Starfish and Ripples - Musings from Guatemala dental mission trip

Recently, my wife, Dr. Gina Kessler and 15 other colleagues from Dentistry Making a Difference went to Guatemala for a dental mission trip.  We have always wanted to do something along these lines.  The opportunity presented itself so we decided to go for it.  Here are some of my musings. 

March 7, 2018 - I am in San Pedro, Guatemala on a dental mission trip with my wife, staff and several colleagues.  We are seeing people who are in extreme poverty with huge dental needs.  My comfort zone is being stretched in huge ways as I am not in my "cushy urban" office anymore.  We are in a 5 chair clinic that opened recently through the Spear “Open Wide Foundation”. 

One patient I will never forget.  Her name is Araceli. She is a beautiful 5 year old girl, dressed in a pink jacket and a traditional style dress. I haven’t treated a child this age since dental school.  I don’t know who is more nervous - her or me.

Araceli (5 y.o) looking into the clinic

In the morning, she had been outside watching us do our work from a window outside the clinic.  Her turn was in the afternoon.  She came in terrified and reserved - probably frozen by fear.  I had a translator help with the communication. I looked in her mouth and my heart sank. She had dental needs in every tooth due to rampant decay. I consulted with the staff dentist at the clinic hoping that she would say refer her to a pediatric dentist - this kid needs to go to the OR for her treatment.  There were none to be seen. The staff dentist and I consulted, it was decided to take out her five front teeth (c-g).  This was just scratching the surface of her dental needs.   

I gave her injections and pulled her teeth.  

She screamed, I cried. I fought through my own emotions and got to work as quickly as I could.  She screamed some more, I cried some more. 

When it was over she calmed down and gave me a hug, thanked me for helping her. I am not really sure if I helped her.  She is a kid that, if she was in the states, she would be brought to the operating room for her treatment. My mind was racing with questions probing the unknown.   Did I really help her?  Did I traumatize her?  How will she get the help she needs?  How will her dentition turn out?  How will her psyche be affected?  I took out 5 infected front teeth. Will her adult smile reflect the beauty of this girl as she grows into adulthood.  If her teeth are this infected, how is her overall health?

Gina, Araceli and me after her treatment.

There is so much dental disease here. There are not enough dentists in the world to fix all the decay here.  How can I possibly be making a difference?

Starfish story link - 

https://www.youtube.com/watch?v=Z-aVMdJ3Aok

I have come to the conclusion that I made a difference for Araceli. I may not have been able to address all the needs in this town.  But I made a difference for her.  Our team of 5 dentists and 12 assistants/hygienists made a difference for the 100 or so patients that were seen in our clinic these past 5 days.  

Hopefully she will start to brush, floss and change her diet. I am not sure if there is clean water where she lives.  She probably doesn’t even have running water let alone indoor plumbing in in her house.  I tried to explain Araceli’s dire need for more dental work to a lady that said she was her grandmother. (She also said she was the grandmother to the several other kids that were there that day).  I am not sure if she understood - I didn’t speak Spanish, she didn’t speak English.  My recommendations were translated to her, but was it heard? 

Guatemala has what is considered extreme poverty.  The average income for a family is $300/month.  Over 25% of the population is considered illiterate.  School is mandated for 6 years, but the average is a little over 4.  There just aren’t resources for them - especially in the rural areas.  

I know that there are similar situations happening in our communities back in the states as well.  I feel that for most though, they have a chance. There is infrastructure to provide opportunities to get help.  I also know there is not enough.  

The dental future for Araceli and her family may have changed trajectory based on this experience.  I hope so. I also hope that her experience in our clinic will ripple out in ways that she will be able to contribute to the world in her own unique way. Who knows, she may become a staff dentist at a similar clinic in her community.  

We never know who we impact or how we affect someone - be it our patients, friends, colleagues, acquaintances, etc.   It could be that we get someone out of pain, fix their smile, remove infection.  It may be that a conversation that we have with our patients every single day finally sticks with someone.   We never know when someone hears something that catalyzes a much needed change in their life.  All we can do is keep doing the best we can - sharing our unique skillset to those in need.  I have had many patients come back for their six month cleaning and check up and tell me how our conversations changed the trajectory of their lives.  I feel that a smile is a window to the soul and we do everything we can to help our patient’s soul shine through. A smile can change a person’s life.  

I have come to the conclusion that we made a difference today for Araceli.  We barely scratched the surface, but we made a difference for her.  

I hope that the difference we made for her (and our patients back at home) ripples out into the world to create more positive difference.  

Starfish and ripples. 

BK

Do you take my dental insurance? Nope and Here is Why!

Lately, I have been thinking a lot about the dental insurance industry and the public's expectations of it.  I am not a participating provider in any plans. 

Why, you ask?  Please read on.  

The definition of insurance: a practice or arrangement by which a company or government agency provides a guarantee of compensation for specified loss, damage, illness, or death in return for payment of a premium.

The key phrase with this definition is: "guarantee of compensation".  

