By Raj Upadya

There is much more to a healthy mouth than preventing and treating decay and gum disease alone. There are other factors that are critical to long-term predictability of a healthy mouth that will allow you to enjoy a better quality of life and better overall health. The well-trained eyes of a different breed of dentists that completely examine a patient are the key to determining the signs of problems before they become painful symptoms. If you wait to treat a condition until symptoms have developed, you have often missed the opportunity for conservative therapeutic options; thus treatment choices will also become much more costly and involved.

There is a scientifically based rest position for your jaw joint, called centric relation, that has been repeatedly proven to be accurate and stable through not only research, but also through patient experiences, and with trial and error of repeated dentistry. If the joints, muscles and teeth have not been working in harmony with respect to their proper positions you can find extensive damage to the teeth, the joints and muscles. This can lead to dental needs for a patient, sometimes in the absence of symptoms. Masticatory physicians are trained to see and diagnose these conditions when they are signs, before they proceed to becoming debilitating symptoms. This approach may be occasionally viewed by traditional dentists as overtreating, though in reality we are being more conservative in the overall dental life span of the patient. (Figure 1)

Figure 1

OCCLUSAL DISEASE (OD) is a common dental disorder that is usually painless in its nature and involves the development of a traumatic or pathologic bite as a result of an erosive disease process. It (OD) is now considered the highest risk factor for and cause of tooth loss. If teeth have worn through the strong outer enamel layer to the soft core, the bite has become unstable, though you may not even be aware of it. The mouth gets its stability from the back teeth supporting the front teeth, and the front teeth protecting the back teeth, working together in unison from a relaxed jaw relationship. The wear through the enamel into the softer inner tooth creates an unstable stopping position for the teeth so that they are no longer able to function adequately. Lack of enough strong teeth with intact enamel or teeth that have drifted out of their proper position overloads the system as well. Quite often, this does not cause any pain but the effects on the teeth, gum, bone and mouth are very destructive as a whole. At one point, it was thought that it was normal for the teeth to wear out and shift over time. Wear that is confined to the outer layers of enamel and has occurred slowly over time can be, in some cases, considered normal. Wear through the strong outer enamel into the soft internal core, however, is considered pathologic, as it has advanced through the entire protective layers of the tooth. (Figure 2)

Figure 2

Unfortunately, pathologic wear and unstable bites have been routinely misdiagnosed and under-diagnosed by the dental profession. It is often the underlying cause of many problems that we see and, regretfully, is most often left untreated. As a result, a large volume of emergency-based, reactive single tooth general dentistry is performed. This self-perpetuating cycle continues as the work that is subsequently performed then prematurely fails because the underlying cause of destruction has not yet been addressed, once again resulting in overall frustration. Eventually, the front teeth often will break from the excessive forces placed on them. This lack of diagnosis and correction is a huge disservice to our patients because many of the problems that develop were and are preventable. Theories of this alarming increased prevalence of worn and displaced teeth include increased use of processed acidic food and/or drink, clenching and grinding, abrasive toothpaste and pathologic bites. Even though the initial cause is somewhat uncertain, the effect is truly becoming epidemic. (Figure 3)

Figure 3

Criticism of masticatory physicians usually comes from not truly understanding the philosophy. Just ask a masticatory physician who was once also in the dark about how to provide dentistry that doesn’t break down and can last through your lifetime with proper care. Consider a masticatory physician the upper level of competency and predictability in delivering dental care. But most importantly, they care so much about their responsibility to their patients’ care and health that they have often sacrificed greatly. These dentists have gone back to school to advanced dental education institutes to learn how to perform dentistry accurately and with predictability. Just like technology, medicine and all other industries that continually learn more to provide better products and service to enhance consumers quality of life, so has dentistry learned that there is more to dental care than decay, gum disease and making things look pretty. Most of the masticatory physicians themselves were tired of watching dentistry they had performed on patients fail. They did the best they could with what they learned in dental school and they cared for the patients well by trying hard not only to fix problems and make the solutions last but without creating other problems along the way. (Figure 4)

Figure 4

The Complete Exam starts far before the patient even enters the dental office - it is a process. The well-trained office:

1. Conducts a telephone interview learning about patient expectations of the dentist, past dental experiences and explains the individuality given to each patient and the practice philosophy and care that they provide.

