Ed Rabinowitz

Dentists are well-positioned to help patients with sleep apnea. However, they must prioritize educating themselves on the condition and working closely with physicians.

Late-night parties, exam-cramming, or Netflix marathons that extend into the wee hours of the morning may be why so many patients seem ready to doze off in the operatory — or not. Instead, it could very well be obstructive sleep apnea that’s to blame.

The Mayo Clinic defines obstructive sleep apnea (OSA) as “a potentially serious sleep disorder” that “causes breathing to repeatedly stop and start during sleep.” And it’s far from rare: According to the 

 (AASM), more than 25 million American adults have OSA. Harold Smith, D.D.S., president of the 

American Academy of Dental Sleep Medicine

 (AADSM), estimates that 20 percent of a dentist’s general practice is composed of patients with undiagnosed OSA.

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“If a dentist is oriented to looking and screening for OSA, he’s going to be a very productive dentist in helping his patients have better qualities of life, catching serious comorbidities early, and possibly saving a life or two along the way,” Smith says.

Smith recalls that in 1993, the field of dental sleep medicine was in its infancy. There were no studies or evidence-based literature for dentists to rely on. Education was anecdotal, based mostly on talking to practitioners who had begun treating patients. But over the last 25 years, Smith says, there has been “a virtual explosion” of literature, evidence-based studies, and clinical trials.

“We’ve come a very long way,” he says. “We’ve come to the point where oral appliance therapy is recognized as a viable option” for treating adult patients with OSA who are intolerant of continuous positive airway pressure (CPAP) therapy.

Oral appliance therapy features a custom-fit oral sleep appliance that fits into a patient’s mouth, much like a sports mouth guard or an orthodontic retainer. It supports the jaw in a forward position to help maintain an open upper airway.

Medical studies have helped physicians understand that oral appliance therapy is a modality of treatment they can consider for patients who are diagnosed with OSA. But what has lagged, says former AADSM president B. Gail Demko, D.M.D., with 

 in Weston, Massachusetts, is an adequate number of educated dentists to fill the need physicians are creating.

Demko explains that OSA treatment is not an extension of what dentists learn in school. Crafting an appliance might be, but by engaging in oral appliance therapy, dentists are treating a medical disease, which falls outside of the typical dentist’s comfort zone.

“It’s incumbent upon us to understand that disease at the level of the physician, and dentists aren’t used to that,” Demko explains. “Any dentist can make one of these devices, but that isn’t the issue. The issue is understanding when to use them, when not to use them, and how the medical concerns of the patient play into it.”

Smith echoes those thoughts. OSA is not the usual type of profit center dentists bring into their general practice. Continuing education for many dentists, Smith explains, is going to a weekend course in periodontics, picking up a few pearls and bringing them back to their practice, and on Monday morning putting those pearls to use.

“Dental sleep medicine is an entirely different thing,” Smith says. “Dentists need to understand that obstructive sleep apnea and snoring are medical conditions, and we as dentists are treating these medical conditions. So the important thing for dentists to understand is they must be a valued part of the medical team in their community. And to become a valued part, you need to be properly educated.”

First, dental patients must receive a diagnosis from a physician.

Patients with OSA must first be diagnosed by a physician, and the patient can then be referred to a dentist. But dentists can play an important primary role in terms of screening. Smith points out that a dentist often sees a patient more frequently than does that patient’s primary care physician.

“Standard care for every patient who comes into a dental office for an examination is an oral cancer screening,” he says. “And an extension of that … is screening for obstructive sleep apnea.” During an oral cancer screening, a dentist can look for the anatomical markers that are fairly common in most OSA patients.

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He cautions, too, that it’s important not to pre-judge patients. “All of us have patients who you would never think have sleep apnea because they’re fit, thin, active and young,” Smith says. “But anatomically, their airway closes at night.”

Demko is also an advocate for screening, favoring a method called the 

 that’s used by physicians. It takes into account a range of criteria, including snoring, fatigue, blood pressure, and body mass index.

