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Basic Rule 7: Who Are You Dealing With?

Posted By Stephanie Wilhelm, Thursday, February 21, 2019
Updated: Thursday, February 21, 2019

A number of years ago I attended a presentation by Suzanne Boswell and I experienced an epiphany.1 Her presentation was on personality styles.2-4 The presentation not only overviewed the four basic personality styles or types, but also involved the audience doing an exercise which ultimately gave us an insight into our own basic personality type. Then the epiphany part. She related our personality type to a preference for either receiving or giving out information and suggested that a dental teams approach with their patients would be enhanced by respecting patient personality type and thereby preference for communication. In no way did she infer that dental teams were to be insincere. Quite the opposite was in fact emphasized. Suzanne Boswell was firm on the concept that every patient receives the same information except that presentation was to be tailored to the personality type. In this way the patient is more likely to hear what was being said and be more responsive. We do not want to insult our patients.

Figure 1 shows the four basic personality types (analytical, driver, expressive, amiable) and they are arranged with the thinkers/controllers (analytical, driver) on top while the feel/responsives (expressive, amiable) are on the bottom.1-4 Also note that the tellers (driver, expressive) are to the right while the askers (analytical, amiable) are to the left. We all have these four basic personality traits (analytical, driver, expressive, amiable) but we will be predominant in one of the corners. I, for example, check out as mainly an expressive. I love to talk, I am futuristic, the whole world is my friend, and the glass is always half full.

What is important about this simplistic layout is that we interact easiest with the patients that are closest to our traits and style. In my case, expressives are a piece of cake while I can easily adapt to the amiables (need reassurance, thoughtful, detailed explanations) and the drivers (quick decisions, want the information fast and concise). It is the personality type diagonally across from your personality type that will give you the most grief. With me it is the analyticals (thinkers, want time and all the facts for decision making) that I use to have all the problems with. Since analyticals want the facts so that they can leave and call our office on their terms, I would be so busy talking my head off about the facts and peripheral topics that I would annoy the dickens out of my poor patient. Needless to say, my case acceptance rate with these individuals was abysmal.  I did not appreciate or respect who I was dealing with. Today I, along with dental team members, now guesstimate a profile on all our patients so that we can best educate and service their needs in a non-manipulative manner that is consistent with our practice model, team ethics, and our individual personality types.

Another important tool that I employ with team members to help assess who we are dealing with is the commitment/ activity table that I learned from Sandy Roth (Figure 2).5

This table identifies patient desirability. We all want committed, active patients, don’t we? On this particular table those are the 2’s with 2a being a more frequent client (possibly a periodontal/prosthetic maintenance patient) whereas a 2c is still a fabulous patient but seen in the practice a little less frequently (possibly an out of town patient). On the other hand we all have 0’s, don’t we! These are the patients that rarely attend and if and when they do it is usually for long overdue recare appointments or emergency care. Somewhere in-between these two extremes lies the grey area of the semi-committed patient. You know the type. These individuals have one foot in the practice and one foot out. This is a potentially scary relationship and situation to initiate any oral care with, especially that which is comprehensive in nature.

Where the table in Figure 2 has helped my dental team and I out is we spend the most time with the individuals that want to spend the most time with us and we clarify our relationships with those individuals that are uncertain or unclear of our services. This does not mean that we treat our patients differently. Au contre. We just adjust the amount of time and the comprehensiveness level of treatment to suit the patient’s commitment/activity level. Most importantly, we would never begin comprehensive oral rehabilitative care, for example, with anyone who is not on the same page as us. Comprehensive care requires a committed, loyal patient who enjoys coming to your office and who is on your side.

Who are you dealing with? A committed active patient who you respect, understand, and want to help achieve the dentistry that they understand to be the best for them with today’s technology and protocols. And they feel the same way too about your team.

Further Suggested Reading and References:

  1. Boswell S. The mystery patient’s guide to gaining and retaining patients. Tulsa: Pennwell Pub; 1997.
  2. Racich MJ. The basic rules of oral rehabilitation. Markham: Palmeri Publishing; 2010.
  3. Racich MJ. The basic rules of facially generated treatment planning. Markham: Palmeri Publishing; 2013.
  4. Racich MJ. The basic rules of being a dental patient. Markham: Palmeri Publishing; 2016.
  5. Roth SR.


