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

Renee Knight

		Treatment planning should involve the entire team, including the patient, lab technicians and specialists.

		Today, there are plenty of high-tech options to help you get your patients to the smile they want.

	The cases coming into your practice these days may be more complex, but the products and technologies behind the treatment plans you deliver have become more sophisticated. treatment planning today is more predictable and more personal, with plenty of products and technologies designed to get patients more involved in their care. 

	From cone beam technology to patient education software to products like Invisalign that have changed the way you treat cases, everyone involved now has a better sense of what to expect from start to finish. Technology has made it possible for treatment planning to become a true collaboration among dentists, specialists, lab technicians and patients. Working this way not only takes out the guesswork, saving you and everyone else involved time and stress, it leads to happier patients who are more likely to accept treatment.

	“To create the ideal smile we need interaction from the staff, the patient and the lab technician. If we get all those done and balanced out with my input, we’re going to come up with a smile that’s realistic and that will last a long time, versus something that’s out of balance because the lab, doctor or the patient drove the final result,” said Dr. Hugh Flax, President of the American Academy of Cosmetic Dentistry (

). “I don’t like to re-do things. I’d rather have a situation where we’re working together, and at the very end we’re actually exceeding the patient’s expectations.”

	The right treatment planning tools can help you get there. Here, we break down some of the latest advancements powering advanced treatment planning in cosmetics, periodontics, implants, orthodontics and endodontics.


	The visual is a huge part of treatment planning, especially when it comes to cosmetics. If your patients see what you can do for them and understand what you have to do to get there, they’re more likely to be on board.


	Interactive patient education is a huge part of today’s treatment plans, and there are now plenty of inexpensive and effective options designed to help your patients understand exactly what needs to be done and why, said Dr. Chris Ramsey. Programs such as Henry Schein’s Guru (

), which is what Dr. Ramsey and his team uses, are great adjuncts to help you explain procedures, but remember they don’t replace the still-important face-to-face time between doctor and patient.

	If you want to add a little more of a wow factor to the patient experience, use an iPad to deliver your patient education. DDS GP (

) provides dental education software on the iPad that offers realistic animations and an easy way for you to upload and categorize photos from cases you’ve done.

	“People like to feel comfortable. In a day and age where the iPod and iPad are items almost everybody touches on a daily basis, there’s now this software patients can hold in their own hands and it doesn’t feel foreign. It feels comfortable to them very quickly,” Dr. Ramsey said. “They can scroll through animations and touch pictures themselves. Once a patient is comfortable, there’s a level of trust and understanding. Once they’re comfortable, a lot of barriers that create the ‘no’ factor go away.”

	Sitting next to a patient as he or she scrolls through images or looks at 3D animations on an iPad make the experience more personal, Dr. Flax said. They can see what the procedure you’ve proposed entails without actually going through it. You’re slowing down and taking the time to make a connection with them, something that has become an important part of patient care and treatment planning. These technologies are enabling you to build deeper relationships with your patients, which in turn creates a more satisfying experience for you and your staff.

	“We’re not telling them this is what they’re going to get. They have some say, so it becomes their smile and not somebody else’s smile,” Dr. Flax said. “I want people to look in the mirror and look at their smile and say ‘wow I look great’ instead of ‘look at what Hugh Flax did to me.’ It should be their smile.”

	When working on cosmetic cases, it’s important to communicate with your lab technicians and everyone else involved. Cases are becoming more and more complex, and you don’t have time to guess what another doctor involved did or didn’t do. Companies such as Sesame Communications (

) have developed software that make this communication easy, Dr. Ramsey said. Through Web-based software, everyone involved can go to one place to update what they’ve completed and see what other doctors have done. 

	Moving to a digital workflow also helps, Dr. Flax said, making it easier for you to communicate with staff members who now don’t have to try to decipher your handwriting to figure out the next step in a patient’s treatment plan.

	Treatment planning perio cases goes hand in hand with successful cosmetic/restorative dentistry, said Dr. Don Clem, President of the American Academy of Periodontology (perio.org). He describes it as a partnership, with periodontics supporting restorative dentists to help them achieve their treatment goals.

	“If I can generate tissue and esthetically manipulate the gingival margins, I can help restorative dentists do a better job placing veneers and achieve a better outcome,” Dr. Clem said. “If we create a healthy environment periodontically and achieve regeneration for optimal esthetics, patients benefit because they have a better looking, better functioning restoration, and the clinician benefits because the practice becomes more efficient and restorative goals are more predictable, given the dentist has a healthy, stable environment-provided by the periodontist-to work with.”