“There are no studies supporting that a physical examination of a crowded oral pharynx leads to sleep apnea,” Demko says. “But the STOP-Bang Questionnaire is highly indicative of obstructive sleep apnea, and it’s used by anesthesiologists screening patients prior to general anesthesia.”

In July 2015, the AASM and the AADSM issued the first joint clinical practice guidelines for oral appliance therapy. The guidelines are a pathway for sleep physicians and dentists to work together to treat OSA.

It’s not the only collaborative effort underway. In February, the AASM held Sleep Medicine Trends 2017 in Phoenix, Arizona, and dentists were invited to collaborate with physicians in a day-and-a-half workshop, “Oral Appliance Therapy: A Model for Physician-Dentist Collaboration.” Demko was one of the participants.

“It was huge,” she says of the first-of-its-kind collaborative workshop. “The more that  physicians understand that we are there to give them another modality for treating their patients that may be more acceptable, more comfortable, and that improves compliance, the better.”

Demko notes that in Europe, about half of all patients with mild to moderate sleep apnea receive oral appliances as a first-line therapy. “It’s nowhere near that in this country because physicians give us two pushbacks,” she explains. First, physicians worry that dentists may not understand the fine points of adjusting devices, as well as the related medical aspects. Second, they’re afraid of losing patients to dental offices, and that patients won’t return for proper follow-up.

It’s up to the dentist to allay physicians’ fears, says Demko. “In the past dentists haven’t been playing as team members,” she admits. “And I think now with Trends, where the AASM is giving us a true chance to come in and be a part of the team on an equal standing with physicians, that’s going to make a huge difference in how physicians perceive oral appliance therapy.”

Profiting from sleep treatment requires a dentist to dedicate themselves to education.

The American Dental Association (ADA) is also taking an active role, having recently drafted a 

Proposed Policy Statement on the Role of Dentistry in the Treatment of Sleep-Related Breathing Disorders

. Craig Ratner, D.M.D., of Staten Island, New York-based 

, and a national, state and local delegate of the ADA, says the association recognizes the need for a decisive policy to better define dentists’ role.

“Sleep apnea and sleep-related disorders are unique in that they are a medical condition that can be treated through some sort of dental intervention, or through the use of oral appliances,” Ratner says. “Dentists can definitely play a major role providing those services to mitigate the conditions.”

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Ratner agrees that dentists are well situated to recognize patients’ OSA symptoms and then collaborate with their medical colleagues. “And not only to collaborate with them, but to educate them on dentists’ and dentistry’s role in the treatment of this medical condition,” he says.

Smith believes that because so many people have OSA, providing treatment can be profitable for dentists who are willing to undertake the proper educational steps. “If a dentist can position himself—through proper education, through networking with his community physicians, through being proactive in screening and finding out about local sleep centers&mdash;he can create a network of physicians who respect the fact that he is prepared, he is educated,” Smith explains. “And physicians will refer patients to him. Then, if you create a significant number of people coming in for your services, it can be very financially rewarding.”

Demko, though, offers a caveat. She found that she was unable to work oral appliance therapy into her general practice because it’s essentially different from the way a restorative dentist works. A restorative dentist may be working three rooms at once, doing very technical procedures and working with patients who are extremely nervous. There isn’t time for much education.

For patients with OSA, however, education is imperative. “All of the big studies show that the biggest dropout rate for patients using oral appliances is in the first month,” Demko explains. “So for me it’s about educating the patient to take it slowly, that it’s not going to be easy. And because insurance demands it, they all have 90 days of follow-up in the original fee. If I can get them back for those three months I know I’m already past that big hump where we lose patients to compliance. So, for a dentist who says I’m going to take this course, increase my bottom line by $100,000, it’s not going to happen.”

