They have a sense of their possibilities and more importantly, they have a sense of urgency that makes them act on those possibilities.  It’s that “fire-in-the-belly” that drives them to get better.

Some people just naturally have this fire within.  As an educator, I have found that you can help them and you can give direction and coaching. One thing you can’t do is slow down these individuals, even if you wanted to. They have two words that propel them to reach new levels, two words that define their mindset: “What’s next?”

But I have also found that you can ignite this fire in people who don’t naturally have it. You just have to find the right spark that captures their imagination and then fuel the fire with some early success. Eventually, the fire takes hold for good.

I think of this often when I see people who are discouraged by the news on the economy and how it can affect their business. I think of the people who have “the fire” and I realize that they are too focused on being the best they can be to spend their time worrying about outside factors they can’t control. You can choose to focus on the U.S. economy and the limitations you see there, or you can choose to focus on your practice economy and on the possibilities that are there—and believe me there are great possibilities.

Those dentists who are highly engaged, always asking “what’s next?” and always driving themselves to stay on top of their game thrive in any economy. Money does not drive these dentists; they’re driven by a desire to be the best, and the money just follows naturally. Economic success is a byproduct of being in love with what you do and committed to doing it at the highest level.

So do what it takes to keep that fire lit and fueled. Share the warmth and light from it with those around you. You’ll find that success that is born of true passion is the most fulfilling kind of success.

Depending on the design of the study, the reported failure rate for inferior alveolar nerve block ranges between 5 to 30 percent. So if you numb three to five patients with inferior alveolar nerve blocks on any given day, the statistical probability of running into this problem happens almost every other day.

That is a significantly frequent occurrence and it would help to improve on the success rate.

In the example above, what could we do? Let’s consider the following:

Anesthetic: While it is a common belief that articaine is more effective than lidocaine, no research has been able to demonstrate the advantage [1].

Elapsed time: Onset of lip anesthesia takes about four to six minutes and pulpal anesthesia onset takes 10 to 15 minutes. Often doing nothing more than waiting an additional amount of time is all that is needed for adequate anesthesia to take effect.

Missed injection: If there is no lip numbness even after 10 minutes, it is likely that the location of injection was incorrect and another injection should be attempted.

Supplementary injection: If lip numbness is present, buccal infiltration in #19, #20 with Atricaine 4% would be the next step [2].

Use buffered anesthetic: Recently there has been a new product [3] in the market, which allows for convenient alkalization of lidocaine right before injecting. Buffered anesthetic hastens the onset of anesthesia. So if you have deposited the anesthetic in an incorrect location, you will be able to detect this quicker. Besides, buffered anestehtic can make the injection less painful for the patient [4].

Use of a timer: The moment you pick up the syringe to inject the patient, have the assistant start a timer. Its amazing how much this objective consistent measurement of time helps with the anesthesia procedure.

• It helps to slow down the speed of injection. Injecting a 2 ml volume of solution over one minute is the ideal speed to ensure patient comfort and improve success [5].

• Timer helps to objectively quantify wait times after the injection.

• If the patient is not numb in the first five minutes and one needs to wait another 10, there is an objective measurement possible.

Technique: Two most common causes of a missed injection [6] are:

• Positioning the tip of the needle too far medially resulting in inadequate anesthesia.

• Positioning the tip of the needle too far inferiorly resulting in anesthesia of only the lingual nerve.

Ideally one would expect to hit bone at around 20–25mm of needle insertion. While in both of the above types of errors, most likely, one would not have hit bone. When injecting the second time, it becomes even more crucial to feel for the bone. Often choosing the point of needle insertion, which is more lateral and higher than the first insertion point, helps. During the process if you hit bone too soon you have to just retract slightly and redirect the needle a little to the medial. In this manner as the needle is advanced you have an assurance that the needle is just lateral to the medial surface of the ramus and you avoid the needle from going too far medially.

Intraosseous injection: When this first line of management fails, an intraosseous injection would be the approach of choice. Some studies would suggest that intraligamentary injection could work just the same but intraosseous injection seems to be more effective.