	Making that treatment plan happen doesn’t just fall on a GP or a periodontist; it should come from a team approach that includes everyone involved with the case, Dr. Peter Cabrera said. And these days, there are plenty of product advancements to help that team give patients the best possible result.

	There are now more options available in soft-tissue grafting, and some of those options are even sterile, something that wasn’t available until recently, Dr. Cabrera said. Some of the new products are coming out with growth proteins already mixed in, which can enhance the body’s healing response. That can be a big factor when patients are deciding if they should go with the treatment you’ve recommended.

	But that’s not all. With tissue engineering, clinicians can draw a patient’s blood, extract certain components from the blood and use those components as part of grafting, Dr. Cabrera said. This, along with the latest soft-tissue grafting products, is slowly developing and is fairly expensive, but does show potential and is an area that should continue to evolve. 

	Bone and soft-tissue regeneration also are becoming more sophisticated, Dr. Clem said. Clinicians now have the ability to regenerate bone around teeth and to regenerate soft tissue around recession areas. They can be regenerated, and root coverage can be achieved with new soft tissue, tissue that doesn’t have to come from the patient. There are banked tissues from human tissue banks that clinicians can use in soft-tissue reconstruction.

	There also have been advancements in terms of using collagen-based materials for root coverage, Dr. Clem said. For reconstructing bone around teeth, new bone grafting materials and growth factors and biologic modifiers are on the market that, at the local site, can help stimulate periodontal ligament cells and bone cells to help regenerate bone around teeth.

	While Dr. Cabrera said there’s still a lot to learn about lasers and what they can do, he sees a lot of potential. Although lasers will never replace a scalpel, they can access different types of tissue depending on the wavelength, produce a bloodless field, and there is some anecdotal evidence that lasers promote faster healing. It has promise to seal wounds or seal tissue to the root, which is something Dr. Cabrera described as fascinating.

	Yes, there are advantages to lasers that might lead you to make them part of your treatment plan, but Dr. Cabrera cautions that at this point, the marketing is ahead of the research. All too often, lasers are overused to make up for the expense, he said. It’s important to only use this technology when the science calls for it, and that means doing your research and staying informed.

	Risk assessment and other diagnostic tools are available that can calculate a patient’s risk for disease and identify a patient’s infection level and genetic risk, Dr. Clem said.

	Calculating a person’s risk factors for developing periodontal disease can actually help predict disease progression.

	This means it’s no longer enough to say a patient has moderate or severe periodontal disease, Dr. Clem said. Clinicians have to think about the patient’s age, if he or she is a diabetic or has cardiovascular disease. Treatment plans must factor in the oral-systemic link; you can’t ignore the other health issues the patient is facing and expect a successful outcome.

	While these risk assessment products are available today, they are only the beginning, Dr. Clem said. He expects to see more products on the market soon and risk assessment becoming an important part of treatment planning for patients with periodontal disease. It will enable clinicians to become more targeted in their treatment planning, improving patient outcomes.

	“In the future, clinicians will have the ability to take a look at their aging population and assess them and say these are the patients I can best manage in my practice and I have confidence based on these diagnostic tools that I should be able to manage these patients in a predictive manner,” Dr. Clem said. “As our population ages, we’ll see the dental community segment their patient population according to risk more, and therefore employ advanced care in other disciplines as well as with a larger knowledge base than ever before. As a result, general dentists will be able to more confidently identify those patients who can be treated in their office and those patients who may benefit by partnering with a periodontist in their diagnosis.”

	Implants have changed the way Dr. Cabrera treatment plans. Today, Dr. Cabrera will recommend an extraction much earlier in the process than he would have in the past. Sometimes, you can anticipate problems that will arise by saving certain teeth. By being proactive, you can spare the patient extra procedures and difficulties. If an implant is inevitable the patient may be better off having it earlier rather than later.

	“A patient I’ve had in my office for 25 years had problems with an upper molar. Twenty five years ago, I would have bent over backwards to save it,” Dr. Cabrera said. “Instead, I said let’s remove the tooth so we can preserve some bone, try to save the tooth next to it and place an implant.”

