Renee Knight is a freelance writer and editor who's been covering the dental industry for 15 years. 

Renee Knight

While there are no documented cases of a clinician acquiring a disease from laser plume, the possibility is there. That’s why it’s so important for you to wear the proper mask when using a laser.


	When you use any type of instrument, you’re going to create a plume or aerosol coming out of the patient’s mouth, New York laser dentist Dr. Robert Convissar said. When you use a laser you create a plume of smoke, and research shows that smoke could contain carcinogens and DNA particles.

“It’s generally not something you’d want to inhale,” said Dr. Convissar, who lectures worldwide about dental laser applications. “It’s something that can potentially cause disease.”


	You need your mask to filter out disease-causing agents that might be in laser plume, and regular cup masks just don’t meet that standard, Dr. Convissar said. Your mask should have a higher filtration rate-0.1 micron to be exact.

These masks are easy to find and come in plenty of different varieties, including tie on, ear loop and ear loop with face shield. Dental hygienists or assistants who are in the room during a laser procedure need the same level of protection.

The filtration your mask should have when using a laser.

“There’s always the potential of contracting a disease from inhaling the plume,” Dr. Convissar said. “The odds are highly unlikely but they’re higher than zero, and you don’t want to be the first case. A patient could walk into your office and have hepatitis that wasn’t diagnosed. If you use a laser on that patient you could potentially inhale some DNA from the hepatitis virus. The same thing goes for any STD or any other number of diseases. The good news is hepatitis and many other diseases are spread by contact with blood and saliva, not by inhalation of plume, so the risk is small. The odds of contracting a disease is highly unlikely but it’s higher than zero, and you don’t want to be the first case.”

The No. 1 way to protect yourself against plume is wearing the correct mask, Dr. Convissar said, and the No. 2 two way is to make sure you have high speed suction right by your laser. That will get rid of the majority of the plume, dramatically decreasing the danger to you and your staff.

If you have oxygen and/or nitrous oxide in the room, make sure they’re turned off before you use your laser. Keep anything flammable away from the surgical site.

Protecting yourself while using a laser doesn’t stop with a mask-you also need to wear safety glasses, Dr. Convissar said. But just like you can’t wear just any mask, you can’t wear just any glasses. You need to make sure the glasses are wavelength specific; every wavelength is different and absorbed by different parts of the eye. Manufacturers typically provide three pairs of goggles for each laser they sell: one for the dentist, one for the patient and one for the assistant.

Many dentists use magnification these days, Dr. Convissar said, and those dentists still need to wear wavelength-specific protection.

“Various optic companies make filters that can go in the dental microscope so there’s no problem,” Dr. Convissar said. “There are a variety of manufacturers that make clip-ons that clip on to loupes to protect the dentist.”


	Before you use lasers in your practice, you need to learn about safety. The bare minimum education that any clinician should have before putting a laser into a patient’s mouth is Academy of Laser Dentistry (laserdentistry.org) certification.

The 12-hour course is given over two days and goes over every wavelength and safety precautions you and your staff need to take when using a laser.


	Lasers are great additions to your operatory, and as long as you take safety precautions-including protecting yourself and your staff from laser plume-you’ll reap the many benefits of laser dentistry.

Articles

You don’t want to be the first. While there are no documented cases of a clinician acquiring a disease from laser plume, the possibility is there. That’s why it’s so important for you to wear the proper mask when using a laser.

Is your laser making you sick?

An associate or hygienist you’ve worked with for years has decided to leave the practice, and not on the best of terms. This colleague may feel slighted or angry for one reason or another, and will use those negative feelings to justify trying to convince your patients to leave as well. This colleague may not even feel any animosity toward you or the practice, but still might feel entitled to the patients you’ve both worked with for years.

Patient stealing doesn’t happen everyday, but as a practice owner, you need to know how to protect yourself so it doesn’t happen to you.

“People tend to not think clearly sometimes,” said 

. “They can justify all sorts of things that aren’t right if they’re in a desperate situation and think it will help their pocket book.”

Although there’s no guarantee they’ll honor it, it’s a good idea to have associates-including hygienists, dental assistants, office managers and financial coordinators-sign an agreement indicating they understand the 

 belong to the practice and they cannot try to take them when they leave, Limoli said. Make sure they understand there will be consequences if the patient list is shared or transferred to another party. Let them know on the front end that they shouldn’t even think about it. A local attorney should be able to help you outline this agreement.

Making sure your team members are happy is also key to making sure they don’t want to steal from you when they leave, said 

. Most people leave because they’re not happy with the leadership, and that’s a role you have to take seriously in your practice.

“You need to be close to your people, close to your team,” Spiel said. “You have to know where their hearts are and be able to address issues that come up.”

Associate dentists typically sign noncompetes, Spiel said. Most dentists honor this and set up new practices outside the boundaries of the noncompete when a relationship ends and use billboards and other means of advertising to draw patients to their new practice. But Spiel said he has one client who opted to go against his noncompete agreement and thinks he’s getting around it by having his staff make the phone calls. In reality that doesn’t matter, Spiel said, and no matter how he tries to paint it, this doctor has compromised his integrity and the practice’s integrity.

“It’s a sad situation because it impacts every other decision that’s made in the practice,” Spiel said. “If you’re willing to compromise that type of clear agreement, how willing are you to compromise things that aren’t nearly as clear?”