Sources:
[1] Mikesell P, Nusstein J, Reader A, Beck M, Weaver J. A comparison of articaine and lidocaine for inferior alveolar nerve blocks. J Endod. 2005 Apr;31(4):265–70.

[2] Haase A, Reader A, Nusstein J, Beck M, Drum M. Comparing anesthetic efficacy of articaine versus lidocaine as a supplemental buccal infiltration of the mandibular first molar after an inferior alveolar nerve block. J Am Dent Assoc. 2008 Sep;139(9):1228–35. Erratum in: J Am Dent Assoc. 2008 Oct; 139(10):1312.

[3] Onset by OnPharma

[4] Kashyap VM, Desai R, Reddy PB, Menon S. Effect of alkalinisation of lignocaine for intraoral nerve block on pain during injection, and speed of onset of anaesthesia. Br J Oral Maxillofac Surg. 2011 Dec; 49(8):e72–5. doi: 10.1016/j.bjoms.2011.04.068. Epub 2011 May 18.

[5] Kanaa MD, Meechan JG, Corbett IP, Whitworth JM. Speed of injection influences efficacy of inferior alveolar nerve blocks: a double-blind randomized controlled trial in volunteers. J Endod. 2006 Oct; 32(10):919–23. Epub 2006 Jul 7.

[6] Milles M. The missed inferior alveolar block: a new look at an old problem. Anesth Prog. 1984 Mar-Apr; 31(2):87–90.

Vivek Mehta DMD, FAGD, Visiting Faculty, Spear Education. Follow him on Twitter @Mehta_DMD.

It’s amazing how whenever an issue with a team member arises it can often be traced to a lack of clarity in one of these areas. Anytime you’re dealing with a number of individuals who have to work together to achieve a complex goal, there is going to be the potential for things to slip through the cracks. It’s what I call the “black holes” of the business.

These are those mysterious places where things just disappear and nobody seems to be responsible—they are the black holes of accountability where possibilities go to die.

We should always remember that good team alignment is always a function of good team leadership, and that starts with providing a guiding sense of clarity. People like to know where they stand. They like to feel a part of something bigger than themselves, but they also want to know exactly what their part in the bigger picture is. They want to know exactly how their role is defined. They want to be able to measure their results against a fair and consistent standard. Clarity provides direction and motivation.

This is why I have devoted several comprehensive lessons on Spear Digital exploring in-depth the critical “value roles” that make up a high-functioning practice. The beauty of it lies in its simplicity. Each role boils down to only a few key areas of accountability. Each set of responsibilities is easy to understand and simple to implement. But when taken together, they have the power to vanquish those dangerous black holes once and for all.

As you can see from the initial PA above the pulpal space for #20 does not appear normal. Just as with the tooth mentioned in my previous article, I could have taken off-angle radiographs to further evaluate; however, again the patient and I came to the consensus that a CT scan would give us the clearest picture of what was going on and that was the way to go.

As you can see in the screen shot from the CT this tooth has suffered invasive cervical resorption. Fortunately in this case we have a fighting chance to save the tooth through crown lengthening to expose the resorptive defect, followed by removal and restoration (which may not require endodontic treatment) of the resorptive area.

Having the chance to save a tooth like this is the reward for paying close attention to those pulpal spaces!

John R. Carson, DDS, PC, Spear Visiting Faculty. [ www.johnrcarsondds.com ]

But at the same time you’d be surprised how many will commit to ideal care—or at least a higher level of care—if you take the time to work on your value creation skills and present to them in a way that really inspires their imagination and gets them thinking about what can be. It’s not about attracting the right kind of patient who is predisposed toward accepting high-level dentistry.

Most of those so-called “quality” patients already have a long history of accepting a high standard of dental care, so your improvements with them are usually going to be incremental. If you really want to elevate your game, you need to connect with those patients who don’t have a history of valuing dentistry, because that’s where the real gains are made. This is where you can change lives. In this sense, some of your “worst” patients can end up being your best patients.