Some examples:

If my home burns down, gets damaged by hail, or ruined by a flood, I expect that my homeowner's insurance will compensate me to rebuild my house and help to replace my belongings. Of course, after I pay my deductible.  I don't expect my homeowner's insurance to pay for my replacing air filters for the heater. I don't expect them to pay for caulking of my shower on a regular basis. I don't expect them to pay for the blowing out of my sprinklers or cleaning my air-ducts. 

If I get into a car accident, I expect that my auto insurance will compensate me to fix or replace my car and help with any injuries as a result of the accident. Again, after I pay my deductible.  I don't expect them to pay for my oil changes, my brakes, rotating of my tires or other preventative measures that I would take on a regular basis to keep the car running smoothly and safely. 

If I get sick, I expect my health insurance to cover for my medical bills after my deductible is met. I trust that my physician knows what is best specifically for the treatment of my medical problem and recommends things in my best interest.  I don't expect my plan to pay for my health club membership, healthy organic eating choices, vitamins or anything that would help me be more healthy proactively.  

Now let's look at dental insurance -

A typical dental insurance plan will pay a certain amount per year for your dental treatment in the range of $1,000-$2,500.  They pay a percentage of the procedures done and fix costs that your dentist can charge for these procedures.  In some states, they control the prices for procedures that they do not cover, but that is another story for another time. There may be a deductible to pay as well as the monthly premiums.  

Let's base these scenarios on the dental insurance model - 

If my home burns down, my insurance pays me $1,500 and I am responsible for paying everything else to rebuild my home, I am responsible for replacing my possessions lost in the fire.  There may or may not be a deductible. They may ask for a pre-estimate of the worth of my home and possessions but that but burned up in the fire and delay the payment accordingly.  Even though the maximum amount they will pay is $1,500.  Oh by the way, your deductible is $1,000... They don't care that you have been doing regular maintenance around the home on a regular basis.  They will question the use of certain pressure fire hoses to put out the fire saying that a garden hose would have been sufficient. Or they may have down-coded the use of a fire truck to a typical water pail passing line that was used in the 1,800's.   

If I get into a car accident, my insurance pays me $1,500 according to my plan, and I am responsible for the remainder of the damage, paying for any injuries, etc. Typically there is a deductible of $2  50-$1,000. I find out that they only pay for 50% to replace my tires.  They won't tell me 50% of what however.  I choose the same tires that I had on the car and they proceed to say that I was overcharged at the tire store that they recommended I go to.   I find myself questioning what benefit I am getting here as I add up my monthly premiums and the payout in my head...."Is this really worth the hassle?"

If I get sick and in the hospital, my insurance pays me my $1,500 while I am responsible for any blood work, x-rays, MRI's, surgeries, medications, ongoing therapies, etc....deductible? As an aside, I ask my physician how much each of these tests she is recommending are going to cost.  Blank stare...After an uncomfortable 60 seconds of silence I burst out, "Doc, I need to know how much this is going to cost me!"  She replies, "I don't know, I can have my office manager check what your benefits are and get back to you tomorrow"  

In any of these alternate scenarios, my financial responsibility would be catastrophic. 

Dental insurance is a misnomer.

It is not insurance.  It is a pre-paid benefit plan. It is in fact the opposite of insurance.  It covers the deductible and you cover the rest.

I think dental insurance is great for basic dentistry - cleanings, check-ups, x-rays, a filling here or there, etc.  If things get complicated with your treatment, your benefits will cover only what they cover based on the plan and nothing more.

What the benefit company isn't telling you - "We are great for basic dental care but don't expect us to be like homeowner's, auto or medical insurance.  Those insurance models cover you to prevent catastrophic loss.  We don't...Please set your expectations accordingly."

I choose to have a relationship based practice.  I take the time to get to know my patients and help them to discover and achieve their oral health goals.  Together my patients and I look at all the options with the pro's and con's of each.  Most of my patients have dental benefits and we do everything to help maximize those benefits for our patients.

As a result, I choose not to participate with these benefit plans.  I wish to have a relationship primarily with my patients.  A relationship that is not tethered by the restraints put on by an insurance company that has never met their subscribers. You are a number to them, a potential for them to pay out against their profits.  I view the relationship that I have with my patients as the most important aspect of my practice. I will only recommend treatment that is in my patient's best interest in achieving their goals for their teeth and smile.

By the way, if you don't have dental insurance, basic dentistry is fairly affordable and the cost of prevention is much cheaper than the cost of complicated dentistry caused by missing regular dental checkups!

If you like this blog post, I would love to hear about it.  Please comment or share it on Google+, Facebook, Linked in, Twitter, etc.  If you are looking for a dentist in the Denver area, we are always looking for new patients.  Please visit our website http://www.tcdodenver.com/ or like our facebook page,  https://www.facebook.com/TCDOdenver.  Or you can contact us  the old fashion way - call us at 303-321-4445.