If someone works with your software everyday, it wouldn’t be difficult for that person to grab a USB flash drive, make a backup of your practice database and then walk out the door with it, Limoli said. You have to keep your system as locked down and secure as possible so this doesn’t happen; don’t authorize every user to make back ups. Make sure only you and your office manager have access to certain reports. Don’t give everyone the ability to delete patients.

“It’s very easy,” Limoli said. “I could walk into a practice, run a patient report, take it with me and get on the phone and call patients for whatever reason I wanted. If I’ve been with a practice and I want more money, but the doctor says no and another dentist who is desperate for a hygienist says he’ll give it to me, how tempted would I be to get that list and call all those patients I’ve been treating for years?”

Also be cautious of team members who can log into the system at home, Limoli said. Make sure you limit what they can do; don’t give them the ability to transfer files or make changes.

If a patient mentions someone who used to be with the practice called and tried to lure him or her away, don’t use this as an opportunity to bad mouth the person who made the phone call, Limoli said. Thank the patient for telling you and for staying loyal to the practice. Write that patient’s name down. Keep a list of all the patients whose records you’ve sent to that hygienist’s or former associate’s new practice.

If you had a good relationship with this former employee or associate, Limoli said to go ahead and give him or her a call. Remind this colleague of the signed agreement and that making these calls is wrong.

If there are only a few patients on your list, Spiel said making a call to confront the person who is trying to harm your practice might help, but for the most part your best course of action is getting legal counsel right away. You can also write a stern letter asking the offender to cease and desist.

“If there’s a pattern, they’re clearly doing it under ill will,” Spiel said. “And it’s a sad place to be in. It’s really a situation that isn’t a fun place to be, but unfortunately what I’ve seen is the only effective way to deal with it is to pursue using legal resources.”

Your front staff will eventually get a call from patients who have decided to stay loyal to a person rather than the practice. Whoever answers your phones should be aware of the situation and know how to handle such a call. It might even be a good idea to give them a call yourself to thank them for being a patient with your practice and to let them know they’re welcome to come back whenever they’d like.

“You certainly don’t want to complain over the phone about that associate or hygienist who’s left,” Spiel said. “You thank them and express your gratitude for their loyalty to you and your practice and how you value them. Don’t go into details with them.”

The hygienist is the one team member your patients see the most. Good hygienists, over the years, establish relationships with their patients and often become like extended family members, Limoli said. These are the hygienists patients request for each visit, the ones who know their children’s names and birthdays. If you have a hygienist like this who’s been with you for 15 years and then decides it’s time to move on, there’s a good chance some patients will follow.

Patients also can develop feelings of loyalty for associates who have been with a practice for awhile. To avoid this, patients need to meet and actually have relationships with more than one associate, Spiel said. Each dentist in the practice should have the opportunity to develop a relationship with each patient.

“It’s also how the front desk and receptionist treats the patient. It’s the entire team,” Spiel said. “Everybody is involved in treating patients with exceptional care and warmth. If everyone achieves that uniformly, if one person leaves the chances patients will follow are slim. They’ll be loyal to the practice, not just one individual.”

Renee Knight is a senior editor for DPR. Contact her at rknight@advanstar.com.

Could former staff steal your patients?

Whether you’re moving to a new office space or adding 

 to the office you’re currently in, there’s plenty to consider before you get started. From cabling to computer systems, you need to think about what makes the most sense for your team and your practice.

We recently talked with Vitaly Rindner, President of 

, a technology consulting company for dentists . Here, he outlines what you need to know before going digital.

 What should dentists consider when adding digital radiography to their practice?

 If you’re switching from analog it’s going to require a lot of additional pieces in the practice. When interacting with a patient to discuss treatment options digital radiography typically requires a computer installed in the operatory. In a lot of cases that computer will have two displays-one facing the patient and one facing the dentist or hygienist. A lot of dentists opt for a TV as opposed to strictly a monitor because when they’re not showing 

 to patients they can use it for patient entertainment.

If they’re retrofitting an existing office space, then putting computers within the operatory often requires cabling the office space because the computer needs to be networked with the server, which stores the digital radiography images. From the server standpoint they should use a server that has redundant components so their office can continue to run in the event of a component failure. It’s also critical to have data backup protection so patient data isn’t lost at some point in the future.

If you have to do a lot of cabling it often will require opening up walls within the practice, so think about adding things such as speakers for music throughout the practice. Patient entertainment options all are very easy and low-cost to do at that stage of construction, but not after.

Also, if you’re going to cable a practice, it’s better to over-cable than to under-cable. You’ll have extra capacity throughout the office space for future use, allowing the practice room to grow.

 How far in advance should they start planning?

 Under ideal circumstances, at least three- to-four-months before the system is installed they should be evaluating what their office needs, such as cabling and computer systems. Some times offices already have a lot of infrastructure in place. They may have a patient management system but not digital radiography. For some, it’s not a huge upgrade, but often that’s not the case. In many cases a lot of equipment has to be installed before everything works together in a cohesive manner.

 What’s the biggest mistake dentists make when adding digital radiography? 

 The biggest problem I find is dentists don’t consider every aspect of how they’re going to use the software. If you want to print out x-rays, for instance, that’s often an after thought, so then there’s really no space for the printer and the process ends up being clunky. Ideally the dentist should think through who would be using the system on a daily basis and try to anticipate their different needs. Dentists also often mix different brands of digital equipment into their office and try to make everything work through the use of software bridges. For example, one vendor for intraoral cameras, another for digital x-ray, a third for their panorex station and a fourth for their practice management. Although this can be made to work, the result often is messy and less than satisfactory.