2. Sends a welcome packet to learn about the patient so that they can prepare for the first visit by customizing their approach to the patient’s needs and concerns. It also allows the practice to share their philosophies and set the proper expectations for the experience and the type of practice that one is entering.

3. The day of the appointment, time is spent with the Doctor clarifying the information provided and learning in more detail about patient needs and health goals. A review of the medical history, dental history and any concerns about dental health and past dental experiences.

4. Together the Doctor and patient care assistant spend anywhere from 1 to 2 hours performing a thorough comprehensive diagnostic exam. Typically recommendations for treatment are not discussed at this exam. The exam is for information gathering to study the findings and work out a plan for getting the patient’s mouth maintainably healthy for the rest of their life. This initial exam is not a quick periodic check by the doctor in the hygiene column — it is an involved diagnostic process that involves the patient’s input and opinions.

The exam should include a diagnosis of the entire Masticatory System not just teeth or symptoms. The System includes the joints the muscle, the supporting structures and the effect they have on the health of the teeth. The working harmony of all of these parts defines health.

5. A discussion with the patient at the end of the exam to review initial findings and what needs to be done to determine recommendations to get you healthy. This could include:

Diagnostic Records

• X-Rays - Examining for decay, infections, lesions, bone height
• Models of your teeth – To study the jaw, muscle and teeth relationship
• Photographs – As important as radiographs. Used to study detailed relationships of the teeth, and help in esthetic diagnosis as well
• Panoramic X-Ray - To study further unseen problems (Figure 5)

Figure 6

6. A complete study and diagnostic work up by the Doctor analyzing all the information gathered at the exam and the records taken. Often a Doctor will completely work the case out on a before and after set of models determining a plan to achieve health and ensuring the long-term results instead of practicing and playing guesswork in the patient’s mouth.

7. The second appointment will be the time for the patient and Dentist to review the information he has prepared and determine the best plan of action to get healthy. These doctors want the patient to understand the problems and make sure they agree with the solutions. They welcome all the questions, concerns and want to understand the patient’s circumstances. Most of the time a comprehensive approach to dental health can be spread out over several years. It is the role of the Dentist to determine with the patient the areas that are in need of immediate attention and the areas that can be deferred or are elective. Not everything is necessarily urgent.

8. A dentists who will maximize any insurance benefits you may have but will not allow the insurance companies to have control over what is necessary to get you healthy. These dentist believe the decision should be between you and your dentists once you both have a clear understanding of what is necessary to get healthy and what insurance restrictions may prevent that.

9. A discussion with you about the time and cost involved in obtaining a healthy mouth. The treatment plan can only be successfully executed as a partnership, therefore your circumstances and budget will be taken into consideration as you and the Doctor plan for your health. Once you both are ready to move forward, a special arrangement of payment will be made for the time, care, skill, knowledge and judgement of the Doctor to make your investment predictable.

Important questions to ask patients:

Have you experienced:

1. Teeth that are sensitive to cold?
2. Teeth that have shifted in any way?
3. Teeth that feel chipped, jagged or rough?
4. Teeth that appear worn or are shorter than you remember?
5. That you have clicking or popping of your jaw joints?
6. That you suffer more often from headaches?
7. That you clench or grind your teeth?
8. That you have sore, tired jaw muscles?

