Dental India Newsletter - 11th January 2004
- Please help us to update our database
- Staff retention - from the web
- 11th National Conference of ISOI - 20-22 Feb 2004, Goa
- Can good practices become great? - Hurston Anderson
- Problems with Staff.... not doing so well. - Question & Answer
- Cyanoacrylates - safer ? Question and answer in Orthodontics
- A Periodontal discussion on referrals
- We value your feedback: Comments and suggestions on this newsletter
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irreversible pulpitis and pain to endo ice and heat that lingered for about a minute.
Carious exposure of the distal pulp horn explained the situation
when the decay was meticulously cleaned out.
MB2 had the same POE with the main MB canal.
gauged mesial to 45, DB to 60 and palatal to 70.
system B, EWT and obtura backfill. Fuji IX, and tetric bldup.
- Photos/case courtesy: Ahmed Tehrani, ROOTS:

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Staff retention is of paramount importance to the smooth operation of a clinic. 
Staff turnover decreases productivity and services during times of vacancies and 
increases costs and time spent on recruitment and orientation of new staff.

The best way to retain staff is to insure that their employment experience satisfies 
as many of their professional and personal needs as possible. This includes offering 
a competitive salary and benefits package, a pleasant working environment, 
opportunities for professional growth and interaction, continuing education, adequate 
vacation time, retirement pension, flexibility for child care, etc. 

When establishing the clinic's scope of services, remember to consider the professional 
development needs and satisfaction of staff as well as the needs of the community. 
For example, many general dentists do not enjoy providing a limited scope of basic 
diagnostic and restorative services without the opportunity to provide more complex 
procedures.

Scopes of work need to be challenging and professionally satisfying to retain an employee 
for the long term. Creating a work environment where quality patient care is paramount 
will enhance professional satisfaction. Programs where financial goals seem to drive the 
provision of care will have problems recruiting and retaining staff.  

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INVITATION
 
11th National Conference of the ISOI
20th to 22nd February, 2004 
Marriott Resort in Goa

We warmly invite you to the 11th National Conference of the ISOI, scheduled to be held 
from 20th to 22nd February, 2004 at the Marriott Resort in Goa  - Organising Committee

Website: www.geocities.com/isoi2004goa
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Can Good Practices Become Great?

For about fifteen years now I have been analyzing dental practices with the ultimate goal 
of helping dentists to improve their businesses.  In simplistic financial terms all these 
hundreds of dental practices could have been categorized as shaky (i.e., struggling to make
ends meet, doctor inadequately compensated), good (i.e., solidly performing, doctor and 
staff compensated adequately), and great (outperforming 90% of comparable practices in the
area, doctor has tax and investment issues).  Sometimes, I am reprimanded for discussing 
success in these essays in terms of financial performance to the apparent exclusion of other 
factors such as quality of care, staff morale, contribution to the community, and personal 
fulfillment.  I would again state that these things are not mutually exclusive.  
All who succeed financially will only do so over a sustained period with the acceptance of 
the community, a reputation for excellence in care, and a willing and eager team.  

Many of our clients had been in the shaky financial category with the need to reduce the 
financial strain as quickly as possible.  Many had even used credit cards to pay our monthly 
fees the first few months while the transition was taking place.  Since reducing expenses is 
seldom an option, an all out effort to increase income while not increasing stress or 
expenses was necessary.  The intent was to move these practices to a good financial situation. 

Some of our clients are great performers already, but they are interested in making some 
sort of change such as adding an associate or partner, preparing for retirement, moving to a 
new location, or purchasing another practice.  The trick here is to undergo the transition 
without destroying the magic that provided the greatness. 

Most of the dental practices we evaluate and/or assist are already good practices that 
strive to be great.  For years we have been working to assist them in this journey.  
It has often been challenging, always exciting, and extremely gratifying.  Going from good 
to great is a rarity because it requires changing daily protocols and approaches, and it 
means taking risks.  The reason there are so few great dental practices is that being good 
gets in the way, and there is a rare combination of attributes that is always in place when 
good practices advance to become great practices.  