Often the digital radiography vendor can help with planning and we work with a lot of dentists to install all the equipment in the office. We have a lot of experience and we know which questions to ask them. For example, we ask how many sensors they’re going to use. Obviously you want to spend as little as possible so many naturally default to one sensor and just share it between operatories, but that slows the practice down in terms of how many patients they can realistically service simultaneously. We also talk about if they want patient facing displays, where they’re going to put different equipment in the operatory if it’s a retrofit. Often, the operatories require special PCs that are very small and heat tolerant. In a retrofit the dental cabinetry likely doesn’t have room for a traditional PC, so you have to use special equipment for everything to work right.

Whether you’re moving to a new office space or adding digital radiography to the office you’re currently in, there’s plenty to consider before you get started. From cabling to computer systems, you need to think about what makes the most sense for your team and your practice.

Get ready to go digital

Of course you want to help when you can. You want to be flexible and make sure all your patients get the care they need. But you also have to be careful.

Most of your patients, if not all of your patients, are good people, people who need your guidance to ensure they maintain the best oral care possible. Because of that, it’s easy to let your guard down and maybe even become a little too trusting. Even though people generally are good, there are some you need to watch out for, the ones who are always looking for ways to walk away with something for nothing.

So how can you tell when a patient sincerely needs help or when he or she is trying to pull a fast one? Do your research, get to know your patients and pay attention. Here, we break down the different patients who may walk into your office looking to walk out with a freebie.

If a patient you don’t know comes into your office and tells you she has cancer or some other terminal illness, is overwhelmed by bills and can’t pay for needed treatment, don’t question the story in front of the patient but don’t just assume that patient is being truthful. Recently a 

convinced her community she had terminal cancer, when in fact she wasn’t sick at all. The community came together to help pay for her wedding, only to find out it had all been a lie. Now of course this is an extreme situation, but people can become desperate when they find themselves in tricky financial situations.

So how can you verify such a story? Ask the patient for the name of his or her physician and other doctors on his or her health care team, said Penny Reed Limoli, owner of the 

. You should talk with them any way if you’re going to provide treatment and become a partner in the patient’s care, and this way you’re able to confirm what the patient is telling you. Check for other community connections through local schools and churches. Ask the patient if he or she is a member of a local church because you’d like to partner with them to help in some way or find out what school their children attend so you can use that avenue to offer help. If the patient is reluctant to give you this information, it’s a sign the story may be made up.

“Most of the time we don’t do our homework at all because who isn’t touched when they hear a story like that?,” Limoli said. “ You don’t want to do background checks but network in the community with other people who know them. It won’t make you bullet proof but it will reduce the likelihood that you are taken advantage of. “

Yes, times are tough right now and many of your patients struggle to pay for the treatment they need. Many of those patients are willing to work with you to find ways to make payments, but there are others who use the economy as an excuse not to pay their bills.

In the last few years, Kimberly Brozovich, a business advisor at Jameson Management, has seen more and more practices agree to let patients who are struggling financially pay their bills when they can. Yes, it’s tempting to help, but helping too much without any real agreed upon payment could lead you to financial troubles. The problem is, who knows when the patient can make that payment, or if you’ll ever actually get paid for the services you provided.  

“All dentists need to have a written financial policy and even if a patient lost his or her job there needs to be some financial responsibility and a plan of action outlined,” Brozovich said. “Find a way to make financing affordable, whether that’s through Care Credit or some sound financial option. You need a plan other than the patient saying, ‘I’ll just pay when I can.”

Even if a patient tells you upfront he or she doesn’t have a lot of money to pay for dental treatment, don’t let that influence the treatment plan you present, Brozovich said. Always show them all the ideal treatment first, not just the most affordable option. It is easier to present the ideal treatment when you know what your patients’ goals are and what is motivating them to be in your office. Once you identify a patient's goals, then you have an emotional anchor to tie him or her back to. Only then does the dentistry become more of a want versus a need.

“Often times the doctor confuses the treatment plan with the financial arrangement and those should be two separate things,” Brozovich said. “The financial arrangement is a summary of the treatment the patient wants to do and the total fee, and the treatment plan goes through the treatment you want to do and doesn’t include the fee.”

Once you find out your patients’ goals and get them motivated to go through with some of the treatment, you can talk about payment options and even about what they can afford to do right away and what they can wait to do later. But don’t just assume because a patient has lost a job or is struggling financially that you can’t work with that patient to figure out finances. You have to get something from the patient beyond “I’ll pay when I can” before you go forward with treatment.

Sometimes, even if you’ve worked a payment agreement out with your patients they show up the day of treatment without the promised payment, Brozovich said. You need to have a protocol in place for such situations to help you decide what to do. Do you go forward with treatment and risk not getting paid, or do you opt for lower production and re-schedule until the patient can make a payment?

“Look at the relationship you have with the patient-- how long have you worked with the patient, is the patient compliant, is this unusual,” she said. “If this is a new patient who needs extensive treatment then you might want to have them call their spouse and take a credit card payment over the phone or look at other revenue resources before treatment is rendered. Look at the treatment you’re providing. If you’re doing six veneers and a new patient is showing up without payment, then you may want to opt to lose that production that day.”

Using deals, such as discounted whitening, are great ways to get first-time patients in the door, but all too-often that first visit ends up being the last, Brozovich said.