Table 1 - The Complete Examination

• Patient Chief Concern/ Desires
• Medical/ Dental History
• Soft Tissue Exam/Oral Cancer Screening
• Periodontal Charting/Assessment
• TMJ Evaluation:
• Doppler Auscultation (5MHz Ultrasound)
• Joint Vibration Analysis (JVA)
• Piper Classification
• CR Load testing
• Muscle of Mastication Palpation Results
• Dental Exam Findings: Caries, Faulty Restorations, Abcesses, etc.
• Occlusal/Functional Findings
• Esthetic Assessment

Table 2 – Signs of Stability and Instability

Signs of Stability:

1. Even tooth contacts in CR
2. Anterior guidance that immediately discludes the posterior teeth in all mandibluar movements
3. Stable TMJs
4. Teeth that are in harmony with the neutral zone and envelope of function.
5. No pain/sensitivity

Signs of Instability: 

1. Excessive tooth wear into dentin
2. Unwanted tooth migration
3. Broken/fractured teeth
4. Excessive mobility
5. CR-MI discrepancy
6. Tooth hypersensitivity

Oral Cancer Exam
The areas of your cheeks, tongue and the floor of your mouth.

IDEAL: 

No Lesions, growths or discoloration. Dentists diagnose a large percentage of oral cancer annually allowing it to be caught early. Masticatory physicians have trained their hygienists to exam for oral cancer at each hygiene visit.

Diagnostic Measures

• Visual and physical inspection by the Doctor and Hygienist
• Tissue fluorescence with VelScope or

Joint Health Exam
The joint that positions your jaw in opening and closing.

IDEAL: 

The joint position in its socket with the disc, fluids and ligaments all in proper form. Health defined by no popping, clicking, grating noise, pain to the touch or pressure of joint loading or deviation in opening and closing.

Diagnostic Measurements

• Screening History of Joint Health
• Blood Flow Evaluation
• Ear Symptom History
• Ligament Health
• Disk Health
• Jaw Range of Motion Exam
• Noise Detection Exam

Muscle Health Exam
The Muscles that open and close your jaw

IDEAL:

All muscles working in harmony by turning on and shutting off at the proper time and place while the putting the joint in the proper position and contacting the teeth all at the same time with equal force and intensity.

• Muscle Health defined by no pain or tenderness to the touch of the muscles.
• Diagnostic Measurements
• Physical touch or palpation of Head Muscles
• Touch of Neck Muscles
• Open and Closing Patterns
• Touch of Facial Muscles
• Touch of Cheek Muscles

Biting System Health Exam
The relationship of your teeth to the current joint and muscle position.

IDEAL:

For proper muscle and jaw position, when chewing food your teeth should all contact at the same time with equally intensity. Your back teeth should separate and your front teeth should contact guiding your lower jaw in left to right and front to back motions. This ideal relationship of your jaw, muscles and teeth are critical in the distribution of the 600 pounds of force from the muscles when chewing and talking.

Note: There are cases where the ideal described is not achieved and a patient may have adapted to the position of jaw, muscles and teeth relationship. The concerns then becomes is the adaptation destructive to the teeth and the joints.

Diagnostic Measurements

• Upper and Lower Jaw Relationship
• Equal Force Tooth Contact Exam – Points of contact defined
• Chewing and Talking Movements Tooth Contact
• Chewing and Talking form with tongue, cheek, and lips
• Unconscious Habit Movement Exam (i.e. bruxing, clenching, grinding)

Gum, Bone and Root Health
The supporting structures that hold your teeth in place.

IDEAL:

The attachment of your gums to your teeth should be tight enough to clean between that space with a toothbrush and the bone around the tooth should be at a height that keeps the teeth tight in their place. Otherwise bacteria can live and cause infections, eat away at bone then loosening teeth. The roots should be attached to the teeth. Health defined as a 3 millimeter space between tooth and gum, no bleeding, no puss, gums pink in color, no root or bone exposed, roots attached to teeth.

Diagnostic Measurements

• Measurement of Gum attachment to teeth
• Recording of bleeding points
• Root Height Exam
• Gum Levels to teeth
• Bone Support – X-rays

Teeth Health Exam
The signs and symptoms of the conditions of the joints, muscle, biting contacts, gums, root and bone are viewed on the teeth. These symptoms can be painful or non-painful depending on the damage. Much like Diabetes, High blood pressure or Clotted arteries.