Empirical knowledge tells me that there are dental practices performing twice or three 
times as well as others under the exact same conditions.  A perfect example 
(without violating confidentially) is a dental practice in Texas that had been producing 
a very good $63,000 per month with a staff consisting of one dentist, one hygienist,
one assistant, one front desk specialist, and one rover from front to back.  
Within two months this practice moved to the great category producing close to $100,000 
per month consistently while increasing staff by one hygienist and one full-time assistant.  
A one-dentist practice in the mid-south that was overstaffed for its production of about 
$70,000 per month grew to average close to $110,000 per month while actually reducing staff.
Why can these dental practices make that leap to greatness while others do not?  
Only recently have I found an explanation that discusses this phenomenon in a way that 
I am convinced is correct. 

Very generally, Collins found that there are six characteristics that are always present in 
great corporations.  The first three are present during the initial time he calls the 
buildup and the other three are present during the breakthrough phase.  The six with very 
brief explanation are listed below. 

1.)      Level 5 Leadership.  The leader is “a paradoxical blend of personal humility and 
professional will.”  This does not require, and probably specifically excludes, management 
superstars.  The leader must be a member of the team not the star.

2.)      First Who …Then What.  Despite the old adage that “People are your most important 
asset.” the fact is that the right people are essential.  One person can spoil a team.  
Teams win together.

3.)      Confront the Brutal Facts.  You must have unwavering faith in your success while 
being realistic about the difficulty no matter how bad it is.  Lack of conviction results 
in lackluster efforts.

4.)      The Hedgehog Concept. To be great you must be able to be the best in the world 
at your core business.  (This requires special discussion to adapt to dental offices, but 
it still applies.)

5.)      A Culture of Discipline. When you have disciplined action, you do not need 
excessive controls.  This involves well-defined internal procedures and protocols as often 
discussed by me.

6.)      Technology Accelerators.  Great companies think of technology differently.  
They are experts in the application of carefully selected technologies.  Buying every new 
gadget is counter to this. 

I am convinced that every shaky dental practice can become a good dental practice and that 
every good dental practice can become a great dental practice, if the dentist is willing 
to think outside the box and make some changes that will require some risk.

- Hurston Anderson


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Subject: not doing so well.... 

I am not sure if this is salvageable. For the 2nd time this week the hygiene 8 am has not 
shown . We average 2 hygiene no shows per day. The staff acts like it is the luck of the 
draw.  They seem to feel they have been given absolutely no direction. I hate coming to 
work and I feel that I am wasting my life. Yesterday the schedule was non-productive. 
I have been more productive when I am here alone!!! The assistant just left at 2pm to 
pick up her child. She can't get here before 9am so I work alone until then. It is a 
free for all and I pick up the tab…….I would honestly gladly hand the keys to this office 
to anyone who would accept them. I can't manage people, I don't feel anyone wants to work, 
but they all want to be paid. I hate the one way street. I pay for education, hep shots, 
uniforms on and on and then get excuses for everything that goes wrong. We lost money last 
year and I am funding my life with credit cards. I feel sick from stress and haven't slept
well for months. I have been lied to, cheated, and ignored by my employees, and I don't have 
any faith in myself as a manager or CEO.   I have tried writing things down for them. 
The paper gets lost, "I forgot. Yatta yatta…”. I am just busy enough not to be able 
to monitor every transaction, conversation etc. that goes on here. 

Hi Dr. A, 

Your situation is salvageable, but it will take many different steps to make permanent 
changes.  We can release the pressure with some quick fix methods, but it sounds as if 
there may be some reorientation and retraining necessary for long-term change.  
It may be that all the staff is not salvageable, but it may be that setting a detailed 
and clear direction will bring them along. 

Most dentists feel they are not good managers. It is particularly difficult, I think, 
because dentists are so smart, IQ-wise.  Throughout most of childhood, the teens, and 
young adulthood most dentists were among the smartest people in their groups.  
Admittedly, entering dental school and meeting a room full of people who are equally 
smart is a bit sobering.  Still, the experiences of our early lives mold our attitudes 
and reactions including our approach to problem solving.  Smart people are accustomed 
to out thinking problems, and it works in many areas of life.  However, effective personnel 
management is not about intelligence, and it is critical for success in any business. 