Tags:  Basic Rules  Consultation  Racich  Treatment 

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Rule 5: 6 E’s

Posted By Stephanie Wilhelm, Wednesday, July 25, 2018
The Basic Rules of.....

Basic Rule 5: 6 E's

When I first started to read about Dr. Earl Pound’s removable prosthodontic technique what immediately became apparent was how organized he was with his patient care. His organizational skills were such that he made removable prosthodontics a predictable procedure or at least as predictable as one could make such a discipline. He did this by having multiple steps and appointments with each one obviously being a precursor to the next but also involving the patient in the process along the way. This had the effect of doing two things. Firstly, the patient was apart of the process and could put their input in as required or desired. If they were agreeing with each step along the way then a successful outcome for treatment was more or less assured. What a relief to know we are on the right track, isn’t it! Secondly, and most important, if the patient was not satisfied with the process no matter what the cause, the services could then be terminated. Wow. Imagine, your half way threw treatment and you leave on pleasant terms. Why was this possible? Because before treatment commenced he followed the 4 E rule (I have added two more “E”‘s to make it the 6 E rule).
The E’s are:
1. Evaluate
2. Educate
3. Empower (my “E”)
4. Estimate
5/ 6. Enter or Exit (Pound had Eliminate)
The process of the E’s means that we are thorough with our patient interviews, case work-up, and case treatment planning and execution. By making the patient an equal partner in the process, ie. co-discovering, with us we are working towards a common goal like a team.2-4 We are up front with our patients with regards to treatment options, treatment length of time, costs, and efficacy. There are no surprises. And we expect to get renumerated at each appointment, just as Dr. Pound did. Dr. Pound received a fee at each appointment so that if services were terminated he was not out of pocket, the patient paid for what was done to that point, and the patient left the practice knowing full well that the pre-treatment contract had been honoured. Pretty smart. This concept can be applied to 21st century dentistry be it comprehensive fixed or removable prosthodontics, or just the routine everyday basics.

In my practice I follow the 6E’s. We thoroughly evaluate. There are no exceptions to this rule. Then we educate. Remember Basic Rule 2. Empowering of the patient results whereby they become a participant in their own care. Furthermore, this education process is not only about our diagnosis, treatment options, and empowering but also about fees and termination of services. We make each step of the way sequential and progressive such that records and treatment to date can be picked-up and continued at another practice of choice if in the unlikely event that “E” #6 (exit) occurs. We insure also that our fees have been looked after as well to this point.

A good example of our approach to comprehensive oral rehabilitation is the common way we provisionalize. In generalized moderate wear, erosive cases we frequently directly bond with hybrid composite; we like to call this the “prototype phase”. We do our thorough examination and evaluation followed by a thorough education of etiology, risk factors, treatment options, and efficacy. Costs are estimated and agreed too. We then perform our diagnostic provisional “prototype” phase (i.e. we have entered (“E” #5) into the treatment phase; in this example we bond establishing form, function, and vertical dimension re-establishment (Figures 1-3).

Figure 1

Figure 2

Figure 3

Figures 1-3: Composite bonding done in one appointment reestablishing form and function to the stomatognathic system.

This can usually be done in maximum one appointment per arch. At this point we have accomplished the first 5 E’s and have been renumerated. We can then proceed to the definitive restorative phase with the material of choice (gold or porcelain) at our leisure (ie. reenter (“E” #5) the relationship again) or services can be terminated depending on the circumstances (ie. exit (“E” #6) the relationship). Therefore, treatment has been predictable and stress free.

The 6 E’s offer another vehicle to optimize patient communication and interaction. The 6 E’s also just make good business sense. As oral healthcare providers we dance a fine line between professionalism and business. Nevertheless, a high regard for professionalism coupled with business acumen will ensure that we keep the busyness that us top professionals deserve.