Thanks for reading!  BK

Is Dentistry a Commodity?

From 1991 - 1995, I went to dental school to learn my craft.  I found out that early on, that the scientific based classes came very easy for me as I was a biomedical engineer prior to dental school.  What didn't come so easy, was the artistic training that was required to be a dentist.  We had to learn how to create teeth out of wax, plastic, amalgam, composite, gold, porcelain, etc.

Looking back to grade school, I was the kid that got sent to the principle's office from art class for being disruptive.  I would do anything to not do art.  I was quickly slapped with reality when I struggled in these early training exercises in dental school.  I had no artistic skills!

I struggled so much that I was required to go to what I call "wax camp" during the summer after the first year of dental school. (Does the movie"The Breakfast Club" comes to mind?)

The other "campers" and I huddled around bunsen burners flames and honed our skills with one-on-one instruction from some very talented instructors.  One day, I don't know when or why, the switch flipped and my right brain connected with my left brain and I was able to wax up teeth at a proficiently high level.  As time went on, I became better and better at it.   In fact, I taught this very same class at University of Colorado School of Dental Medicine for 7 years.

So back to the question, is dentistry a commodity?

Dentistry is an imperfect blend of art and science.  It is not mass produced on a conveyer belt in a factory.  It is provided uniquely and personally to our patients.

A mentor and master of dentistry, L.D. Pankey once said, "I've never had a tooth walk into my office. It was always attached to someone.  Get to know that person, and I may get the opportunity to treat that person's teeth."  Words which I live by in my practice philosophy.  We treat people holistically - mind, body, spirit. You are not a set of teeth, you are a "whole" person.

So is dentistry a commodity?

Can a person go to a dentist and say that he needs a size 12 upper molar and the dentist picks one off the shelf and glues it in?  NO

Can a person go to a shoe store and ask the salesman to fit him in a size 12 shoe? YES

Can that person buy a size 12 shoe for $30, and a size 12 shoe for $300?  YES

Is that shoe store being chastised by community organizations for "gouging" its clients?  NO 

Why then do dentists get chastised by insurance companies for charging a fair price for their services provided uniquely to an individual?  Usually people (insurance agents) placing unfair judgements on things they have no experience with.

If a dentist charges more for a service than a patient values, the patient will not buy that service. Simple economics - supply and demand.

If a person sees a value in either price point for the shoe, he/she will buy that shoe.

The same thing goes in dentistry.  There are different levels of service and challenges in treating patients.  A more difficult procedure may cost more as the dentist to takes more time, care, judgement and skill to perform that procedure to the level of care that the patient expects.

And any patient has the right to put value on things important to them.

Most third party entities (insurance companies, government agencies, etc.) have been masterful at creating a "dentistry is a commodity" mindset to the consumers.

I am emphatically saying that it is not a commodity.  Dentistry is a blend of art and science executed with proper judgement and skill that only comes from our highly specialized training and experience.

There may come a day that one can choose a size 12 upper molar off the shelf -

Then again, there may not...

All this could be a moot point as clean teeth do not decay - AND - 95% of dental problems are preventable!

If you like this blog post, I would love to hear about it.  Please comment or share it on Google+, Facebook, Linked in, Twitter, etc.  If you are looking for a dentist in the Denver area, we are always looking for new patients.  Please visit our website http://www.tcdodenver.com/ or like our facebook page,  https://www.facebook.com/TCDOdenver.  Or you can contact us  the old fashion way - call us at 303-321-4445.

Thanks for reading!  BK

Who is John Galt? - Disruptors in Dentisty

Disruptors are innovators.  They are businesses that shift a mindset of how consumers think, purchase, etc.  thereby challenging established businesses.

Harvard Business School professor and disruption guru Clayton Christensen says that a disruptor displaces an existing market, industry, or technology and produces something new and more efficient and worthwhile. It is both destructive and creative.

Some examples of disruptors are companies like Apple, Netflix, Amazon, and Uber

I identify Apple - not for the computers that it builds, but another niche that it took over – music and listening device sales.  iPods, iPhones and iTunes has changed how we buy and listen to music.  There are hardly any CD stores anymore other than those that sell used ones.  When I grew up, I would buy records.  The cover art would attract me to give new bands a listen.  I judged the band by entire albums that it recorded.  Today, we buy songs, not albums. They are instantly downloaded onto our computers.  No waiting in lines, no browsing through tedious shelves of records/cd’s.

 We create playlists with the drag of the mouse.  We use auto shuffle and the “genius” feature to create our own personal radio stations.  They connect to our cars, our phones, our tablets and all are stored on our computers.  CD players are becoming a thing of the past.  Music is stored on hard drives, jump drives, iPods, etc;

Netflix took how we rent movies to a new level.  For a low monthly fee we can have unlimited movies shipped to our house  - hassle free; or immediately available to  view on our computer or smart TV’s through an internet connection.  Blockbuster used to charge late fees, “you didn’t rewind the VHS” fees, etc.  I dreaded having to to pay this fine.  The buying experience was a hassle and expensive.  Netflix is easy, customized to my preferences and instant. Are there even any Blockbuster stores left?