Demko says the AASDM offers a series of courses for dentists who want to take steps to educate themselves in dental sleep medicine. There’s an introductory course, a full-day clinical course, even podcasts on everything from billing to oral exams. The goal is to guide dentists through the steps necessary to fully understand OSA, but also “to try to explain to them that they can’t go into this for bottom line,” says Demko. “If they go into this for bottom line they will fail. I don’t want to see 25 new patients and none of them have a device made for them. But to have four new patients and all of them have a device made, that’s the difference between understanding what you’re doing, and not.”

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Articles

Dentists are well-positioned to help patients with obstructive sleep breathing, however, if they're thinking adding appliance-based therapy to their practices will create another profit center, they need to think again. Experts say effective sleep therapy happens when dentists commit themselves to being properly educated on the condition. It also requires collaboration with physicians, something that hasn't happened historically in dentistry.

Sleep Apnea in Dentistry: The Business of Treating the Disorder

Dentists are optimistic about their ability to grow practice revenue over the coming two years, according to the 

. Two-thirds of respondents indicated they expect to see practice revenue growth in the near term.

“People are excited about opportunities,” Dan Croft, head of healthcare practice solutions at TD Bank, said. “I think it’s a reflection of general optimism in the dental industry.”

And that added revenue isn’t expected to stay dormant. Forty-two percent of respondents indicate they plan to buy or lease new equipment or technology, an indication dentists are ready to make investments in overall practice health.

“New equipment and technology, coupled with effective practice marketing, will allow privately owned practices to grow their customer base and better compete against larger corporate and group practices,” Croft says.

, who maintains a private practice in North Haven, Connecticut, has been a leader when it comes to technology integration. He believes technology is a key factor when it comes to positively affecting the patient experience.

“If you’re not investing in your practice with technology, your practice is deteriorating at a very rapid rate,” Fantarella says. “We all lose probably about 12 percent every year; and if you’re not (investing in technology), you’re not only not growing, but you’re not replacing that 12 percent.”

Fantarella believes the practices that are doing well are those that have reinvested and redefined the dental experience for patients. Technology, he says, is enabling them to operate more efficiently and pass those savings on to patients.

“There are two dentists in North Haven who have literally come to my lectures because they want to know why I’m taking all their patients,” he says. “I’m not taking their patients. Their patients are making a choice for better value and a different patient experience.”

Fantarella points to courses on how to sell dentistry, saying that he resents that phrase. He doesn’t believe dentists sell dentistry. Rather, they educate patients on what is possible, then enable them to manage the costs and experience so (the procedure) is something they want to do.

“I’m not going to convince you,” he says. “I’m just going to show you what we can do, how quickly we can do it, how painlessly we can do it, and how cost-effective it can be. And (the patient) is going to say, ‘Well, why wouldn’t I do that?’”

“When you look at the technology that’s coming out … it opens a lot of opportunities to see patients faster, and patients have a better experience.”

The TD Bank survey, which was a poll of dentists who attended the recent 

 in Boston, also found that 29 percent of respondents are considering buying, selling or merging their practice in the next few years, and 19 percent are considering bringing on a partner.

Fantarella says that, in his opinion, those figures should be closer to 80 percent.

“That’s an old model,” he says. “It’s going to be about larger practices, many dentists, sharing overhead. I have millions of dollars worth of equipment. Your average dentist can’t get out of school and buy that.”

Bringing in associates and investing in technology has enabled Fantarella to not only double his operatories but also double revenue over the last two years.

“It’s a phenomenal success story,” Croft says. “He’s a good example of how technology in the right situations can result in great expansion. But obviously, you have to have the right situation.”

Croft says there are partnership and merger opportunities to be had, but there’s also apprehension in the field about partnerships.

“People hear a lot of stories about partnerships that dissolve or have problems,” he says. “For all those reasons, I think you’re see more mergers versus true partnerships.”

According to the TD Bank survey, the most worrisome challenge facing dental practices is overhead costs — 52 percent of dentists indicated as much.