Typically, a patient hears about your whitening deal and that’s all that patient wants to talk about once in the chair. This patient isn’t interested in what problems may be going on in his or her mouth. You have to find a way to make this patient a forever patient, and not just someone who comes in, takes advantage of your whitening deal and is never heard from again.

“Dentists often get manipulated in these quick new patient numbers because the number of new patients has gone up but the conversion is very low,” Brozovich said. “If you use something to motivate patients to come into your practice such as whitening, once you get them in the door you want to help support them with goals.”

Patients who take advantage of you and your team don’t always have financial motivations. Sometimes they simply don’t have respect for your schedule, or the fact that there are other patients you have to see throughout the day as well.

Patients who routinely show up late or who don’t show up at all are taking advantage of you and your team, not caring what it does to the rest of your schedule that day. Of course there will be times when patients have emergencies that force them to cancel or show up late, that’s understandable, but you can’t ignore the patients who seem to make a habit of coming in late or missing appointments all together.

So what can you do? Limoli suggests having one of your team members talk with the patient, without being accusatory or negative, about what you can do to help them get to their scheduled appointments on time. Remind them that your team strives to see them in a timely manner and that you need the entire appointment time so that you’re not rushing through treatment.  Ask them what’s the best way to remind them about upcoming appointments and make sure you use that method when it’s time for that next appointment reminder.

If you don’t talk to the patient and ignore the problem, then the patient will think it’s OK and will continue to show up late to appointments, Brozovich said.

“These patients manipulate the doctor so easily because the doctor and the team are passive aggressive with that situation,” Brozovich said. “The patient gives an excuse, the doctor and team accept it and treat the patient or ignore the situation. And so just like you need to have a written financial policy, you also need a written protocol on what to do with late patients.”

You need to decide how late is too late, Brozovich said, and how to communicate that when the patient calls to let you know he or she is running behind schedule.  Don’t make the patient feel bad about being late, but let that patient know you’ll do as much treatment as you can, and sometimes you may need to re-schedule part of the appointment. The appointments are as long as they are for a reason, and if you try to squeeze everything in into a shortened about of time, you won’t be as thorough and at the same time you’re telling the patient you don’t really need an hour to do the exam, 45 minutes is plenty of time.

These patients only come to your practice when a tooth hurts. They don’t see the value in regular hygiene visits and have no plans to come back to your office once your fix whatever the problem is. You find ways to fit them in, provide same day treatment and then send them on their way until the next emergency comes up.

It’s up to you to give them a reason to come back, Brozovich said. After you’ve dealt with whatever the emergency is, it is important to motivate the patient to come back for a comprehensive exam.  

In most cases, there are more areas in the patient's mouth that need treatment. During the emergency appointment take another photo of an area of the patient’s mouth that needs to be treated and communicate to the patient that you are concerned. Invite the patient back for a comprehensive exam. If you know you’re talking with a patient who’s made a habit of only coming to your office when something hurts, talk to that patient about identifying goals and the importance of prevention. Give him an emotional anchor, something that will change him from an emergency-only patient who only sees you when he absolutely has to, wreaking havoc on your schedule and adding stress to the practice, to one who’s actively involved in improving their oral health.

Remember, you don’t need to be suspicious of every patient who walks through your door, but it isn’t a bad idea to get to know them and to be aware of the complications any new patient can bring to your practice. This will not only help you avoid losing out financially on individual cases, it will help you bring more money in as you turn some of these one-time patients into forever patients and perpetually late patients to on-time patients. It’s worth the time and effort it takes to make it happen.

Of course you want to help when you can. You want to be flexible and make sure all your patients get the care they need. But you also have to be careful. Most of your patients, if not all of your patients, are good people, people who need your guidance to ensure they maintain the best oral care possible. Because of that, it’s easy to let your guard down and maybe even become a little too trusting. Even though people generally are good, there are some you need to watch out for, the ones who are always looking for ways to walk away with something for nothing.

Are your patients taking advantage of you?

with your lab technician, you’re losing money.

Between time spent on re-makes and time lost going back and forth with your lab after you’ve sent the case in, not communicating with your lab on the front end can be a costly mistake. As a dentist, chair time is your biggest commodity, cosmetic dentist Dr. Robert Lowe said. If you’re not at chairside or if you’re constantly re-making cases when you are, you’re costing yourself money.

When you don’t communicate effectively, there’s a good chance your lab won’t give you what you need. And it’s not because the technicians there aren’t good at what they do. They’re not magicians, and if you don’t provide them with the information they need and then opt not to return their calls or have an assistant who isn’t knowledgeable about the case handle it, it becomes difficult for them to do the level of work you and your patients expect. You can’t expect your lab to “make it work,” which, unfortunately, is what many dentist do, said Daxton Grubb, President of 

“That old school mentality, along with not being able to get the doctor on the phone is really where it lies,” Grubb said. “That causes us to move in a direction we shouldn’t, unless we’re into gambling. Let’s minimize our expenses now. Let’s get the patient back in and re-evaluate before we lose time and spend money on something that won’t work.”

with your lab. If your lab technician tells you there’s something questionable about the impression you sent, you should listen, Grubb said. Maybe the patient didn’t bite down all the way or maybe the margins don’t look right. Regardless of what the problem is, if your lab technician tells you a new impression is in order, then it’s time to call the patient back in. This might seem like an inconvenience, but it’s a lot easier than starting over when you realize the restoration simply isn’t going to work.