Your example of herding cats is appropriate.  Unfortunately, few employees are dedicated 
to their jobs anymore, anywhere.  I do not want to denigrate all who work in dental offices 
because that is not fair, nor accurate, but in most cases it seems that dental office 
employees are there for the pay check, period.  Our consultants all spent years working 
and managing in dental offices, and they are incredibly talented, so there are ambitious 
creative thinkers in the industry.  However, the harsh reality is that most dental office 
positions are not high paying, and do not have a great future potential.  That is why a 
dental office that has a management philosophy which relies on the staff to be self motivated, 
creative problem solvers will be dangerously dependent upon key individuals.  Sometimes, 
the practice will sail along with few morale problems and healthy growth.  Then, someone’s 
husband is transferred, or someone is going through a difficult personal problem, or a new 
staff member is added who is a strong personality with a negative attitude.  Almost 
immediately, stress increases, the staff is unhappy, the patients start canceling more or 
simply just not showing at all, and eventually the finances suffer.  Written, understood, 
and followed structure and internal systems must become the "Supervisor" that a 
dentist cannot be during the day.  We use the word protocols because the internal 
organization cannot be based upon guidelines, but rules to be followed precisely.  Too many 
dental offices have general guidelines as the only structure.  That is not enough. 

Also, give yourself a break.  If you were able to oversee everything all the time like most 
managers of small businesses you could easily get it under control.  That added 
"evil" twist with dentistry is that you must spend your day in the treatment rooms or 
there is no income.  This leaves the staff to their own devices.  If they are trained and motivated
they can easily follow protocols and perform miracles. Of course, some cannot be trained 
and some cannot be motivated.  If you have any of those employees, they will not be able to 
help us, and they should be asked to "shine their lights elsewhere". But, that is 
not the majority of employees.  We and you will be discussing each and every person in 
detail, and we will make quick judgments if anyone is just never going to be able to 
contribute.  Don't worry about that, though.  It is unlikely that you would have hired 
anyone that incompetent.

Probably, we will be able to get the ship righted by first cleaning up the schedule.  
A first appointment cancellation/no show is inexcusable.  We must treat our appointment 
times as treasures, with some are more important than others.  Each hygiene hour is worth
$100+.  Losing that hour is like losing a one hundred dollar bill.  It is essential that 
we know our patients.  We must never allow our treasured first appointment to be occupied 
by someone who has any potential for canceling...based upon their history in the practice.  
No patient with a bad history or from a family with a bad history can be appointed for 
Monday, either.  It is important for the first day of each week to go smoothly, and that 
is also true for the first appointment of each day.  A cancellation or no show is not the 
patient's fault only.  It is the fault of the dental office, especially the scheduler/
confirmer.  Now, we do not gain anything by coming down on her like a ton of bricks.  
She must be educated, motivated, and trained, if she is capable.  If she is not, 
we must have someone there who is.  If the attitude has become so negative that it is beyond
help, we must find the ringleader, and replace that problem.  You do not have a huge staff, 
so it will be a breeze to discover upon whom you can depend.  It is better to hire employees
who have a positive outlook on life, but if that is not possible, they must not be assertive.
A negative dominating personality will ruin a dental practice more quickly than anything else.

For the doctor the key person for his/her psyche is the assistant.  If the assistant does 
not assist well, the doctor will always have a heightened stress level.  You must have an 
assistant who lightens your burden.  If this assistant cannot be depended upon, you would be 
better taking an inexperienced person with a good attitude and training her to assist.  
A replacement trained assistant would be preferable, but you cannot allow anyone to throw 
you off first thing in the morning.  The attitude and momentum build or collapse based upon 
the first appointment each day.  If you have an assistant who cannot be there until 9 you 
must either not see patients yourself until 9 and use the time for office work, lab work, etc. 
or you must get someone who is available when the practice needs her.  A practice is bigger 
than the unique needs of one person.  Everyone there could be affected if this practice fails.
How can you give raises, increase benefits, etc., if you are losing money?  You owe it to 
yourself and them to see that this practice prospers.