Amazon capitalized on the fact that a book is still readable after it had been read, music is still listenable after it had been listened to, and anything should be able to be purchased on the internet easily!  They created a personalized buying experience based on your browsing and buying habits.  It greatly affected the big chain bookstores like Border’s or Barnes&Noble.  It also helps you find the lowest price for a boxed item and they deliver it right to your door.  If it wasn’t exactly what you were looking for, ship it back.  Hassle-free!

Lastly  -Uber is putting a huge dent in the taxi business.  With Uber, you can press a button on your phone app and a nice clean car will be at your location within 15 minutes. Yellow Cab gets to you when it gets to you and the entire cab experience pretty much stinks!

All of these disruptors have innovated, streamlined and penetrated market share, challenged, and even ruined wildly successful businesses while reinventing the delivery of these services.  They have changed the consumer’s mindset and changed the paradigm on how these services should be purchased, used and consumed.  The consumer experience is exactly the way the consumer prefers.  We (the consumers) wouldn’t have it any other way.

Another commonality of these disruptors is that they didn’t just enter the marketplace and were welcomed with opened arms.  The status quo or “established” business model was not happy and tried to stop them. 

In reality, the status quo was asleep at the wheel.  They were lazy, and arrogant.   They felt they were too big to fail. Those established business models that survived disruption evolved their business models to better serve their consumers.

The question “Who is John Galt?” comes to mind from Ayn Rand’s book Atlas Shrugged! John Galt represents creativeness and innovation.  The status quo must constantly channel it's inner John Galt if it wishes to remain relevant to the people it serves.

There are disruptors popping up in every niche and dentistry is definitely not immune.  They are here and they are aggressively working to innovate and change the status quo. 

Disruptor #1 - Large Group Practices are delivering dental services cheaper, quicker and more efficient than the typical private practice.  They are aggressively growing around the country.  They are aggressively hiring up new dentists.  They are aggressively advertising their services.  They have created a niche for themselves and continue to attract patients.  They haven’t perfected the consistent customer experience yet, but at some point that they will figure it out. 

There are some really lousy dentists that practice in this setting.  There are also really good dentists in this arena too.  To be fair - There are also some really lousy dentists in private practice settings.   There are also some really good dentists in this arena too.

The unfortunate reality with the large group practices is that they are being judged by the lowest common denominator.  For every bad patient experience, the entire organization’s reputation takes a hit. If these companies are going to take their disruption to the next level, they need to shore up some of the bad players in their organizations.  They need to do this from within.

A dental organization in the Pacific Northwest is self-regulating through a peer review process similar to the one used in organized dentistry.  I commend them for taking the initiative to self-regulate and get rid of the bad apples from their branches.   

Disruptor #2 – Dental Insurance has been a driving factor in changing consumer perception with respect to the dentist.  There is a mindset that if one doesn’t have insurance they can’t go to the dentist. 

Dentistry is equal parts art and science.  The product that we deliver is a unique service and experience every single time.  The dental insurance industry has been really good at “commoditizing” these services. They view all fillings, crowns, and other procedures as commodities.  They don't take into account level of the level of difficulty it took to achieve a positive result.  Dentists must impart the value of their services to their patients and that dental insurance is a nice benefit but it the cure all to their dental health.

On the flip side - Dental insurance does help with the basic preventative services - cleanings, check ups, xrays etc.  And many people go to the dentist because of the benefits that they receive.  

Disruptor #3 – New Technology is continually changing how we practice.  Film based x-rays are as antique as the horseless carriage.  CAD/CAM, digital impressions, articulations, etc are going to make dentistry more efficient and even more predictable.

Disruptor #4 – This past year, Metropolitan Denver Dental Society (MDDS) built the first and only dental learning center operated and run by and component of organized dentistry.  The new facility has 4 fully operating dental operatories that are being used for hands on learning opportunities.  They have functioning lab benches, auditorium and video streaming from the operatories into the various remote video-viewing stations.

The Metropolitan Denver Dental Society is dedicated to supporting its members, promoting the highest ethical practice of dentistry; providing continuing professional education, including a premier annual dental convention; and oral health education to the public.  This learning center, The Mountain West Dental Institute, will help them fulfill their mission.  Many dental associations around the country are very interested to see how this works.  Some people say they took a big risk....that is what disruptors do.

The Colorado Dental Association recently hosted a presentation in which approximately 100 dentists showed up in person and an equal number viewed the presentation remotely via live streaming technology.  This new use of technology will allow dentists from around the state/country meet, learn, network and communicate.

America is the land of opportunity.  Anything is possible with creativity, hard work, perseverance and a little bit of luck.  Every business must constantly raise the bar if it is to remain relevant and vital.  The business models must evolve to stave off the disruptors and to keep the consumers interested in their product or service.