Many dentists send their lab an impression and a prescription, Dr. Lowe said, but that’s not enough. Often, the lab will provide you with a check list of everything the technicians need to complete a case, which usually includes a photo of the patient’s full smile and a picture of the patient’s full face.

“In today’s digital world with digital photos, there’s no reason not to. I send a CD with intraoral pictures with every case,” Dr. Lowe said. “That’s the way my technician sees my patients. It’s not just a picture of the tooth we’re trying to match. I send a picture of the patient’s face, of the patient’s full smile, how much of the gum line shows in the smile and how many teeth show in the smile. The technician never gets to meet the patient unless the dentist sends photographs.”

And when it comes to the prescription, don’t just leave a note telling the technician to call you. It’s best to provide the necessary information up front, but most dentists don’t do that, said Bennett Napier, Co-Executive Director of the 

National Association of Dental Laboratories

. According to an NADL survey, 2/3 of the respondents said clinicians routinely give them incomplete prescriptions.

If the lab doesn’t get this information up front, it will take longer to complete the case, Napier said. That means you won’t get your case back when you expect to, which only leads to anger and frustration.

Your lab technicians shouldn’t be afraid of you. Dr. Lowe makes sure the technicians he works with know they can call if they have a problem or questions. They shouldn’t be afraid to tell you about problems, and you should be comfortable talking with them about any issues that come up. If you’re not happy with something the lab did and you just get angry about it, the situation isn’t going to change. You’re just going to get more and more frustrated when the problem continues and move your business to 

 in an attempt to solve the problem. In most cases, it doesn’t need to go that far. If you talk with the lab about the problem and how you’d like it resolved, the problem likely will go away much quicker.

It also doesn’t hurt to let the lab know the best way to reach you when the technician needs to talk out a problem, Grubb said. Let the lab know if you’d rather communicate on the phone, via text message or e-mail.

If you’re what Grubb describes as a “hopper” who moves from lab to lab because none of them can meet your expectations, maybe it’s time to take a look at how you do business. Are you and your lab just isn’t getting it, or are you doing the minimum and still expecting quality results in return? If communication is lacking on your part, it’s time to change the way you think about your dental lab. This is a crucial relationship, and you have to respect the lab technicians and know you trust them with your cases.

Building a strong relationship with your lab starts with both sides knowing what the other expects and needs, Dr. Lowe said. Interview your technicians and make sure you establish expectations for both sides. If you lay out your expectations up front, they’ll be more likely to meet them and vice versa.

“The lab technicians blame the doctor for not taking good impressions and the doctor blames the lab technician because the fit’s not right,” Dr. Lowe said. “A good dentist/technician relationship has to start with communication on all levels. It starts with each party letting the other one know what they need to get from that person to do their best work. And when there’s a problem, both sides have to take care of it regardless because we’re dealing with humans. Nothing is perfect.”

To really strengthen the relationship, it’s also a good idea to meet your lab technician in person, Grubb said. He encourages his clients to come to his lab for a tour so they can see and really understand what they do there. Clients always leave with a new understanding and an appreciation for the lab technician’s role. But although he pushes it on every client, only about 5 percent of them take him up on the offer. That 5 percent represents his most successful, most easy-to-work-with clients.

In an attempt to stay connected, he also puts together CE events, lunch and learns and even has a dentist on staff who talks with dental assistants about why communication is so important to successfully completing cases.

“It’s amazing the connection between coming to the CE, visiting the lab, opening up communication and a successful dentist,” Grubb said. “It’s amazing the connection, how they all link together.”

Working with a local lab is another great way to enhance communication, Grubb said. You can actually go there in person and talk about cases face-to-face, which is such a benefit to both you and the lab technician.

Remember, poor communication doesn’t just cost you time and money; it costs the lab you’re working with and your patients. When communication is lacking, it can be frustrating for everyone involved.

To make the process smooth from the beginning, don’t take any short cuts, Dr. Lowe said. Give the lab technicians all the information they need to do their job, and don’t skip any steps along the way. This will only cost everyone time in the long run.

“The problem is time. Everybody is in a hurry. Everybody is trying to do too much too fast and I think there comes a time when expediency and efficiency and speed and quality start to separate,” Dr. Lowe said. “That’s different for everybody. You have to know your own limits. Not to say you shouldn’t be productive, but don’t take so many short cuts you end up spending more time to get it right.”

You and your lab technician need each other to do your jobs. To get the best results for your patients, you have to put the time in to build this relationship. You have to know you can trust your lab to do quality work, and you need to give technicians the respect they deserve.

If you take the time to communicate and work on building a strong relationship, it will only make your cases more successful and your patients happier. And in the end, that makes you look good.

“I tell you, one of the best relationships we have is with our technicians,” Dr. Lowe said. “Patients don’t ask their friends what dental technician did their work. They ask what dentist did their work. The work the technician gives you has your name on it so it has to be good.”

If you’re not communicating with your lab technician, you’re losing money.

Hidden costs: Working with a dental lab

You’ve noticed one of your patients has lost a lot of weight and seems to have trouble focusing during appointments-assuming she shows up. Or maybe another 

in the practice spends a lot of time in his office with the door closed, only to come out acting much differently than when he went in.

Paranoid. Confrontational. Unreasonable. Moody. Whether these words come to mind when you think about a patient or someone you work with, chances are they describe someone who is struggling with addiction. Either way, it’s important for you and your staff to recognize addiction and have a plan in place to address any problems, whether it’s a patient causing a scene in the waiting room, a recovering alcoholic who should avoid certain medications or a hygienist who can’t seem to make it to work on time.