When we arrive Monday it will be 100% business.  We will first try to find ways to get your 
income increased, even if it is through means that are temporary.  By that I mean, we will 
be watching that the schedule contains enough treatment and patients with good history for 
keeping appointments and paying their bills.  Really, scheduling is about three days only...
today, tomorrow, and the next day.  Nothing beyond that is relevant right now.  We must 
always try to fill today, tomorrow, and the next day before looking at anything else.  
If we do that today, then tomorrow we will be adding the following day, etc.  If there is 
good production next week and tomorrow is a bust, we must see if there is any way to bring 
some of that forward, or we must dig through charts looking for production.  In dentistry, 
the schedule is the thing.  You will hear us emphasize this ad nauseum, and we will have the 
schedules faxed to us each day, if we think there is a chance that our message is not being 
taken seriously.  We are very much positive in our approach, but we are firm about what will 
work and what will not.  I do not mean to brag, but we know what will work, and we can 
detect quickly who will work.

Obviously, everything is filtered through your sensitivities first, but we will help you 
turn this practice around.  Usually, when there is a staff just looking for direction the 
impact is immediate, and the income jumps the first month.  Sometimes, we run into a bit
more difficult group to inspire.  It is just as the President says about foreign countries 
and terrorism.  They are either with us or against us, ultimately.  It is important to find 
out which as soon as possible, because this is a team effort, and the entire team must be 
contributing.  Whatever the difficulties, we have seen them before, and we have a way to 
overcome any difficulty.  The analysis I did on your practice is based upon our experience, 
and we expect to be held to that standard.  As I said before, just hang in there.  
Help is on the way, and we have a 100% record of achievement for more than ten years.  
In 99% of the cases everything can be resolved, and the existing team pulls together, 
joyfully.  That is what we expect to find, but if we do not, we still have the solution you 
require.

- Hurston

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Are the chemicals used in direct bonding like cyno-acrylates pretty safe in the mouth as it 
is reacted upon by various secretions and digestive processes. We had seen a couple of 
Leukemia cases with bonded orthodontic appliances- might be totally unrelated, but a pinch 
of salt in the corner of the mind-particularly on the pungent and toxic nature of primers 
and cyno-acrylates ? Does anybody have a validated study report on absolute safety of these 
chemicals in the GIT?
 
-Dr.M. Jayaram, INDIA


Cyanoacrylates have been used for many years.  Most people know it as
super glue.  Emergency rooms use it in place of sutures.  It is called Derma
Bond marketed by Johnson and Johnson.
http://www.dermabond.com/
They also market liquid Band Aid
http://www.jnj.com/innovations/new_features/BANDAID_Brand_Liquid_Bandage.htm

The stuff is actually produced by Closure Medical Corporation which in
2000 entered into agreement with Colgate Palmolive for Colgate to market
Orabase Soothe-N-Seal.  Soothe-N-Seal is the first cyanoacrylate medical device
approved by the FDA for the over-the-counter consumer market for canker
sores.
http://www.closuremed.com/PressReleases/pr_12-21-00.htm
http://www.colgate.com/cp/global.class/showcasetool/templates/displayProduct.jsp?id=44

Glustitch is also another company that manufactures cyanoacrylates for
medical/dental use.
http://www.glustitch.com/

Here is some literature on the use of in dentistry.
http://www.ncbi.nlm.nih.gov/entrez/
query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9812430&dopt=Abstract

http://www.dent.ucla.edu/pic/members/litreview/dressing/lr_dressing01.html

http://www.dent.ucla.edu/pic/members/litreview/dressing/lr_dressing10.html

Jonathon Lee, DDS
Private Practice
Foster City, CA USA

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Hi Larry,
I think that my point was not clear enough. 
I never imply that:
All unecessary surgery are malicious !
 
I just have the impression through my many months reading  your message that a few 
notorious case has given you the doubt in the need for periodontal referral. My impression
may be wrong... 
 
