year`s worth of cases in one weekend.
As far as how long does it take, the answer is . . . forever. You never stop learning. I learn with every Institute I do. Each time, I see a case that makes me think of another way to improve the results. I know my Institute partners, Dr. Hornbrook and Dr. Rosenthal, both feel the same.
Many dentists make the mistake of thinking they know it all or enough anyway, but the truth is they don`t know what they don`t know. I`ve seen my assistant instructors fall into that trap because they have seen hundreds of cases. Then, something will happen that will snap them back into reality that they really don`t know everything. We`ve never had anyone take a program where they weren`t shocked at what they didn`t know!
That smug complacency has to be fought hard by every dentist out there. You may be at a level where you don`t have as much to learn, but the information available is limitless in dentistry. Never, never stop learning. It`s the one way to keep the enthusiasm alive
Dr. Dickerson lectures internationally on esthetic dentistry and marketing a cosmetic practice, and is visiting clinical professor and director of the Comprehensive Esthetic Restorative Continuum at Baylor College of Dentistry, as well as director of the Las Vegas Institute of Cosmetic Dentistry. He has had over 50 articles published in leading national dental journals on techniques and innovative uses for esthetic restorations, as well as marketing and managing a cosmetic dental practice.