• Tooth By Tooth Health
• Looseness
• Cracks
• Fractures
• Shifting of teeth
• Missing Teeth
• Erupting Teeth
• Strength of teeth and existing dentistry performed
• Worn teeth
• Contour/Shape
• Seals of existing restorations
• Color
• Notches in enamel at gumline

 Conclusion

There is a pot of gold at the end of the rainbow… a complete exam leads to a complete diagnosis, which does translate to profitability for the practice, and the most ethical care that the patient can receive… Without doing the exam, you cannot make the diagnosis, so you won’t be able to present or produce the treatment.

by Kirk Barendt from ACT Dental

Building and maintaining a dental practice is a major accomplishment for any dental professional. Growth is an important part of our mission, but without healthy growth we all can be burned out. So many practices just run through the motions of the day. Most complaints we hear from team members are they always running over, we are never on time, no time for lunch and most important no time for family where dentistry is where our life starts and stops.

#1. You can’t do anything without a great team.

If you don’t have this, stop here and complete #1 before going onto #2. Invest time and money into improving yourself as an attractive leader so that you can attract quality team members. I have a mentor who says, “In order to attract attractive people, you must first become attractive.” We live in a very savvy marketplace now. We are also engaged in the “Great War for Talent.” The most talented auxiliaries in dentistry are not dumb; they know their value in the marketplace and have little tolerance for wasting time in the wrong practice. Perspective talented team members are often doing more homework on you than you are on them.  It is no accident if you haven’t been able to sustain a great team. Change this before moving onto #2.

#2. Fill out this form CLICK HERE.

Do this as a gift to yourself. Ask yourself the question, “If I were able to make the vision for my life come true, what would a typical week of it LOOK LIKE?” Don’t tell me about your vision. Show it to me. That is often the problem. We are doing way too much talking, explaining, and writing and not enough listening and showing. Have your team members complete the same exercise.

#3. Have a team meeting about the exercise you just completed.

Ask yourself and your team how important it is to your life to make these things happen. Examine why you haven’t done these things in the past. Chances are, you will only come up with one answer…. FEAR. My good friend and mentor, Dr. Greg Tarantola, says that, “Dentists are famous for hallucinating when it comes to fears in their practices!” Ask the question, “Is it truly a legitimate limitation of our practice not to make our vision happen, or are we hallucinating about our perspective?” If you have too many limitations, take a bunch of courses or change your limitations or work with a coach to change your perspective before moving onto #4. Remember, your perspective determines your reality.

#4. Post this completed VISUAL VERSION OF YOUR VISION in the break room of your practice.

Make it the fulcrum for all of the decisions you make as a practice.

#5. Start training your patients and team to fit into this vision.

The greatest implementers I have ever worked with in dentistry have all designed their lives and then lived into them. Dr. Frank Spear quotes Dr. Phil by saying, “We teach people how to treat us.” I believe this to be absolutely true. Make sure you are first creating enough value for the people you serve, and then make sure they are behaving properly in the practice. Systems influence behavior. Teach them how to treat you. Tell them what time to come in for appointments. Tell them how things work in your practice. Tell them what to expect financially and how everyone pays for their dentistry. Make sure that you are not trying to fit into their schedule; fit them into your schedule. Don’t say things like “When is a good time for you?” Instead, say things like, “The best time to do this particular procedure is at 8 am next Tuesday.” Your patients and your team are dying for you to lead them in the right direction once the trust has been established. If you don’t lead them to behave properly in your practice, patients and team members will drag you into a black hole and leave you there.

#6. Engage in the disciplines that will make this happen.

If you need to, get a mentor or coach to hold you accountable to making sure you take little steps in the right direction each day. You don’t have to do everything right away, but make a firm commitment to change your practice and your life over the next year or two. It is all a matter of discipline. Those who get this make their vision a reality. Those who don’t only wonder about what should have been and deal with the pain that comes with that.