Although it’s not common for a patient to come to the office high, it does happen. Dilated pupils, an inability to focus and nervousness are all signs that you might be dealing with someone on Meth or other drugs, said Audrey Ticknor, RDH, MA, who presents seminars part-time for MAPP-SD (Methamphetamine Awareness and Prevention Project of South Dakota). If you suspect something isn’t right, Ticknor recommends asking the patient directly if he or she is under the influence.

“You are providing treatment to them and if you are doing a procedure that requires local 

 and they’re already high, that could cause a medical emergency,” Ticknor said. “You need to get the information out of them.”

Remember you can’t make a diagnosis, said Dr. Harold Crossley, who is an expert on street drugs and chemical dependency as well as the clinical pharmacology of dental drugs. Maybe the patient you think is an alcoholic had a few shots of whiskey before coming to the office to relieve some anxiety, or maybe the marijuana you think you smell is something else. Making accusations will only leave you open to lawsuits.

What if the patient you suspect is using drugs or 

 brought children to the appointment? What if you fear the patient may cause a traffic accident if he or she drives home? These are all serious situations, and Ticknor recommends offering the patient bus fare, asking the patient if there is someone you can call to come pick them up and, as a last resort, to call the police.

When you’re in this kind of situation, you don’t want to have to think too much about what to do or to debate a course of action with other staff members. You need to have a plan in place, a plan that everyone on staff is familiar with and is ready to implement if the need arises. Sit down with your staff as a group and talk about different situations that might come up and how the team will handle those situations.

As part of establishing a protocol, talk to the local police about who you should contact and what you should do if something happens in the office, said Dr. Mark Storer, a Chicago dentist who lectures on addiction. Ask them what the chain of command is. And make sure you have a contingency for all sorts of different situations, from a domestic dispute in the waiting room to a confrontational patient who refuses to calm down.

“The big thing is putting out the fire before it gets worse,” Dr. Storer said. “The one thing you don’t want to do is get involved with any physical contact with a patient whatsoever. And you don’t want your employees to get involved, either.”

It also doesn’t hurt to have resources on hand that you can offer patients, Ticknor said. Ultimately it’s up to them to seek treatment, but it doesn’t hurt to provide them with information about clinics and treatment centers in the area.

“You can’t do much beyond talking to patients and referring them to services,” Ticknor said. “It’s just like 

. You talk to the patient and say ‘Here are the health risks. You’re putting your life in danger. Here are the 

 risks, here are the costs that might be associated with your continued use. Now that you have all the information, I hope you make right decision.’”

Every office’s patient questionnaire should include questions about drug and alcohol addiction, Dr. Crossley said. It’s important to know if you’re working on a patient with a history of addiction because it does affect treatment. If the patient is recovering from drug or alcohol addiction, you need to be careful with prescribing pain medications and using mouth rinse that lists alcohol as one of its ingredients.

“They’re not going to hide it because they’re worried about relapse,” Dr. Crossley said. “And my opinion is if the patient denies having a history of chemical dependency and you use narcotics to control pain and that patient relapses, that’s his or her responsibility.”

It’s also a good idea to encourage their sobriety, Ticknor said. Ask them when their anniversary is and tell them how great it is to see them looking healthy.

“It always helps to know somebody cares or somebody notices, because it’s not easy,” Ticknor said. “Recovery is probably harder than actually going for the treatment because it’s something you have to continue to do everyday. It’s a struggle. It has to be constantly on their mind. Do I make it through the day or is this the day I fall off the wagon?’”

This type of encouragement is especially important in the early stages of recovery, Dr. Crossley said. Working on patients who are still in rehab can be challenging, but it can also be gratifying.

“Patients in the early stages of recovery have low self esteem and feel like they’ve ruined their life,” Dr. Crossley said. “They go to the dentists and have their teeth cleaned. They don’t ache any more so there’s no excuse to take a narcotic. You fix up their front teeth so they can smile again. They start to build their self esteem and they feel good. It’s really gratifying to see that.”

Dentists have access to drugs through prescriptions and samples. They have stressful lives filled with social, financial and professional pressures. They often think because they know so much about pharmaceuticals and what different drugs do, they can handle using something to take the edge off, Dr. Storer said, but that typically isn’t the case.

When a dentist is abusing drugs, staff members usually notice first. Patients are 

 about the dentist’s behavior. Maybe he’s 

 or showing up late for scheduled appointments. His handwriting might change. The inventory of controlled substances might go up, or someone might notice that he’s writing a lot more prescriptions for family and friends. His office behavior has changed, and everyone on staff knows something is wrong.

Even though you might want to confront him, Dr. Storer said that isn’t a good idea. If one of the hygienists on staff is the one to start the conversation, she may lose her job. If your practice is in a small town, rumors of a drug problem would bring scandal to the practice.

Instead, Dr. Storer recommends contacting your state’s concerned dentist program or another agency that handles addiction. You can tell the volunteers what’s happening at your practice and they’ll investigate. It’s an anonymous call that may save the person you’re concerned about.

“It shows the dentist there is a way out,” Dr. Storer said. “He doesn’t necessarily have to lose everything, and it’s better to do it voluntarily than to be forced to do it by a professional regulatory system. The idea is for these programs to intervene and get the doctor into recovery so he can practice again.”