Evolution is the survival of the fittest.  Those that can adapt and create change will evolve into the new paradigm and address the needs and desires of its consumers.

The status quo does not exist indefinitely.  It will constantly be challenged. 

“Who is John Galt?”

Disclaimer –I am not passing judgment on these disruptors.  I am just sharing my observation and thoughts.  I may or may not subscribe philosophically with various paradigm shifts.  Each serves a niche that is attractive to various people.  That is why they are growing/gaining the market share and shifting the perceptions of the consumers.

If you like this blog post, I would love to hear about it.  Please comment or share it on Google+, Facebook, Linked in, Twitter, etc.  If you are looking for a dentist in the Denver area, we are always looking for new patients.  Please visit our website http://www.tcdodenver.com/ or like our facebook page,  https://www.facebook.com/TCDOdenver.  Or you can do it the old fashion way - call us at 303-321-4445.

Thanks for reading!  BK

Obamacare - How will it affect dentistry?

I was recently asked by a friend how do I think that the Affordable Care Act (ACA or Obamacare) will affect dentistry.  This took some thinking on my part.

I have spent the past 5 years going to Washington DC to discuss dental care with our legislators. When the ACA was being discussed prior to becoming law, we did everything we could to get a seat at the discussion table to very little avail.

The year after the ACA was passed in Washington, we had a political pundit,  Dr. Frank Luntz ask us the question, "Are you happy with the results?"

No one could really answer because no one really knew or understood what was being thrust upon us as dental practitioners.

Frank's dad was a dentist.  As a child growing up, he recalled the animated stories his father would share about his patients. He was truly a caring practitioner. He loved the practice of dentistry, but he loved the relationship that he had with his patients even more.  Improving the health of the patients that he cherished is what he looked forward to every day that he practiced.  This is what I look forward to every day that I practice too.

Tragically, I see this style of practice on the decline.

From his personal experience, he went on to say that dentistry, as a profession, should be thrilled that it was basically left out of the ACA.  He reminded us that -

Dentistry is the last free market health care system that is working in this country.  

The reason - We keep the doctor patient relationship sacred. For more elaboration see my blog from July, 2011 The Sacred Cow.

In all aspects of health care there is trending consolidation of providers.  This means that private practices are joining up with hospitals or large groups called medical service organizations (MSO's). Included in these MSO's, hospitals are joining up with other hospitals and insurance companies to improve efficiency and improve access to information and resources.

As with any new paradigm, there will be some confusion from both sides of the fence as this takes affect.  All-in-all it should improve health care delivery as long as the doctor patient relationship is kept in the forefront. I hope that doctors are allowed to treat patients like they know best as opposed to management making decisions based on financial impact.

I expect many people to be upset at the changes from what they are used to with how they received health care in the past.  I also expect many people to be thrilled with the heath care that they are now eligible to receive.  The old adage comes to mind - "You can't please everyone, all the time".

There are many (including me) who are upset how the bill was passed and what was promised to the citizens.  I don't think that the legislators knew or could predict the extent of the problem at hand.  Therefore, they couldn't predictably fix the problem with the ACA bill.  What our legislators on both sides of the aisle knew was that our health care system needed to change.

The ACA is a start to solving the problems, it will evolve over time but it will never solve everyone's problems, expectations or needs.  We must accept this fact.  It will cost more and provide less than what we are used to.  We must accept this fact too.

I personally trust my physician to recommend the finest care to me.  Whatever he needs to do to evaluate my health, I expect him to recommend.  This should be in a "patient bill of rights".  I am cautiously optimistic that this style of practice will continue.

The insurance industry is the real winner in the ACA as they will have 48 million more people in the system that are now mandated to pay their premiums.  As a small business owner, I have seen my own health insurance premiums rise significantly over the last several years.  I predict that they will continue to rise as the ACA is implemented.

My predictions on how the ACA will affect the dental profession -

  Please note that these are my views and my views only.

In dentistry, we are seeing consolidation in a different form - through explosive growth in corporate dental service organizations (DSO's).  They seem to be sprouting up everywhere.  They provide a niche for people who are looking for low cost dentistry. This could be either good or bad depending on the perspective of the experience.  This practice model has been around for decades. They are a safety net -providing basic dental services (cleanings, fillings, crowns, dentures, partials, etc.)

I am hearing that these corporate dental organizations are recruiting heavily at the dental schools to attract new dentists to work for them.  Many new dentists are taking jobs with these firms as it is very difficult for them to find jobs elsewhere that satisfy their needs - such as make a decent living and paying off their student loans (average $250,000).

There will also be a rise in Federally Qualified Health Care facilities (FQHC's).  This is also a safety net capturing those patients that are lower income and have medicaid as a primary coverage.  These offices also provide basic dentistry similar to the DSO's.

Dental insurance - There are health insurance plans that offer dental benefits as an add on.  These plans are what I refer to as "skinny plans".  They offer the absolute basic dental services such as cleanings and exams.  I hope that these companies that are offering these plans are being honest to their clients about the limited extent of these plans.