“Everything is expensive,” Fantarella says. “America is expensive. There’s only one way to combat it, and that’s to get more efficient and grow.”

Croft echoes those thoughts. He says that much of overhead is fixed costs, so if a practice is able to grow revenue there’s going to be much more profitability.

“If your average patient accounts for $300 and you can increase that to $500 or $600, you become much more profitable, right?” Croft asks, rhetorically. “There’s efficiency with doing larger procedures. So if you can do more procedures and grow your patient base, you’re going to have much greater profit margins.”

After several years of lower expectations, dentists once again are opening their checkbooks to make investments in overall practice health, according to a recently released survey from TD Bank. That's a reflection of the overall optimism dentists feel regarding revenue growth in the coming years. About two-thirds of respondents said they expect their practice revenue to grow in the near term.

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Pat Little, D.D.S., F.A.G.D., C.F.E., knows something about promotion. That was the biggest challenge he faced early in his career when launching two dental practices from scratch.

“How do you let people know that you’re out there and available,” Little recalls thinking.

Having been raised in a small town, Little looked to establish his practices in similar Georgia locations. And in small towns, word travels quickly.

“It would have been much more difficult if I tried to do that in a large city,” he acknowledges. “But I didn’t want to buy a practice and go immediately into debt. I just felt more comfortable building something on my own.”

, Little conducts embezzlement examinations on behalf of dentists and advises them on matters related to fraud and embezzlement. In other words, he helps dentists “keep what they have built.”

When Little had to discontinue clinical dentistry due to disability, he enrolled at Kennesaw State University where he began his accounting and general business education. He goal was to become a dental CPA. But after working in public accounting, he decided it wasn’t the field for him.

“I didn’t like taxes and all the things that go with public accounting,” Little says.

But when one of his clients was embezzled, it opened his eyes to the sizeable problem dental practices face. According to Little, two out of every three dental practices will experience fraud and/or embezzlement.

“As a dentist, our primary job function is providing healthcare, so we’re not trained to be business people,” Little says. “We work all day in the back treating patients, so we have to delegate a lot of our duties to someone working up front. So there’s almost a separation between the dentist and the front team member. If the right systems aren’t put into place, it opens up the door for someone to take advantage of the doctor’s trust.”

Serial embezzlers, the type that move from one employer to another, are in the minority, Little says. Most dental practice embezzlers are senior employees who have earned the doctor’s trust and respect, so more responsibility is delegated their way.

“Most embezzlers start off honest,” Little says. “Then something just happens where they take advantage of all the trust that has been placed in them.”

Little says he went to dental school to become a dentist. That was his training. When his chosen career path was no longer an option, it was a bit shocking.

“I was in my 40s at that point,” he recalls. “So I was well into my professional career. It’s always a challenge at that age to completely reverse and find something new. That was the most stressful, taking that deep breath and figuring out what to do.”

Returning to college to obtain his accounting degree at age 47 was a culture shock, Little says, adding that he was old enough to be the father of many of his classmates.

“My kids were that age,” he laughs. “But I have that analytical personality. It’s something I don’t regret doing.”

Challenges abound in fraud and embezzlement as well. Little explains that most dental practice fraud doesn’t usually involve dollar amounts that reach into the hundreds of thousands. But when the dollar amounts are smaller, they can often be more difficult to detect.

“A smart embezzler will always keep their embezzlement at a low level, because that's how they avoid being detected,” Little says. “That’s how they move the needle.”

The typical embezzlement tends to be around 3 to 5 percent of the practice’s collections, Little says. That’s the area where the dentist will first notice cash flow issues. If the employee is disciplined enough to stay below 3 percent, they can prolong the embezzlement for a fair amount of time.

“(The embezzler) can earn a pretty good living at that 2 to 3 percent mark,” Little says. “But what happens is they get greedy. They get away with it for a while and they take more chances, and that’s when the doctor notices.”