These programs only investigate people who need a license to practice, so that means the program only works for dentists and hygienists. If you suspect another member of your staff has a problem, the best thing you can do is sit down for a one-on-one conversation (maybe include a witness) and encourage him or her to seek treatment. Remember you can’t necessarily fire an employee who has a substance abuse problem.

To help avoid this type of situation, Dr. Storer also suggests you put together a policy for the office that mandates everyone has to take a toxicology test. Include random drug tests and the right to ask an employee to take a drug test if you suspect there’s a problem with drug abuse. Make sure everyone on staff is aware of the policy.

Whether it’s a patient, a colleague or a staff member who is affected by 

, it’s important for you to know something about this disease and how to handle certain situations. It’s probably not something you’ll deal with everyday, Dr. Crossley said, but when it does come up, you and your staff need to be prepared.

“Preparation and knowledge are really helpful. And compassion, too,” Dr. Storer said. “My perception of drug abuse has changed in the 28 years I’ve been a dentist. Most people who use aren’t on the street. They’re using it as a coping mechanism to perform on a daily basis because for some reason or another they can’t take life on life’s terms. They need help.”

You’ve noticed one of your patients has lost a lot of weight and seems to have trouble focusing during appointments-assuming she shows up. Or maybe another dentist in the practice spends a lot of time in his office with the door closed, only to come out acting much differently than when he went in.

How to spot an addict

, to build a rapport that helps keep them 

What you don’t want to do is become too familiar or so comfortable with your patients that you end up taking it too far, and saying something that leaves them feeling uncomfortable and maybe even looking for a new practice.

We talked to Penny Reed Limoli, owner of the 

, for advice on how to keep it friendly without crossing the line. Here’s what she had to say.

 If a patient is late for an appointment, it’s really none of your business why, so unless the patient offers up a reason, don’t ask. If you ask a patient why he or she missed that last appointment or showed up late today, it automatically puts that patient on the defensive, Limoli said.

When you’re asking your patients questions, avoid the word “why” because it comes off as accusatory, Limoli said. But that doesn’t mean you should let it slide if a patient is constantly running late or missing appointments. Tell the patient you missed him at last week’s appointment time, and ask if everything is OK. Tell the patient it seems like you’re having trouble finding appointment times that work, and you and your staff will do everything you can to support him to find an appointment time that fits his schedule. Better yet, tell your administrator to have this conversation with the patient.

 You dental practice isn’t a place to find a date, so don’t ask your patients out. That’s a great way to get reported to your state dental board. Even if you’re not looking for a date, and you’re just trying to find something to talk about, don’t ask probing questions about a patient’s personal life, Limoli said. This can be misconstrued as sexual harassment and get you in trouble. If a patient starts talking about her husband, boyfriend or family that’s fine, but you shouldn’t be the one to bring it up.

 We’ve all wanted to tell parents to control their out-of-control kids when they’re running amuck in a restaurant or department store. But if a patient’s child is misbehaving while they’re in your practice, resist the urge to question that patient’s parenting skills, or even give them a bit of friendly advice. Nobody wants to be told how to raise their children, and if you offer your opinion you may never see that patient and his or her child again.

Now, if you see a child practicing habits that can lead to poor oral hygiene, then you might want to step in, Limoli said, but you still want to avoid negative comments. Try telling the parent about the dangers that come with what the child is doing and what they can do to correct it to improve their child’s oral health.

  Whether you have strong religious beliefs doesn’t matter, your patients don’t want to hear them. Avoid asking your patients if they go to church, because if they don’t it may make the conversation turn awkward and the patient feel uncomfortable. Instead, ask your patients to tell you about themselves and their community involvement, Limoli said. That doesn’t put them on the spot, yet gives you a chance to get to know them a little better.

 Conversations about politics can get heated, and that’s not the type of conversations you want to have with your patients. If the patient brings up the latest headlines or starts talking about their favorite presidential candidate, try to stay as neutral as possible, Limoli said, especially if your political views don’t line up with the patient you’re working on.

It’s OK, actually a good thing, to get to know your patients and to offer a friendly environment in your practice, you just have to know where to draw the line. Ask your patients about what their interests and hobbies are, but don’t get too personal. You don’t want to make your patients uncomfortable or give them any reason to consider giving their loyalties to a practice down the street.

You want to be friendly with your patients, to build a rapport that helps keep them loyal to you and your practice. What you don’t want to do is become too familiar or so comfortable with your patients that you end up taking it too far, and saying something that leaves them feeling uncomfortable and maybe even looking for a new practice.

And that's why you shouldn't cross the line with your patients

That’s how some people feel about their smile. They want their teeth white and bright, even if the white they’re going for doesn’t look natural.

Although it’s rare, there are patients who will go to great lengths to get what they feel is the perfect white smile, from overdoing the whitening strips to over brushing to trying to buy more product from you than they really need. 

“They just want their teeth as white as they can get them,” Dr. Michael Sesemann said. “They’re not even thinking about damage or about being outside the range of natural.”

That’s where you come in. Whether you’re talking about preventing patients from taking it too far or helping patients understand why they need to slow down, it all comes back to you and your staff educating them about what too much whitening can do to their teeth. 

If a patient keeps buying more whitening product than you think he or she needs, there’s a good chance that patient has a problem with whitening, said Dr. Sesemann, who is the President of the 

. Complaints of sensitivity and teeth that look unnaturally white are also signs that someone is bleaching too much. But it’s important to remember that not every patient who over bleaches can achieve that level of white.