If the reimbursement rates to the dentists are too low, dentists will not participate with these plans
- making it hard for patients to find dentists that take their insurance.

If the insurance companies drive the costs down through lower reimbursements, dentists will evolve their practice model to accommodate.  Please note that most dental offices are small businesses and provide dental care to the community that they serve while providing jobs to their support staff.  As with any small business, they must be profitable to remain viable.

I bring this up because there is a precedent of insurance companies cutting reimbursements to dentists in several states including: Washington, Missouri, Idaho, New Jersey, and Connecticut.  To show how volatile the relationship between dentists and insurance companies are see Washington Dentists vs. Delta Dental.  

Episodes like this don't make dentists happy.  Dentists want to provide a service to their community.  At the same time, we wish to keep our businesses viable with minimal third party interference and regulations that affect the "sacred cow" (doctor patient relationship).

With lower reimbursement rates, dentists must either see more patients per hour or cut costs. This could affect the practice in several ways including less time with the patient leading to a less personalized service. The dentist could also choose to use cheaper materials that may not last as long or be optimal for the situation as what he/she is currently using.  

If there are not enough providers to fill this void, a new dental provider model has been making dental headlines over the past few years.  This "Midlevel" provider will be able to do irreversible dental surgical procedures with minimal training - usually 2 years after high school.  This scares me, but as with anything, survival of the fittest.  If this provider model can provide the care that dentists and hygienists currently provide, they will stay, if not they won't.

Again, this is a slippery slope that will create a potential two tiered dental system with a significant percentage of the population receiving care that is from a provider that is seriously under-qualified to perform.

There is a 2.1% medical device tax. It hasn't been defined yet on what is going to be taxed.  My prediction is that anything fabricated by a lab (crown, denture, veneer, etc) will be subject to this tax.  I also predict that this cost will be passed along to the patient in some way.  When we brought this up to our legislators, they weren't sure yet on what was going to be taxed.  The term medical device is not spelled out in the bill.  As much as we tried, this tax isn't going away.

Expansion of medicaid coverage to children.  All plans must include dental benefits for children up to the age of 19 (including medicaid).  This will put millions more children in line to have access to dental care.  I predict there will initially be a shortage of dentists that can provide proper care for these kids.

Expansion of medicaid benefits to adults.  The ACA is encouraging the states to expand dental services to adults.  I predict again that there will initially be a dearth of dentists that take medicaid.  Medicaid reimburses at around 30% of what the dentist's usual fees are.  Plus, medicaid creates a plethora of extra paper work and reporting to get reimbursement.  Again, not an incentive for dentists to participate.  Some corporate models have already stepped into this niche and I expect several more to adapt into this niche as well.

One potentially good thing the ACA incorporated is an increased focus on healthy lifestyle, and prevention strategies.  We dentists have been doing this for the past 50 years.  Dentistry can help lead the charge here. The goal of dentistry involves optimization of health and function.  The removal of infection that could potentially spread to other parts or systems of the body is imperative for optimal health.  The ultimate function of teeth is to chew food.  The best way to maintain optimal health is to have proper nutrition and lead a healthy lifestyle.  If you have no teeth, it is very difficult to get good nutrition.

Odds and Ends.  I hope that the ACA also consolidates the respect of all health care providers.  We all have an interdependent essential pieces of health care.  All health providers must learn to communicate better with each other and with our patients for the best interest to improve the delivery of healthcare to those that we serve.

Patient's responsibility. The ultimate responsibility of health lies on the citizen patient.  He/she must live a healthy lifestyle to remain healthy.  Many health problems are preventable. Many health problems are not preventable.  If the system is clogged with the health care problems of the preventable kind, there are not enough resources available to help those with the non-preventable kind.

With respect to dentistry - 

Clean teeth do not decay, most gum disease can be prevented with brushing and flossing! 

I welcome comments and perspectives on this.  I am no expert and would love to hear other opinions - especially if I am off base here.

If you like this blog post, I would love to hear about it.  Please comment or share it on Google+, Facebook, Linked in, Twitter, etc.  If you are looking for a dentist in the Denver area, we are always looking for new patients.  Please visit our website http://www.tcdodenver.com/ or like our facebook page,  https://www.facebook.com/TCDOdenver.  Or you can do it the old fashion way - call us at 303-321-4445.

Thanks for reading!  BK

Veneers, Veneers and More Veneers

A smile is the window to the soul.  

As a dentist, I do everything I can to help my patient's soul shine through.  

BK Mission Statement

Smiles communicate happiness, pleasure and confidence.  Many of my patients who come to me for smile improvements, are happy people but self conscious and may not project their inner happiness as effectively as they would like.  This could affect any relationship that they are in whether it be personal or professional.

93% of all communications are non-verbal - of which body language including facial expressions are a large part of that.

A new improved smile is life-changing!