The main goal of embezzlement examinations, Little explains, is to confirm whether or not any fraud or embezzlement is occurring. If there isn’t any illicit activity, it’s important to understand what made the dentist think there was. Recommendations can then be made to change some practice procedures.

“If it is occurring, we want to let the doctor know why it happened, who’s doing it, what the technique is, and what the doctor’s options are as far as whether the doctor wants to press criminal charges, file a civil suit,” Little says.

It’s also critical that no one from Prosperident step foot in the doctor’s office during an embezzlement examination.

“Everything is done remotely,” Little explains. “We want to make sure the suspect has absolutely no idea that an investigation is being conducted.”

Little says that although he’s had to discontinue clinical dentistry, it’s still very rewarding knowing that he’s serving his profession. He understands where his dental colleagues are coming from; that they went to dental school to become dentists. If he can do something to help them run their practices a little better, or keep them out of trouble, that’s his reward.

“One of the things I hear from conference participants when I lecture is they feel comfortable talking to a dentist, because I know exactly what they’ve been through,” Little says. “It gives me a unique perspective.”

And that’s Little’s approach. He knows the field, he knows the jargon. He puts himself in the dentist’s position to better understand where he or she is coming from.

“It helps that we come from the same backgrounds.”

According to Pat Little, D.D.S., F.A.G.D., C.F.E., embezzlement can affect between 3 and 5 percent of a dental practice's revenue. Little knows a thing or two about that, and he has dedicated himself to helping dentists avoid pitfalls that can lead to fraud and embezzlement. Unfortunately, when it comes to dental practice embezzlement, it's often more senior employees that you need to keep an eye one, Little says.

Getting more five-star reviews for your dental practice may be as simple as asking for them. Does your practice have a system in place for asking satisfied patients to write reviews? 

Positive online reviews: If your dental practice isn’t getting them, it’s time to ask why. It’s also time to make those positive online patient reviews a reality. Because every business needs a positive reputation online in today’s highly competitive market.

“When you look at today’s consumer, they’re not saying to themselves, ‘Oh, I need to go to a dentist, just any dentist,’” explains 

, which helps small businesses attract local customers. “They’re very much aware they have options.”

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Those options go beyond the limited scope of reference that a friend or neighbor may provide. Sure, those references still exist, but they’ve been expanded. And they've been expanded online. Now consumers can visit any number of online review sites and get a feel for what their experience will be like with a particular dentist.

“When someone sees one dentist that has 45 reviews and with an average of a four-and-a-half star rating, and the next one might have only four stars and only 12 reviews, they’re naturally going to trust the one that has more reviews and a higher star rating,” Yerian says. “Because more people have had a positive experience there.”

Yerian explains that if a business simply exists online, if it doesn’t initiate conversations with its customers, that business will often be the victim of negative reviews. That’s because people love to vent when they’re angry or think they’ve been wronged in some way.

“Unfortunately, it doesn’t necessarily happen the same way when (customers) have a positive experience,” Yerian says.

That’s where tools like LocalSignal can help. Yerian says the system makes requesting patient reviews on Facebook, Google and Yelp easy. It prompts small businesses like dental practices to initiate conversations with their customers to learn about their experience by building those interactions into the process. It can be as simple as the receptionist asking patients about their visit on the way out. When a patient responds positively, ask them if they would be willing to leave a review on Google or Facebook.

“Nine out of 10 times a patient who just had a positive experience is going to say, ‘Absolutely. That’s not a problem,’” Yerian says. “All we need is a percentage of them to actually do that, and we can turn that tide of the negative reviews being the more dominant review in that space.”

Obviously, Yerian points out, there needs to be a comfort level to ask patients about their experience and encourage them to submit a review. More specifically, that responsibility falls on the shoulders of staff.

“Dentists need to remember that the customer experience is not only once they get in that chair, it’s also when they’re checking in, and when they’re checking out at the front desk,” Yerian says. “Those people at the desk, coaching them on customer service and really caring about the experience, and really nurturing that relationship with those patients is paramount to the success of something like this.”