Smile Reminder is a patient engagement software service designed to maintain and retain existing patients while identifying and acquiring new patients. Utilizing the latest automated text/email messaging technologies and social media tools, Smile Reminder helps you to increase productivity and grow your practice, while you focus on your patients. Read more

How many times do you go home from work and you have a story about your day that isn’t so up beat? It could be anything from a great case that went in your operatory and the doctor failed to compliment you on it, a team member not working as much as you did today or even a case that you presented and treatment was accepted. Does this sound like something that you have experienced?

One simple system implementation can change the way that you walk out of work, the way that your day is done. ‘The Afternoon Meeting” is a structured format that takes about 15-20 minutes and allows the day to be celebrated, numbers and goals to be discussed, treatment that was closed to be brought to everyone’s attention and even the failures of the day to be addressed.

Read more

The Pursuit of Excellence

“People who have accomplished work worthwhile have had a very high sense of the way to do things. They have not been content with mediocrity. They have not confined themselves to the beaten tracks; they have never been satisfied to do things just as others do them, but always a little better. They always pushed things that came to their hands a little higher up, this little further on, that counts in the quality of life’s work. It is constant effort to be first-class in everything one attempts that conquers the heights of excellence.” ~Orison Swett Marden~

How do you avoid mediocrity in your staff and practice when it seems that everywhere we look, mediocrity is the accepted norm? Good enough is the new standard, set by those who don’t want to stretch themselves. In general, in a group, people will often sink to the lowest common denominator to keep the peace. That makes it imperative that you make certain that your lowest performer is well above average, or you will find your staff infested with so-so-itis. Read more

Crown #1 The    cusps of tooth#      was undermined and weakened and had to be supported with full crown preparation. (per Fundamentals of Fixed Prosthodontics. Quientessence, 1978, Operative Dentistry.)

Crown#2 The full crown restores the fractured     cusp of tooth#      .

(per Fundamentals of Fixed Prosthodontics. Quintessence, 1978, Operative Dentistry.)

Crown#3 Due to the evidence of fractures exsisting in the     cusp of  tooth #        ,

It was nessary for a cusp supporting crown preparation. ( per Fundamentals of Fixed prosthodontics. Quintessence, 1978, Operative Dentistry.)

Crown#4 The     year old amalgam on tooth      has ditched, decayed, percolated, open cavo-surface margins. Crown needed to support extra-wide outline form beyond limits of amalgam or inlay.( per Fundamentals of Fixed Prosthodontics. Quintessence, 1978, Operative Dentistry.)

Crown#5 Tooth #       has had recent endodontic thereapy. The tooth was restored to optimum function with a full crown.(per Fundamentals of Fixed Prosthodontics. Quintessence, 1978, Operative Dentistry.)

Inlay/onlay#1 An Onlay/inlay was necessary since more than 50% of the incline of the     cusp was involved. ( per Fundamentals of Fixed Prosthodontics. Quintessence, 1978, operative Dentisry.)

Inlay/onlay#2 Wide marginal ridge outline form beyond isthmus includes 50% of cuspal plain of tooth #      .( per fundamentals of Fixed Proshodontics.Quintessence,1978, Operative Dentistry.)

Onlay#3 The     cusp of tooth #    was undermind and weakened and had to be supported by an onlay preparation. (per Fundametals of Fixed Prosthdodontics. Quintessence, 1978.)

Inlay/onlay#4 The inlay/onlay resotres the fractured     cusp of tooth #     . (per fundamentals of Fixed Prosthodontics. Quintessence,1978 Operative Dentistry.)

Inlay/ onlay#5 Due to the evidence of Fractures existing in the     cusp of tooth#    it was necessary for a cusp supporting onlay/inlay preparation.(per fundamentals of Fixed Prosthodontics, Quintessence,1978, Operative Dentistry.)

Onlay #6 The     year old amalgam on tooth    has ditched, decayed, percolated, open cavo-surface margins. Onlay needed to support extra-wide outline form beyond limits of amalgam or inlay. (per fundamentals of Fixed Prosthodontics. Quintessence, 1978, Operative Dentistry.)