You don’t have to go to great lengths to find these people. In fact, if between you and your hygiene team you’re seeing about 20 patients a day, I can almost guarantee that at least two have the means and the inclination to embrace a higher standard of dentistry—if you work on closing their value gap.

The question is, can you identify those patients? Are you holding yourself accountable to reach out to them and give them the opportunity to enjoy ideal dental health, regardless of your preconceptions about what they may accept? Remember, they may not say yes to everything today, but you owe it to them—and to yourself—to begin the education process. Many patients come around slowly, but they do come around if the message of value is consistently reinforced.

The images below are of an impression made at the time of uncovering an implant in order for me to make a provisional. The surgeon thought an angled abutment might work.

In this case it simply can’t, the facial aspect of the implant platform is slightly labial to the cervical margins of the adjacent tooth preparations. Even with a custom abutment in order to angle it palatally enough we most likely will be into the screw head. Even though there is very thick tissue it will migrate apically and the esthetics will be severely compromised.

This patient now has three options:

• Remove the implant and graft the area and do another implant.

• Bury the implant and do a bridge with an ovate pontic.

• Trough around the implant and reposition it and hold in place with a tall healing abutment and relining the provisional on top of the healing abutment.

Learn more about techniques relating to implants, as well as, occlusion and wear, esthetics and treatment planning from Spear Digital Campus.
View the free lesson: Connecting Implants and Teeth.

And they often disagree, sometimes quite intensely. In fact, I myself am usually one of the people making an impassioned argument.

I admit that it can take tremendous discipline for me to yield and let others get their say, but ultimately I do because I want to hear all the ideas. I don’t get too concerned when things get a little heated because, to be honest, I like the fact that they are engaged enough to get that passionate about being heard. It means they care. And it’s just fun sometimes to watch smart people disagree.

In the end, some ideas make it and some don’t—and some are modified and developed beyond what the original thinker envisioned. But we keep going until we have something that best serves the interests of our clients and as a result, our organization. Then we all go to dinner to celebrate. The strong disagreements of the day are now forgotten and the team is even closer for having gone through an intense collaborative process.

Often, as a leader you want to try to minimize the conflicts among members of your team. This is certainly important in most work situations. But there are times, such as team strategy meetings, when—as long as it doesn’t become personal—some conflict is healthy, and even necessary. In fact, when I see a team meeting where one or two people are doing all the talking while others sit quietly and are unresponsive, I view it as a sign of a dysfunctional group.

The ideal team dynamic you’re trying to achieve for these kinds of meetings is one where everyone is respectful, deeply invested, and no one is afraid to express their convictions. When passionate minds meet sparks sometimes fly, but that’s how creative fires are lit.

e.max: There are three ways the technician can work with this this material. The original version of Lithium disilicate, Empress II, was initially designed to be used as a coping with powder and liquid glass ceramics then applied to it.

This approach is still an option with e.max today, and can work very well when an opaque e.max core is fabricated to cover a dark prep or post and core, and then stacked ceramic is applied over the opaque core.

Far more common today, the material is fabricated as a full contour restoration and then either externally colored or the incisal is cut back and layered. The major advantage of the externally colored, or monolithic version is strength. The advantage of the cut back and layered version is esthetics.

This set of e.max was done as a monolith and externally stained, whether this approach is successful esthetically has everything to do with the teeth you are trying to match. If the teeth are uniform in color, without a lot of internal characterization in the body or incisal edge, then external coloring can be successful. It can be challenging however to apply the stain evenly on both units and to create the same color.

On these two units the right central has definitely had additional blue colorant applied to the incisal 1/3. In addition from a surface point of view, externally staining doesn’t give you the same control over surface texture and luster you get with layering, followed by texturing and then polishing to achieve the correct surface. In fact the glazed surface of these two crowns is slightly different, the right one having a slight bit of orange peel texture while the right is very smooth.

Finesse: This set of crowns was fabricated by the same technician that created the e.max restorations. What you immediately notice is that the two centrals are two different shades, but the incisal edges are fairly similar. These teeth are on the thin side because the distals have been brought back too much, resulting in the right central being .4mm to .5mm thick on the facial, allowing the slightly discolored prep to show through. In addition, I’m fairly certain there is much more external stain on the right central that amplifies the shade difference between the two even more.