Yerian says that customer service is really at the heart of getting outstanding patient reviews. He refers to it as connecting with humans in an authentic way. And he believes that in a standard dental practice, if the entire staff and made an initiative to learn how to connect and care for patients in a non-medical, relationship-based way, it would have a night and day impact not only on the reviews, but the emotions and feelings patients have about the practice in general.

“Because it isn’t just about reviews,” Yerian says. “Patients still have friends and relatives they talk to. They’re going to start transmitting that positive experience to them.”

One approach that Yerian discourages is providing small gifts to patients, such as pens or personalized notepads or even discounts on certain dental services. He explains that it’s important to obtain authentic and candid reviews from patients, not provide incentives for them to do so. Dangling incentives will encourage the people who only want that carrot to complete a review.

“The person who wants to leave an authentic review may look at that carrot and say, ‘That’s odd that they’re offering (the gift) to me when all I’m trying to do is share my positive experience,’” Yerian says. “It almost feels like a bribe.”

Patience is also an important element. Everyone wants to post positive reviews faster, but Yerian says that building that database of reviews can take time. And the practice is a perpetual business that’s going to be operating as long as the practitioner remains active. It’s not necessarily closing in three months.

“Everyone wants to get reviews faster,” he says. “But if done right, you’re going to have a quality result that will produce many quality returns.”

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The best way to continually build positive reviews is to directly ask patients for them. That means building relationships and providing a high level of customer service so that patients have a willingness to post those reviews. Over time, this approach will yield more positive reviews that will block out any negative reviews your practice may have received. 

Engage Patients to Obtain Superlative Online Reviews

What kind of experience are patients having when they come to your practice? That might be the most meaningful measure of success you can have.

What does success mean to you? How do you measure it?

Those are not trick questions, and there is no right or wrong answer. That’s because every dental practice is different, and true success will depend on the individual dentist’s end goal. Are you looking to grow? Become a multi-practice? Or merge with a corporate dental group?

Drew Champgane, D.M.D., a partner with Sparks, Nevada-based 

, says that when many dentists start out, they tend to get caught up in procedures. As a result, they can get very busy doing a lot of things and still not end up being successful.

“I think the best first step (toward a successful practice) is having the right patient flow,” Champagne says.

, agrees. Croft says that the type of practice TD Bank would like to finance would exceed industry benchmarks in the area of steady practice revenue growth. In other words, acquiring new patients, and the number of active patient records.

Champagne has been with the family practice for about 10 years. He and his brother, Jason, purchased it from their father a while back. And while profit and loss statements, and overhead are important considerations, he believes too often dentists can get lost in those numbers.

“I think some of the most important things are new patient numbers,” Champagne says. “How many new patients are you seeing each month? And then, what’s your hygiene retention rate? Obviously, there’s going to be some attrition. But if you’re bringing in 100 new patients each month but losing 200 hygiene patients out the back door, that’s the lifeblood of your practice.”

To Croft’s success measure of number of active patient records, Champagne says the goal of the practice is to make sure every patient has his or her next appointment scheduled before they leave the office. If a patient comes in for a hygiene recall with X-rays and an exam, staff is making sure they’re scheduled for their next hygiene appointment, or perhaps restorative work, before they leave.

“We call it wins and losses,” Champagne explains. “A win is when you have that patient scheduled for their next visit before they leave the office.”

Champagne says that his brother, Jason, is more of the “numbers guy” in the practice, whereas he tends to work off more of a gut feeling — much like their father did.

“I don’t know how many metrics dad looked at, but he always made sure everyone in the practice was happy,” Champagne explains.

That’s patients as well as staff, he adds, noting that many staff members his father had when he first opened the practice in 1981 are now retired, but are still patients of the practice.

“They love the environment he fostered,” Champagne says. “It created a great work experience. And sometimes, that’s even bigger than the money that comes in. Creating that work experience and amazing relationships with patients and staff members is something that lasts a long time.