Thank you for choosing John C. Cranham, DDS . Our primary mission is to deliver the best and most comprehensive dental care available. An important part of the mission is making the cost of optimal care as easy and manageable for our patients as possible by offering several payment options.

Payment Options:

You can choose from:

-   Cash or Check 5% Discount

-   Visa, Mastercard, American Express

Please note:

________________, DDS requires payment prior to the beginning of your treatment. If you choose to discontinue care before treatment is complete, you will receive a refund less the cost of care received.

For patients with dental insurance we are happy to work with your carrier to maximize your benefit and provide you with the documentation you need to receive reimbursement for your treatment.

A fee of $50 is charged for patients who miss or cancel more than 2 times in a calendar year without 24-hour notice.

John C. Cranham, DDS charges $50 for returned checks.

If you have any questions, please do not hesitate to ask. We are here to help you get the dentistry you want or need.

Patient, Parent or Guardian Signature

_________________________________________

Date

________________________

“DRAFT”

I HEREBY give _______________________the absolute right and permission to use my photographs/slides for educational or promotional purposes.  The undersigned completely and forever releases any right to present or future compensation in connection with the use of said photographs/slides.

Signature___________________________________  Date_______________________

CONSENT FOR TREATMENT

1. I hearby authorize doctor or designated staff to take x-rays, study models, photographs, and other diagnostic aids deemed appropriate by doctor to make a thorough diagnosis of (name of patient) ______________________’ s dental needs.
2. Upon such diagnosis, I authorize doctor to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care.
3. I agree to the use of anesthetics, sedatives and other medication as necessary.  I fully understand that using anesthetic agents embodies certain risks.  I understand that I can ask for a complete recital of any possible complications.
4. I agree to be responsible for payment of all services rendered on my behalf or my dependents.  I understand that payment is due at the time of service unless other arrangements have been made.   In the event payments are not received by agreed upon dates, I understand that a 1 ½% late charge (18% APR) may be added to my account.  If required, I also understand a check of my credit history may be made.

Patient’s signature ________________________________ Date _________________

Witness ________________________________________ Date __________________

Parent/Responsible Party’s Signature ________________________________________

Relationship to Patient ____________________________________________________

• lab prescription
• master impression upper
• master impression lower
• Impresson of upper approved provisional restoration
• Impression of lower approved provisional restoration
• occlusal registration
• opposing model or impression of opposing arch
• facebow transfer record
• mount with mounted lower preop
• mount with mounted upper preop
• photo of shade tab (printied
• Photo of adjacent tooth (printed)
• stump shade
• impressions or models of the provisionals
• full series preop
• provisional photographs
• Photo of Preps
• All photos saved to disc or jump drive

Bridges:

Replacement: “Replacing old bridge due to deficient margins & 2 degree caries on tooth #’s __ & ___. Initial placement was ___ years ago.”

Initial Placement: “Partial is to replace missing teeth. These are tooth #’s …..”

Broken Tooth: “Patient broke #___ to the gum line. # ___ was extracted and a 3-unit bridge was placed to restore quadrant to optimum function.”

Veneers:

Replacement: “Veneers 6-10 were decayed at the margins and were replaced for restorative reasons.”

Scaling & Root Planing:

“PT has generalized subgingival deposits of plaque & calculus. PT has moderate/heavy bleeding in ___ quadrants.”

Broken Tooth:

Tooth #____   broke to the gum line. It was extracted and a 3 unit bridge was done to restore the quadrant to optimum function.

Endodontic Therapy:

“Tooth #___  developed an abscess. Endodontic therapy was done to restore tooth to optimum function.”

“Filling on #___ came out. Decay spread to nerve. Endodontic therapy was done to restore tooth to optimum function.”

“Patient had extensive caries to the nerve. Endodontic therapy and build-up were done to restore tooth to optimum function.”

* Code for implant abutment D6064