Further Suggested Reading and References:
1. Pound E. Personalized denture procedures: dentist manual. Anaheim: Denar Corp.; 1973.
2. Roth SR. ProSpective volume one. Reclaiming the passion of dentistry. Seattle: ProSynergy Press; 1993.
3. Roth SR. ProSpective volume two. Defining the mission of dentistry. Seattle: ProSynergy Press; 1995.
4. Roth SR. ProSpective volume three. Advancing the profession of dentistry. Seattle: ProSynergy Press; 1996.

Tags:  Basic Rules  Racich  Rehabilitation  Treatment 

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Rule 4: What Could Go Wrong?

Posted By Stephanie Wilhelm, Friday, April 13, 2018

The Basic Rules of …..

Basic Rule 4: What Could Go Wrong?


When we really stop and think about it, what could go wrong with our oral rehabilitations and why? The answer I break down into three main areas: diet, hygiene, and parafunction. All three of these etiologies are patient preventable only. We act as the facilitators of dental education and patient oral care. That is why excellent communication and rapport are essential before embarking on a major undertaking such as an oral rehabilitation. Let’s now take a look at these three etiologies.

Dr. John Kois has championed the concept of risk factors and assessment for restorative and prosthetic dentistry. This is a profound concept and one that must be completely assessed before treatment commences. Dr. Kois discusses risk assessment in the areas of esthetics, occlusion, and periodontics for example. I agree with his approach.1-3  When we look at risk factors especially post treatment with an eye to their effect on oral rehabilitation longevity we can readily appreciate that a non-compliant patient will doom our efforts. I can attest to this. The saying “good judgment comes from a lot of experience and a lot of experience comes from a lot of bad judgment” I am sure we have all learned the hard way. In fact, a patient that refuses to participate in effective personal and professional oral hygiene care will undoubtedly have future problems or compromises with their oral health. Root caries, periodontal issues, and esthetics (eg. staining) to mention a few. The patient has to be advised pre-treatment on a lifetime of maintenance requirements. This is documented in their file and the patient is to be reminded of this if they are found to be waning.

Diet is another source for failure. Specifically, sweet intake. The patient needs to be educated on the relationship between sweets and caries and the significance of the frequency verses the volume of consumption. The patient also needs to appreciate that sweets are more than just chocolate and candies. There are many sources of sweets that the patient might not realize that are damaging, such as fruits or sports beverages (sweet/ food breakdown product “acid” attacks or acidic substances).4,5 Age and the associated decline in salivary flow also require explanation. Strategies to offset lifestyle decisions can then be formulated. Protection with daily fluoride rinses or stimulation of salivary flow with sugarless gum or lozenges could be introduced. Once again, this is documented in the patient’s file and they are to be reminded of this if they are found to be waning.

The third and most significant reason for oral rehabilitative failure is parafunction, better described as bruxism.6 We have known for quite some time that a patient’s teeth are never to be together unless they are chewing or swallowing.7 A patient’s teeth might touch for a split second when they chew or they might touch when they swallow (my teeth do not touch when I swallow). We all have patients that ask how long their new restorations will last or what kind of guarantee I will give them. My standard response is “I will guarantee the work for the rest of their life but only on one condition - as soon as their teeth touch once, the guarantee is off.” This of course is unrealistic and somewhat of a sarcastic response but it nevertheless gets the patients attention and drives this point home. Keep your teeth apart! Isn’t this the first thing we tell TMD (temporomandibular disorder) patients to do? Oral rehabilitative patients are no different. For those patients that brux at night or who just want to protect their investment while they sleep, it is a simple task to fabricate a full coverage hard acrylic maxillary orthotic. It’s that simple.8

Diet, hygiene, and bruxism. Make the patient aware of these three vices and we are well on our way to a successful post-treatment scenario.9 Failure to properly educate and monitor these three etiologies will be your undoing.