I'd like to share an example with you:

One of my patients moved to a new neighborhood.. She was slow to make new friends/acquaintances with her new neighbors.  She was perplexed by this as she had never had difficulty with making friends in the past. She had some dental issues that allowed us to have a conversation about her smile.  Once we improved her smile, she mentioned to me that people seemed more friendly to her.  A close friend told her that she didn't smile very much before and perhaps her new neighbors judged her as unfriendly. This brought tears to her eyes as she explained this to me.  She had no idea that she was hiding her smile.  Her new smile outwardly projects her inner beauty, happiness and confidence.

Here are some examples of  what can be done to improve smiles with veneers.

 Case 1: Before: Stained old restorations

After- Veneers and teethwhitening.

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Case 2: Before - Worn front teeth from grinding

After - Four veneers, teeth whitening, and bite therapy to protect her new smile

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Case 3: Before - stained, yellow teeth

After - Four veneers, whitening

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Case 4: Before - Old restorations, improve smile

After: Four veneers, teeth whitening

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Each case is carefully crafted to match the patient's facial structures, personality and function.  Before we start we have a discussion dedicated to help the patient identify their goals with their smiles.  The better we can identify these goals, the better we can create the smiles that he/she desires.

For more examples of smiles that we have created and lives that have changed, click on the link - Smiles

If you like this blog post, I would love to hear about it.  Please comment or share it on Google+, Facebook, Linked in, Twitter, etc.  If you are looking for a dentist in the Denver area, we are always looking for new patients.  Please visit our website http://www.tcdodenver.com/ or like our facebook page, https://www.facebook.com/TCDOdenver.  Or you can do it the old fashion way - call us at 303-321-4445.

Thanks for reading!  BK

Cracked Tooth - Ouch!

My friend Dr. Alan Mead - a dentist in Michigan wrote a very informative blog about cracks in teeth a while back.

 http://meadfamilydental.com/2012/05/dont-wait-until-it-breaks/

As a dentist, I see cracks in teeth everyday.  After personally experiencing teeth breaking around old fillings, I find myself sharing how painful it was and how it always seemed to happen at inopportune times.

There are two factors that if addressed properly, can pretty much ensure that you can predictably keep your teeth:

The first is health - we emphasize brushing and flossing.  Clean teeth do not get cavities and minimizes the chance of gum disease.

The second is function.  If you are putting too much force on a tooth - something is going to give once that threshold has been exceeded.

The functional threshold of one of my patient's tooth was exceeded this week. Here is her story -

She presented with EXTREME pain that began suddenly while eating dinner the night before.

I looked at her tooth and saw a fracture on her lower right molar. The fractured part of the tooth was still present and when anything touched it, the segment would move and it sent her into writing agony.  The tooth has a well placed conservative filling.  I would put this tooth at low risk for a fracture if she presented for a routine exam.  The radiograph that we took was inconclusive for a fracture or any other infection.

Figure 1 -(Tooth #30) fracture noted on left side of tooth extending along the filling through the middle of the lower (lingual) wall.  It is slightly brown colored along the filling.

We discussed her options: Remove the fractured portion of the tooth and determine if it was restorable. It would need at very least a foundation build-up and a crown.  I informed her of the potential additional need for a root canal or a possible extraction.

We attempted to get her numb but was unsuccessful due to the acute problem.  Sometimes a tooth is so "hot" (or inflamed) anesthetic doesn't work. When this happens, I get more confident that root canal therapy is indicated.

We referred her over to Dr. Rahim Karmali, a root canal specialist here in Denver, who then did an evaluation that included a three dimensional - CT scan of the tooth.

Figure 2: CT scan clearly illustrating the extent of the fracture.

Figure 3 - Sagital view - fracture down to the boney crest

Figure 4 - Shows the fracture extending on the root surface

The technology that is available to us allows us to better predict the restorability of teeth.

It was obvious to Dr. Karmali, myself and the patient, that this tooth, unfortunately, was not restorable.

So as I mentioned previously that I see cracks in teeth everyday.  I am proactive when I see these fractures and tell and show my patients what I see and give options to fix the situation.

When my patient asks me how long before this tooth needs to be fixed.  I will reply with the words of my good friend Dr. Mead, 

"I recommend that you fix it the day before it breaks!"  

I also share this unfortunate experience and hope that it doesn't happen to your tooth...

Case study - Addressing Jaw (TMJ) Problems to a Wonderful New Smile with Veneers and Crowns.

I haven't blogged in a while....My patient care coordinator Monique asked why?

"I haven't been inspired to write lately!"

She said, "Why don't you share some of the smiles that we have improved?  They are life changing!"

I thought about it for a moment...""Not a bad idea!"

So here it goes.....

This particular patient of mine presented with jaw pain after a car accident.  He had many broken bones and chipped teeth. He went through many surgeries and has healed up nicely.

I treat a lot of patients with jaw pain.  I enjoy it - When I was in dental school, we were taught to do bite splint therapy. If they don't get better, send them to their psychiatrist as they are crazy.  I didn't buy that as I had a history of jaw problems and I wasn't crazy...