It’s also something patients notice. Champagne acknowledges that the aspect of going to the dentist is often the butt of many jokes. He says that a dental practice is not an amusement park where people come and say it’s exactly where they want to be that day.

“I’ve had a number of patients tell me that when I work with certain assistants, they say they watch us work together and can tell we go hand-in-hand,” he says.

Speaking of going hand-in-hand, there are patients who are so comfortable in relationships with their hygienist that, if the hygienist calls out sick one day, those patients will often reschedule even if another hygienist is available.

“(The patients have) been seeing them for 10 years,” Champagne says. “(Patients) spend an hour with them, and it’s a pretty intimate hour spent together.”

Champagne says he’s been fortunate in his career to have many mentors, from his father and brother to some of his father’s colleagues he worked with at the University of Louisville School of Dentistry — the same school his father attended.

“We’ve all come up with the same approach that if you treat patients right, if you keep them coming back, the money will come,” Champagne says.

Historically, he adds, dentists may not have been the best businessmen. But they were able to create a good business because they provided patients and staff with great experiences.

“Having good patient retention affects your bottom line,” Champagne says. “Without a doubt.”

Are you giving your patients the optimum dental experience? Metrics aside, happy patients are retained patients, which improves patient flow. And that's one of the best indicators of a successful practice.

Maximize the Patient Experience to Measure Practice Success

 witnessed more pain and human suffering at a young age than any child should.

Growing up in Vietnam in the late 1960s and early 1970s, Letran’s life was a newsreel. She experienced bombings and saw some people dying while others fled their homes. And in 1976, when Letran was 8, her mother died from cancer.

“My dad and his two younger sisters, we all moved in together,” Letran, D.D.S., recalls. “We lived as a big, extended family.”

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Then in 1981, the Vietnamese communists went to war with China in the north and Cambodia in the west. Young men were being drafted. One of Letran’s aunts decided to escape the country. She took her two children, Letran and her older brother, and two other cousins, and left.

“My dad told me, ‘You’re the oldest daughter in the family. You need to go help your aunt,’” Letran says.

So she left her father and two younger siblings, and after several months in a refugee camp in Malaysia followed by six months in New Orleans, settled in California. She never saw her father again.

When Letran was an undergrad at the University of California, Riverside, she knew she wanted to work in health sciences. But being a physician?

“I didn’t like the idea of having a beeper,” she admits. “To me, it seemed like you’re tied up to your work.”

She looked into pharmacy, and even interviewed a few pharmacists.

“They told me they count pills,” Letran laughs. “That didn’t sound too exciting. So, that left dentistry. I sort of went into the field by default.”

But it turned out to be a wonderful career move.

“I think it gives me the most freedom,” she says. “It’s a career about relationships, where I am ultimately in control. And looking at the way medicine is now, I don’t think you’re able to develop a relationship with your patients. But we still can in dentistry.”

After graduating dental school, Letran did a general practice residency at 

. She followed that with a mini residency at 

Rancho Los Amigos National Rehabilitation Center

. Most patients she saw were medically compromised — quadriplegics, children with cerebral palsy, many in wheelchairs.

Today, in private practice, Letran still takes care of those individuals.

“I have quite a few of patients like that,” she says. “You know, it could be people with MS coming in a wheelchair, or patients who are blind, patients who are deaf. They’re just a patient; just a person that I would treat in my office.”

The work she does could be viewed as rewarding. On some levels, it could be seen as giving back. But Letran doesn’t see it that way. Instead she sees herself as a service leader within the community.

“I see it as no different than seeing a patient on the schedule and knowing that person is difficult and demanding,” Letran explains. “It’s satisfying and fulfilling in the sense that I serve a patient in need.”

Letran tells the story of a patient in her 80s who has been coming to the practice for the last 20 years.

“She never looks happy,” Letran says. “She barely ever smiles. The first time I met her I was so hoping she would leave.”