Further Suggested Reading and References:

1. Kois Center.

2. Kois JC. The restorative-periodontal interface: biological parameters. Periodontol 2000 1996;11:29-38.

3. Malament KA, Socransky SS. Survival of Dicor glass ceramic dental restorations over 14 years: part 1. Survival of Dicor complete coverage restorations and effect of internal surface acid etching, tooth position, gender, and age. J Prosthet Dent 1999;81:23-32.

4. Coombes JS. Sports drinks and dental erosion. Am J Dent 2005;18:101-4.

5. Lussi A, Hellwig E, Zero D, Jaeggi T. Erosive tooth wear: diagnosis, risk factors and prevention. Am J Dent 2006;19:319-25.

6. The glossary of prosthodontic terms. J Prosthet Dent 2017;117 (5S):e1-e105

7. Lundeen H, Gibbs C. Jaw movements and forces during chewing and swallowing and their clinical significance. In: Advances in occlusion. Boston: John Wright PSG, 1982. p. 2-32.

8. Racich MJ. The basic rules of occlusion. Markham: Palmeri Publishing; 2012.

9. Racich MJ. The basic rules of being a dental patient. Markham: Palmeri Publishing; 2016. 

Tags:  Basic Rules  Racich  Treatment 

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Rule 3: 3 Reasons for Treatment

Posted By Stephanie Wilhelm, Tuesday, December 5, 2017

Basic Rule 3: 3 Reasons for Treatment

People seek dental treatment for three main reasons: appearance, comfort, and function. Dr. Earl Pound spoke and wrote about this concept decades ago and in today’s supercharged world of cosmetic dentistry these words still hold as true now as they did back then.1 Dr. Pound was a removable prosthodontist who realized that the main reason that people sought out his services was for appearance, however, he also realized that the patients would never be happy with their appearance unless they were comfortable and functioning satisfactorily. We see this often in our practices. A good example is a procedure such as anterior veneers. Let’s say for example that a patient has some cervical temperature sensitivity after cementation of some freshly placed maxillary central incisor conservative laminates. Chances are that the patient will inspect their new restorations to possibly find a minuscule amount of root exposed on one of the teeth. A minor discomfort issue might then escalate to an appearance concern. On the other hand, let’s imagine that one of the new veneers is contoured incorrectly in the incisal one-third such that phonetics (ie. function) is altered. They are unable to say “F” as they did before. The patient might once again inspect their new restoration closely and once again an appearance concern might ensue. It is of critical importance therefore to listen to patients’ chief concerns and although cosmetic or esthetic priorities quite frequently top the list, the prudent practitioner must identify discomfort and dysfunction considerations first.

Discomfort concerns are either of an acute or chronic nature. The dental profession has become very proficient over the last century in handling patient acute pain situations. Prompt, efficient care is important and we can thereby move forward with our treatment in a timely and sequential manner after we address the acute concern.  Chronic pain is another matter. It’s as if the average practitioner runs for the hills when confronted with a patient or patients with conditions such as long term TMD (temporomandibular disorders). Interdisciplinary care is widely preached and encouraged by academics and leading clinicians but sadly this aspect of it is commonly ignored. More frequently the sexier and more lucrative cosmetic dental disciplines get the limelight unfortunately.2 There are many fine, contemporary textbooks available that cover the topic of patient discomfort, that are easy to read and allow immediate clinical application.3,4 Please avail yourself of this literature or refer your patient to other health care providers in a timely fashion in order to provide optimal care and service for your patients in an evidence-based manner.

Dysfunction is multifaceted and it also needs to be definitively addressed as well before moving forward with oral rehabilitative treatment, comprehensive or not. Dysfunction can be psychologic, physiologic, anatomic, behavioral, or pathologic. We have to identify which one it is and either structure a program to deal with it or refer to another medical or dental health care provider. If the dysfunction is related say, to bruxism, then patient education and appropriate follow-up (ie. evaluation, differential diagnosis, and preliminary treatment plan) is indicated. For bruxism as an example, the patient would be educated on diurnal bruxism (ie. “keep your teeth apart”) and for sleep-time they would be advised that bruxism is now considered a sleep movement disorder.5 The later would be managed with a sleep-time only orthotic use and referral to a sleep clinic for assessment would be offered.6 Oral rehabilitation could then proceed following The Basic Rules of ...