What I hope you’re realizing in this article is that the materials really aren’t making the difference – it’s what the technician chose to do. The technician that followed the Rx the most accurately is featured in the final photograph; they chose to use Feldspathic.

However, it wasn’t the fact that they were Feldspathic that made them the best; it was that they incorporated the correct tooth form and alignment that resulted in a uniform 1mm facial thickness. In addition they got the shade, surface texture and surface luster all in the ballpark. The same could have been done with any of the materials described above. So when dentists ask what the best material is for anterior esthetic restorations, my answer is always the same. It is the one your technician knows the best and does the best, because it is all the other factors that make the biggest difference in the final result.

The concept of Facially Generated Treatment Planning can greatly simplify treatment planning for wear patients. You can find more information about material selection, esthetics and occlusion within Spear Digital Campus. Download the free resource:
The 8 Steps Checklist-Facially Generated Treatment Planning.

But if you’re going to get the most of your “on practice” CE time, you’re going to have to have a strategy and you need to appoint it. You need to have a CE plan. Our philosophy at Spear is that success is built on excellence in treatment planning and case acceptance. If you believe that too, you have to approach your CE plan as strategically as you would a treatment plan. You have to diagnose your needs (which particular skills you want to develop), and assign the right budget of time and resources to get it done within a determined time frame.

It’s easy to just look at the cost of continuing education and be concerned about the expense, but think of what it can be worth it to you. How many complex cases would it take in a year to completely fund your education? And beyond those tangible return there also the intangibles: the renewed sense of passion and excitement and the energy that brings to your everyday life when you are performing at a higher level. You can’t put a price on that. And the rewards keep coming because you will have the skills for the rest of your life—skills that allow you to serve your patients at a higher level. Everybody wins.

The other thing I often hear from dentists is that they just don’t have the time to devote to that much education. But again, it’s a matter of what you get back. When you increase the level of your dentistry you increase the value of your time, which means you will able to do more satisfying dentistry in less time and be able to take more time away from the practice.

If this sounds unlikely, I invite you to read this success story from one of our clients, Dr. Peter Virga. He has gone from taking six weeks off a year to taking 12 weeks, and he attributes that change in lifestyle to the higher level of case acceptance he has gotten the training to achieve.

So don’t leave your ongoing education to chance. Don’t approach it in a haphazard, piecemeal way. Have a CE plan for yourself and your team, understand its value and execute that plan with full commitment. You may surprise yourself with how great the returns can be.

The ADA unveiled the multifaceted campaign, Action for Dental Health: Dentists Making a Difference, at a National Press Club event with media representatives, members of Congress and oral health advocates and professionals.

“We’ve made great progress, with each generation enjoying better dental health than the one before,” said Dr. Robert Faiella, ADA president. “But there’s still a dangerous divide in America between those with good dental health and those without. Our mission is to close that divide. Good oral health isn’t a luxury. It’s a necessity.”

The Association simultaneously released an ADA Dental Divide in America Study conducted online by Harris Interactive on behalf of the Association April 24-29 among U.S. adults. The study confirmed “a disturbing dental divide in America” that is also indicated by prior research from multiple sources, the Association said.

According to a new ADA Health Policy Resources Center analysis of 2010 Medical Expenditure Panel Survey and U.S. Census data, 181 million Americans did not visit a dentist that year. Nearly half of adults over age 30 suffer from some form of gum disease, according to the Centers for Disease Control and Prevention, and nearly one in four children under age five already have cavities.

The release states that The Action for Dental Health campaign is national and coordinated in its scope and approach and designed to address the dental health crisis in three distinct areas:

1. Provide care now to people suffering with untreated disease.

2. Strengthen and expand the public/private safety net to provide more care to more Americans.

3. Bring dental health education and disease prevention into communities.

To learn more about ADA’s Action for Dental Health: Dentists Making a Difference, visit ADA.org.