	Not only can implants help you treat patients more predictably, they give you and your patients more options, Dr. Ramsey said. Instead of just giving a patient a lower denture, you can give them a denture that’s implant-supported-and that can be life changing.

	And then there are the patients with single tooth problems. Once you show them their options, chances are they’re not going to want to go with a bridge when they find out they’re a candidate for implants.

	“The best thing we can do for patients is to keep a single tooth problem a single tooth problem,” Dr. Ramsey said. “If there’s a problem with one tooth, with where we are with implant dentistry we don’t have to touch the other teeth. Many times, I show them what used to be done and explain that we don’t want to use that any more today. Then,

	I show them why we should consider these other modalities of treatment where things like implants can help us do things more predictably.”

	Developments in bone and soft-tissue regeneration have made it possible for more patients to receive implants, Dr. Clem said, and can help patients who have disease that’s developed around implants they already have.

	“We’re understanding implants are not impervious to disease and we can have bone and tissue loss around implants,” Dr. Clem said. “That can be devastating to patients from a functional and an esthetics stand point. Many times, we will incorporate periodontal regeneration material and techniques that have been developed around teeth and apply them to implant treatment.”

	From a pure treatment planning perspective, three-dimensional imaging probably is the most significant development Dr. Cabrera has seen in recent years. Not only does he use it to help more predictably plan his implants cases, but he’s also finding the imaging can pick up other issues from an anatomical perspective, issues he once had to speculate about. From a surgical perspective, he doesn’t have to wait and see what he’ll find when he gets in. He can see it in the image. Three-dimensional imaging tells you how much bone loss the patient has and makes it possible to anticipate with much greater accuracy what you’re going to encounter.

	While cone beam technology can mean great things for your treatment planning, Dr. Cabrera warns clinicians still need to know anatomy and biology, as well as have the necessary clinical experience to successfully execute the procedure. You simply can’t rely on three-dimensional imaging, something Dr. Cabrera fears too many clinicians are doing.

	Once you have the proper training and knowledge base to use cone beam technology, Dr. Flax said it’s an “absolutely essential” tool for planning out where to place an implant and to determine what size implant you’ll need.

	“The rule in business applies to implants as well: location, location, location,” Dr. Flax said. “I think you do your patients a disservice, whether you can afford the technology or you have it referred out, you have to have this technology to get the positive results you’re expecting in implant dentistry.”

	When a patient comes to your practice with a tooth that you can’t decide if you should save or extract, you have to get the endodontist involved. He or she can tell you if the tooth should be saved or extracted, and should be part of treatment planning early on, said Dr. Louis Rossman, a past president of the American Association of Endodontists (

) And today, there are many treatment planning tools available to help make these cases more predictable and outcomes more successful, yet another reason you can’t afford to not have an endodontist on your team. Remember, no matter the case, you always have to look at what’s best for the patient. 

	The surgical operating microscope is a must to successfully treatment plan a case, Dr. Rossman said. It provides enhanced vision through magnification and illumination, and allows the endodontist to treat what he wouldn’t be able to see with loupes or lower-power magnification.  

	“It has revolutionized surgery, increasing our ability to gain access to areas previously not attainable,” Dr. Rossman said. “We can reduce the amount of bone removal and, using ultrasonics, provide a retrograde access to the roots, canals and isthmus that was not possible years ago.”

	Not only that, the microscope makes endodontics cleaner for the patient and the operator, Dr. Rossman said. For instance, when gaining access through a crown, it makes it possible to see canals, find additional canals and reduce the amount of tooth structure removed to gain access to these areas. His Zeiss microscope (zeiss.com) even has a camera attachment for documentation and education.

	Using ultrasonics in concert with a surgical operating microscope will only improve your results and allows clinicians to do procedures that never could be done before without removing tooth structure.

	Digital radiography is a great tool for patient education, Dr. Rossman said. You can show your patients right on the monitor why they should consider treatment. The clarity the latest sensors provide is outstanding, which is key for predictable treatment planning and educating patients about what’s going on in their mouth and what you plan to do about it. Beyond that, digital radiography allows clinicians to evaluate patients using much less radiation, which Dr. Rossman said is the biggest benefit.

	“The new Schick sensors are built to last,” Dr. Rossman said. “The ability to replace the weak link of a broken wire has been solved, and the image is superb.”