Appearance dentistry is driving the dental industry today with unprecedented demand for cosmetic services. I hope that I don’t have to remind you that esthetic and cosmetic dentistry are not one and the same. Cosmetic dentistry can’t always be made esthetic but esthetic dentistry can always be made cosmetic. Cosmetic is defined as “superficial measures to make something appear better”, whereas esthetic is defined as “pertaining to a sense of the beautiful”.7 It’s esthetic dentistry then that will make our patients happy with their appearance more times than not. There are many books available to help clinicians understand and practice smile design and facially generated treatment planning that is highly esthetic (and cosmetic if the patient so chooses). 8-14 This essay series will address esthetic dentistry in detail as we go through The Basic Rules.

 Three Main Reasons for Treatment:  Three Main Reasons for
Restorative/Prosthodontic Failure:
  • Appearance
  • Function
  • Comfort
  • Diet
  • Hygiene
  • Parafunction

Knowing the three main reasons why patients come to our office is an essential overall concept to understand, but defining what could go wrong with our oral rehabilitations and why, is mandatory. The answer I break down into three main areas:  diet, hygiene, and parafunction. All three of these etiologies can be prevented only by the patient. Poor dietary choices, bad hygiene, and relentless bruxism are three vices to make our patients aware of and if we can, then we are well on our way to a successful post-treatment scenario. We act as the facilitators of dental education and patient oral care. Failure to properly educate and monitor these three etiologies will be our undoing. That is why excellent communication and rapport are essential before embarking on a major undertaking such as an oral rehabilitation. 

Dr. Pound was right about appearance, function, and comfort. Dr. Pound also developed and enhanced a total body approach, not just the teeth and smile, to his patient care experience by discussing with patients general health guidelines many of which are standard today. He discussed with his patients the importance of exercise, diet, vitamin and antioxidant protocols. When his patients came to him with one of the reasons for treatment, he dealt not only with their chief concern, but he also gave them a whole lot more and never forgot that the patient would never be happy with their appearance unless they were comfortable and functioning satisfactorily.

Further Suggested Reading and References:

1. Pound E. Lost – fine arts in the fallacy of the ridges. J Prosthet Dent 1954;4:6-16.
2. Roblee RD. Interdisciplinary dentofacial therapy: a comprehensive approach to optimal patient care. Chicago: Quintessence; 1994.
3. McNeill C. Science and practice of occlusion. Chicago: Quintessence; 1997.
4. Okeson JP. Orofacial pain: guidelines for assessment, diagnosis, and management. Chicago: Quintessence; 1996. 
5. Blanchet P, Rompre P, Lavigne GJ, Lamarche C. Oral dyskinesia: a clinical overview. Int J Prosthodont 2005;18:10-9.
6. Racich MJ. Predictable fabrication and delivery technique for full-coverage hard acrylic non-sleep-apnea dental orthotics. J Can Dent Assoc 2006;72:233-6. 
7. Flexner SB, ed. The Random House dictionary of the English language. 2nd ed. New York: Random House; 1987. 
8. Magne P, Belser U. Bonded porcelain restorations in the anterior dentition. A biomimetic approach. Chicago: Quintessence; 2002.
9. Chiche GJ, Aoshima H. Smile design: a guide for clinician, ceramist and patient. Chicago: Quintessence; 2004.
10. Fradeani M. Esthetic rehabilitation in fixed prosthodontics. Vol. 1 & 2. Esthetic analysis; Prosthetic treatment. Chicago: Quintessence; 2004, 2008.
11. Racich MJ. The basic rules of oral rehabilitation. Markham: Palmeri Publishing; 2010.

12. Racich MJ. The basic rules of occlusion. Markham: Palmeri Publishing; 2012.

13. Racich MJ. The basic rules of facially generated treatment planning. Markham: Palmeri Publishing; 2013.

14. Racich MJ. The basic rules of being a dental patient. Markham: Palmeri Publishing; 2016.


Tags:  Basic Rules  Racich  Treatment 

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