“Sometimes the reason people turn into bleaching addicted patients is because they have a very high translucence to their teeth and the bleaching really has little effect on the whitening objective they’re trying to obtain,” Dr. Sesemann said. “Those folks are buying a lot of product and bleaching a lot, but they’re not getting the results they want.”

And depending on what they’re using and how much, over bleaching can lead to sensitivity, it can weaken enamel or soften composite restorations if the product is too acidic, Dr. Hugh Flax said.  Another fear, although it hasn’t been documented, is bleaching too much may stimulate external root resorption, Dr. Sesemann said.

Patients who are whitening too much may not even realize they have a problem. If you or one of your staff members asks them how frequently they’re whitening, they’ll likely tell you, Dr. Flax said. Simply asking that question can open up a dialogue and create an opportunity to educate that patient.

“It’s all relative to that particular person’s situation,” Dr. Flax said. “When we have people complain about sensitivity or asking unreasonably to improve the color of their teeth when they are as white as they can get without over whitening or over brushing, we have to say ‘hey, we need to take a step back here. You’re getting into an area where you’re not getting any benefits and you’re causing problems for your mouth.’ For some people that’s a wake up call.”

For patients who have translucent teeth, it’s important they understand that no matter how much they whiten it’s not going to make a difference; their teeth aren’t getting any whiter, Sesemann said. They likely will keep trying if they don’t understand this, and that will only lead to problems in the long run.

If one of your patients is asking about whitening options, take the opportunity to provide some education. Bring out a 

 and show the patient where the natural shades of teeth were before society decided it was better to go outside that range, Dr. Sesemann said.

“We try to educate them on the particular shades that would look good with their complexion,” Dr. Sesemann said. “And when that shade might be getting hyper white and looking false in appearance when compared with the natural color of teeth.”

When people see the natural shades vs. the hyper white shades and are aware of the harm too much bleaching could cause, they become much less anxious to get that extra bright smile, Dr. Sesemann said.

People whiten for different reasons, said Dr. Flax, who is the Vice President of the American Academy of Cosmetic Dentistry. Maybe they’re trying to boost their confidence before a job interview, or maybe they’re trying to attract that special someone. No matter the reason, both you and your staff need to be involved, especially if the bleaching starts to get out of hand. 

Your team members should talk with patients and give them advice about their smiles, Dr. Flax said. It’s important that patients know all of their options; they may decide to go another route cosmetically if whitening isn’t getting them where they want to be.

“We’re here to give them advice and to lead them to better health and a better looking smile,” Dr. Flax said.” “If their smile and their health are going in the wrong direction, it’s our duty to share that with our patients. Of course it’s the patient’s ultimate decision to continue what they’re doing, but sometimes somebody confronting them about it and bringing it up makes them start to think ‘whoa maybe I’m not doing the right thing for myself.’”

The whiter, the better. That’s how some people feel about their smile. They want their teeth white and bright, even if the white they’re going for doesn’t look natural. Although it’s rare, there are patients who will go to great lengths to get what they feel is the perfect white smile, from overdoing the whitening strips to over brushing to trying to buy more product from you than they really need. 

Whitening addiction

It all started with a scared little girl who found comfort in a puppy.

The little girl, Maya, came to Dr. Allan Pike’s pediatric dentistry practice in Portland for a pulpotomy, a procedure they needed to get done right away. But things weren’t going well, at least not until dental assistant Julie Dubansky offered to bring in her puppy, Madison. That seemed to calm Maya down, and was the beginning of what some of Dr. Pike’s patients drive as many as three hours to experience: Dog day at the dental office.

Before Maya came in for her next appointment, her parents called to confirm Madison would be there. Maya was planning to bring her a bone.

“Madison was there and happy because she got a bone, Dr. Pike was happy because he got the work done and I was happy to bring my dog to work,” Dubansky said. “And Maya had a positive experience. Everybody was really happy with the whole interaction.”

Dr. Pike already had gerbils in his office that he encouraged his patients to play with and feed, so it only seemed natural to “blow it up” to a dog, Dubansky said. So once Dubansky found out about a program to certify dogs for animal therapy, she decided to enroll both her dogs, Madison and Morgan. Dr. Pike made some calls to the health department and his state dental board to make sure he could put the dogs to work in his practice, Dentistry for Children.

Once everything was in place, it just seemed to snow ball, Dubansky said. Patients would request certain dogs, and each time Dubansky brought them in she had to bath them, brush their teeth and clean their ears. Soon they decided to devote an entire day, Wednesday, to the dogs.

Parents often call in seeking Wednesday appointments for their children, and some who have moved away still drive to Portland for their doggie fix. Madison and Morgan, who began their work at the practice in 1996, recently retired. Dog day at Dr. Pike’s office lives on with the newest therapy dog, Olive, who began her career about a year ago.

Children are often scared when they walk into a dental office, as are their parents. Nervous parents may be reliving a bad experience they had at the dental office or are simply worried about how their child will behave during that first visit. These parents tend to hover, making the child more nervous and making it difficult for the dental team to build a relationship with that child.

The dogs help take their mind off their fears. The parents relax, and so do the children.

It all started with a scared little girl who found comfort in a puppy. The little girl, Maya, came to Dr. Allan Pike’s pediatric dentistry practice in Portland for a pulpotomy, a procedure they needed to get done right away. But things weren’t going well, at least not until dental assistant Julie Dubansky offered to bring in her puppy, Madison. That seemed to calm Maya down, and was the beginning of what some of Dr. Pike’s patients drive as many as three hours to experience: Dog day at the dental office.