	There are plenty of advancements in endodontics that simply make treatment planning more predictable, Dr. Rossman said. From titanium rotary files that allow clinicians to completely clean and shape the root canal system better, to the M-wire NiTi from DENTSPLY Tulsa Dental Specialties (

) that reduces the chance of separation of the instruments, to new materials that seal off perforations and the apex of the tooth surgically, endo cases are more predictable than ever before.

	Apex locators also are great treatment planning tools that allow for a more accurate determination of working length of the root, which in turn allows for a better, more predictable outcome.

	Another technology that can help with predictability? Cone beam. This technology can help when you know certain fractures exist, but you can’t identify them. It also can help you identify anatomic anomalies that may have contributed to disease in re-treatment cases. Finding these problems before you’re in the middle of a procedure will only help you achieve the results you told the patient you were after.

	“It’s a new world of endodontics,” Dr. Rossman said. “We can now achieve a success rate we could only dream about years ago.” 

	Advanced technology has given orthodontists a variety of enhanced techniques to choose from when treatment planning their patients, allowing for a decrease in chair time, treatment time and an increase in overall comfort and the final outcome, Dr. Jacqueline Fulop-Goodling said. Today’s technology enables clinicians to show their patients their final smile before initiating their patient’s orthodontic treatment. Software programs also aid in taking the guesswork out of a patient’s treatment time and can motivate patients to stay on track and return to the office, although their visits are less frequent now.

	Depending on what’s most important to you and your patient, there are plenty of directions to take when it comes to orthodontics.

), one of the clear aligner options, consists of a series of aligners that patients switch out every two weeks. Each aligner is individually manufactured with calculations to gradually shift a patient’s teeth into place. It takes out the discomfort associated with braces, and saves you and your patient time. Rather than the patient coming in for multiple visits, you take one impression and from that a software program creates the patient’s custom-fit aligner.

	There are other products designed to shorten treatment time, such as SureSmile. SureSmile, in Dr. Fulop-Goodling’s opinion, can cut an average orthodontic treatment time of 18 months in half. How does it work? It uses advanced 3D imaging, virtual simulations and robotically bent archwires customized for each patient’s treatment plan. With this system, you don’t have to bend an archwire by hand. When the SureSmile wire is inserted into the brackets, each tooth moves directly to the prescribed position and with greater accuracy because of the different anatomy of each tooth. Even the same tooth, like a mandibular first molar on the right and left side of the same patient, varies naturally in anatomy.

	Even though products like Invisalign and Clear Correct (

) offer a more subtle option, some patients don’t want a removable orthodontic appliance to straighten their teeth. 3M ESPE’s Incognito™ Orthodontic Braces (hiddenbraces.com) may be the right option for these patients. These are placed on the lingual side of the teeth, Dr. Fulop-Goodling said, and are hidden from view.

	Regardless of what you and your patients are thinking for the final result, you have plenty of options to get them there.

	“Every orthodontist has their own signature smile. Some like a broader smile and like to expand their cases while others like a more natural-looking narrower arch form,” Dr. Fulop-Goodling said. “Today, there is a larger menu to create a nicer smile. Removable braces like Invisalign, fixed braces on the facial surface like SureSmile or on the lingual surface like 3M’s Incognito braces aren’t the be-all and end-all of orthodontics today. There is an array of treatment options and so much more to learn and know, including using these techniques in conjunction with other ones, such as surgically facilitated orthodontic treatment, or accelerated osteogenic orthodontics. Previously, it was perfecting smiles with perfecting bracket placement and wire bending techniques.

	Today, it’s perfecting the most ideal smile with the least amount of discomfort, least amount of time and in the most technologically savvy way.”

	When Dr. David Sarver, spokesperson for the American Association of Orthodontists (

) was growing up, children who needed braces ended up with a metal band put around every tooth. That not only led to problems with oral hygiene, it meant an extra quarter of a millimeter of space between each tooth. That added up to space that all too often would lead to extractions. Bonding adhesive technology has changed all that because that extra space once needed just to put the braces on is no longer part of the plan. Losing the metal bands has enabled more patients with crowding to keep all their teeth.

	Using computer imaging technology, clinicians can show their patients what their smile will look like once the recommended treatment plan is completed, Dr. Sarver said. You can take a picture of your patients, put it into the software and show them what will happen to their smile if you lengthen or straighten their teeth. You can compare a patient’s current smile with the smile you’ve created, side by side on the screen, and you can explain different aspects of the treatment. This is much more effective than just words. The patient can see what is possible and what needs to be done, which leads to a greater understanding of the options and higher case acceptance.