But she didn’t. She kept coming back, complaining from the time she made her appointment by phone all the way into the exam chair. Letran takes it all in stride.

“That’s what makes this career interesting and fulfilling,” she says. “Between the challenge of the work and the personality of the patient, I don’t think anyone can have a monotonous day in dentistry.”

Letran is also a certified high performance coach. She defines high performance as a heightened and sustained level of clarity, energy and productivity. She was trained, she says, by one of the best personal development coaches around, 

“One of the reasons I want to be a high performance coach is because I lead my life basically as a high performer,” Letran explains. “I know very clearly what I want. I do the same things to get to my goal. I’m very energetic. I don’t take any supplements, and I don’t drink coffee. I show up every day with energy and joy, and kind of make everybody in my office do the same thing.”

But it doesn’t stop there. Letran attends conferences and seminars looking to help others learn the benefits of being a high performer. She takes business owners and entrepreneurs through the process of understanding where they are and what they should be doing. Then she gives them steps — changes they can make in their habits and business strategies to become high-performance leaders.

“You should be able to have kids and have a family, and still do your work, and still have time to do other things,” Letran says. “A lot of times I hear people say, ‘I don’t have time,’ you know? And ‘I’m too tired’ and it’s 3 o’clock in the afternoon. So, I want to help people be able to do what I do.”

When Letran does allow herself personal time, she often spends it reading. Her material of choice? Business, and personal-development books.

She also spends a lot of time with her children.

“They’re a little bit older now,” she says. “Two of them are in high school, and the oldest one is in college. And we love to travel.”

They also love to talk, and will often go out to eat and spend time sitting around and talking.

“We just love spending a lot of time with each other.”

When Emily Letran, D.D.S., says she has seen it all, she has. A native of Vietnam who came to the U.S. in 1981, Letran rose above the death and destruction she experienced as a child, and today helps other dentists realize their full potential.

From War-Torn Vietnam to the U.S.A.: One Orthodontist's Success Story

Dental labs are more integrated in patient care than ever before. They're also a major component of a practice's overhead. That's why dentists need to prioritize their working relationships with labs.

, understands the value of partnering with the right dental lab. Kaye Dentistry is a world-class reconstructive, cosmetic and implant practice, so working with the right lab is critical to his success.

Not to mention that lab costs comprise between 8 and 10 percent of a practice’s overhead. With that amount of money on the line, you want to feel comfortable in your lab relationship.

“I think about two-thirds of dentists change labs within two years,” Kaye says. “And I think it may be related to changes in quality. So having a partnership with a lab where the quality has changed, or it’s not what the dentist expects, then you have somebody you’re able to communicate with. That’s a great partner.”

Kaye explains that in today’s digital world, open communication between the dentist and the lab is critical. Lab technicians can see the preparation of a tooth even before a prescription has been sent. So while there have always been partnerships with dental practices, the lab today is truly integrated into patient care.

And the beauty of building that relationship, Kaye explains, is you can try a lab first to see if it works for you.

“Most labs will give you that opportunity,” Kaye says. “That’s the beauty of selecting a lab. There are no long-term contracts with a lab. If you get a recommendation, you can try a lab, and see how it works.”

However, the concern within the dental profession is that when you try a new lab the first two cases may be done by a five-star technician, and the work is great. But as you move on over time and send in more cases, you might get assigned to their second- or third-rate technician.

“We know that all technicians like all dentists are not equal,” Kaye admits. “So that’s always a concern. The quality has to be continually monitored when you have a lab. The tenth crown or the hundredth crown should look as good as the first. And I think with digital we have more of a chance to attain that.”

Approximately 10 percent of a dental practice's overhead is tied up in lab costs. Partnering with the right digital dental lab can be a boon or a bust when it comes to affecting that debt percentage. Gary Kaye, D.D.S., F.A.G.D., explains how building a strong business relationship with your dental lab will save you money in the long run.