Larry: My opinion concerning less need for referral stems from several reasons.
1.  New tools and technology have greatly expanded the quality of service that can be 
accomplished non-surgically.  For instance:
A. Recognition that periodontitis is a bacterial infection requiring more medical 
approaches and less dento/mechanical procedures for success.
B. Thinner ultrasonic inserts that eliminate many of the "access" problems that necessitated 
surgery in the past.
C.  Many hygienists and some general dentists who have developed treatment skills to the 
point they are as effective at periodontal therapy as periodontists.
D.  The ability to easily and effectively deliver antibacterial solutions to the depth 
of pockets by cooling ultrasonic tips with antibacterial solutions intead of water when 
necessarry
E. The discovery that "pocket elimination", although desirable, is not essential 
for sucessfull therapy.
F. Diagnostic tools and tests giving us more information concerning residual periodontal 
infections
 
2.  I think (and I may be wrong about this) that the people who come to this discussion 
group are not the typical cross section of hygienists or dentists.
I'm aware that many, if not most  of the the therapists that come here are far above 
average in their knowledge of, and ability to treat more advanced cases.  For therapists 
who have not yet reached that stage,  my criteria for referral which states "refer 
any case you are not comfortable with" should help encourage referral of cases that 
I would not necessarily refer myself.
 
I never imply that:
 
Perio surgery comes without  initial phase (oral hygiene instruction,Sc and Rp with or
without anti microbial therapy )reevaluation and regular maintenance.

I consider those steps a must .
 
If all periodontists worked this way, I would not object to early referral.  
This means the patient would hear something like this during case presentation:  
Mr. Jones, we will do initial therapy non-surgically.  We will then do maintenance once 
every 3 months or so.  If at the end of a year, I decide that one or more sites need 
surgery, we will proceed with that phase of treatment.
 
Unfortunately in too many cases, not just notorious ones, the treatment plan is: 
phase one - non surgical debridement performed by the hygienist followed by 

phase 2 -surgery by the periodontist.  
 
There never be a fight between nonsurgical antiinfective therapy and surgery, they all
work together with good diagnosis and treatment planning and individually tailored to the 
best interest of our patient.
 
That's how it should be.
 
I don't think that monitoring 3 to 4mm pocket depth is the same as the one with 7mm pocket 
depth. Most of us would prefer not to have those 7mm pockets in our mouth, not to have 
anaerobic bacteria dwelling in those pockets and the bad odor they generate together 
with the inflammation and bleeding .
 
It is common that non-surgical therapy on average will eliminate 1/2 the original pocket 
depth.  Also, in general the deeper the pocket, the more dramatic the pocket reduction.  
This means it would be rather rare to be Monitoring (I would say treating and maintaining 
because we don't just observe this pocket every 3 months, we treat it)  If I or my patient 
had a residual 7mm pocket there wouldn't be enough anaerobic bacteria dwelling there to 
cause bad breath and hopefully no inflamation and bleeding.  As you know, we can also have 
anaerobic bacteria, with resultant bad breath and inflamation in a 3mm. pocket
 
How about the gouging of the root when you do your scaling and root planing for a long 
period in the deep pocket that you don't have access?( We all know that do happen)
 
My teaching of debridement technique utilizes more ultrasonics and limiting hand 
instrumentation for the most part to gentle instrumentation with a very sharp Gracey curette 
mostly as an explorer with added pressure when I encounter something that feels like calculus.
This avoids removal of healthy cementum, removal of diseased cementum, and avoidance of 
goughing of of the root.  This also minimizes the occurence of post operative root 
sensitivity.
 
And one day, if those teeth finally give up, there will not be a lot of bone around for 
the future implant.
 
Before I taught in a dental hygiene school, I too thought those severely compromised 
teeth would give up.  After years of being there and observing patients on maintenance 
who couldn't afford a periodontist, I learned most don't give up.  It came as a big surprise 
and had a lot to do with shaping my periodontal opinions.
 
Best Regard,
Tram 
PS: I am a periodontist