I spent many years after dental school taking classes on how to treat patients comprehensively -and this included the orthopedic treatment of the jaw and how it relates to the bite. By following some of these protocols, I am now able to treat a wide variety of dental issues predictably.

So we started with bite therapy that included various types of splints over two years to allow the jaw to heal. As his jaw healed and then stabilized, we started discussions on idealizing his bite.  He didn't present with esthetic concerns, but as we got to know each other through his treatment, he revealed to me that his front teeth chipped during the accident.

Adding length to the front teeth without addressing the function could be a very risky procedure.  The length of the front teeth could affect how one chew's food, how one grinds their teeth and also could affect how one speaks.

If the increased length interferes with the normal jaw movements or grinding patterns, the restorations are at high risk to break. It could affect the jaw muscles or one could develop headaches.  Teeth that are too long will compromise the 's', 'f', and 'v' sounds - giving the patient speech impediments.  They must also fit the features of the face to look as natural possible.

If any of these factors are not addressed, the results could be devastating.

Fig. 1 - Multiple short and chipped teeth

As part of idealizing his bite, we were able to add length and repair the smile within the harmony of his function.

Here is the after photo.

Fig. 2 -Restored smile with veneers and crowns

Happy patient.  He admits to me that he was very self conscious with his smile prior to the restorations.  Now he smiles confidently and most important, he is comfortable!

“Team of Rivals” - Reflections from my trip to Washington D.C. May 13-15, 2013

The Colorado Delegation in front of the Capitol

I am currently reading the book “Team of Rivals: The Political Genius of Abraham Lincoln, by Doris Kearns Goodwin.  The movie “Lincoln” was based, in part, on this book – although the movie only depicted a small segment of the story.

When “Lincoln” hit the theaters, I was enthralled by it.   I knew how it would end – happily, the slaves would be freed and tragically, he ultimately would meet his demise from an assassin’s bullet. 

The story illustrated his focus on doing what was right in his heart.  He faced tremendous challenges within himself, his wife/family and his political advisors.  Not to mention, the social norm at the time (slavery), the soldiers that were fighting in the Union Blues and the forgiveness that he exhibited toward the Confederates.  Lincoln, filled with guilt over the realities of war, always considered the southern states his countrymen and reinstated them to full citizenship upon the ending of the war. 

Lincoln was torn every minute of every day.  I could imagine the questions that he would be asking himself – “Am I doing the right thing?  Is it worth the war and all of its casualties? Why do the people I am leading, continue to follow?  Is all of this worth the personal sacrifice to me and my family?”  And the most important question,  “Why me? Couldn’t Seward or Chase be in charge?”

There was so much history in the movie that I was unaware if, I went and saw the movie again – and ultimately bought the book.  The book tells the back-story of how Lincoln arrived at becoming the leader that he was. 

 “Team of Rival’s” – Lincoln took his biggest political rivals – people he ran against for President and lesser political positions - and made them his cabinet.  He made them his closest, most trusted advisors.

This is the political equivalent of President Obama asking John McCain or Mitt Romney to fill the same roles. 

I have been in Washington DC this past week as part of a delegation of the Colorado Dental Association and the American Dental Association to try to improve the delivery of dental care to our communities.  During our time here we heard many politicians and pundits describing for us the current state of politics and the political process. 

As you already know, the climate isn’t pretty.  The government is spending much more than it has and nothing is getting done.  There is party posturing and political stalemates on every front. 

Our delegation met with all of our legislators or legislative staff.  We are looking to reform dental insurance - to break up the monopoly that they have.  With a monopoly, there is no competition.  With no competition, there is no innovation in the plans and the insured don’t always get the best benefits at the best price. 

A new medical device task is being implemented soon.  But there is no definition of what constitutes a “medical device”.  We asked to repeal the tax.  If they aren’t going to repeal the tax, at least define what is to be taxed.  As of now, no one has any idea!

I didn’t get a feeling like we were making an impression on any front.  I hope we planted a seed of change that we can nurture over time into definitive action.

Back to Abe Lincoln…As we were meeting with our legislators, searching for inspiration I began to think, what would a leader like Lincoln do in today’s Washington?

I would think he/she would act courageously, inspire us as a country and bring us together by forgiving the past to move us forward. 

I would hope that he/she would say, “We as a country are in trouble. If we continue along the path we are on, the country and all of it’s people will not be free.  Unfortunately, there is no easy solution.  Everyone must be willing to sacrifice and compromise your beliefs so we can once again be the country that we once were. We must not live in the past and pass along the blame that it was the democrats or republicans fault.  It does no good.  We must move forward with a unified vision of a thriving future -an America that courageously stands on the principles upon which it was founded.  We must change or suffer our demise.”

The only way to do this is for our president to look back in our history and create a “Team of Rivals”.  Get the political fighting done behind closed doors, come out with a unified front and unite us, inspire us and let’s move forward before it is too late.