	“We can, with some degree of assuredness, feel that this plan we just showed her is what we’re going to get,” Dr. Sarver said. “What the visual imaging allows us to do is have an actual template by which we can have a discussion in a common language. We can both see that. Then I can measure what we are trying to offer her so I can have a plan to go by rather than saying ‘let’s try this’ or ‘let’s try that.’

	”Treatment planning this way gets your patients more involved, and not only helps them understand their options, but understand why cooperation and compliance are so important for a successful outcome. They know what they have to do to expedite treatment so a two-year treatment plan doesn’t become a four-year treatment plan.

	“They can see that you’re visualizing an outcome, and the more interaction patients have with the doctor, the more satisfied they are going to be with the outcome,” Dr. Sarver said. “If your doctor has a discussion with you, you’re more likely to be happy with that doctor. This is a way we can talk with the patient. Here’s what I see, what do you see? Here’s what I recommend, here are your options. Patients buy that, but for the right reasons. It’s not because you are selling them something but because you are helping them understand their choices.”

	Want something even more effective than a photograph to show your patients’ what their smile looks like today? Video technology does that, and is something Dr. Sarver expects to become a standard for treatment planning esthetic cases. How does it work? Use video cameras to record the motion of your patients’ smile. This engages your patients, getting them to smile in a natural way that allows you to truly evaluate their smile.

	As with implant cases, cone beam technology can be a huge help when treatment planning orthodontic cases. But often a 3D image of the entire head may not be indicated. Limited-field cone beam is a great option, Dr. Sarver said, because it limits the size of the area you’re looking at, and that limits radiation exposure. This technology can show you things you wouldn’t see on a conventional panoramic field, which will lead to more predictable, precise results.

Articles

   The take-aways   Treatment planning should involve the entire team, including the patient, lab technicians and specialists.  Today, there are plenty of high-tech options to help you get your patients to the smile they want.    You have more control than ever before.

It's all part of the plan


	Team dentist for Major League Baseball’s Cincinnati Reds and the East Coast Hockey League’s Cincinnati Cyclones

	Imagine your patients walking into your practice to find a local professional athlete sitting in your waiting room.

	As the team dentist for the Cincinnati Reds and the Cincinnati Cyclones, that actually happens in Dr. Alexander Della Bella’s office. And that, he said, is a great practice builder.

	Start small. But Dr. Della Bella didn’t start his career in sports dentistry as a team dentist for professional athletes. He got his start by volunteering to make custom-fit mouthguards for local high school teams and by making himself available to treat any traumatic dental injuries that happened during their games. He also took the time to meet parents and educate them about the importance of wearing a mouthguard and why a custom-fit guard is the best option. Working with the teams got him out in front of the community and also enabled him to expand his practice to treat patients suffering from other traumatic dental injuries, including car crash victims.

	Going professional. As a hockey fan, Dr. Della Bella was thrilled when he first heard a professional team was coming to Cincinnati. So thrilled, in fact, he immediately called team management and offered to be the Cyclones’ dentist. That was in the early 1990s, and since then he’s also added the Cincinnati Reds to his list of professional teams he treats.

	What it entails. Every year during spring training, Dr. Della Bella goes down to the Reds’ spring training facility to perform a comprehensive exam for all the baseball players. This includes an oral cancer check-something most people don’t associate with sports dentists, but with the use of spit tobacco products, they should. During the year, he may go to the games or is on-call in case he’s needed. Because the dental injuries can be more severe, he’s on site for most of the hockey games and said in the course of a year he probably sees six significant dental-related injuries.

	Why you should try it. Over the years, Dr. Della Bella has found sports dentistry to be a great practice builder, from expanding what he can treat in his practice to happy parents who love that he cares enough to donate his time to help protect their children from a sports injury.

	“It’s what has kept me going for 26 years,” he said. “Try to find different things along the way that catch your interest and make it exciting to be a dentist. For me, with my love of sports, combining the two has been a way to keep me invigorated and to keep me excited about the dentistry that I do.”


	Co-founder, ORA Dental Studio and ORA Oral Surgery & Implant Studio, Eco-Dentistry Association Gold Certified Charter Practices

DPR: What made you decide you wanted to open green practices?

All of the co-founders-myself, my partner Dr. Goran Kralj, Dr. Mladen Kralj and Dr. Reggie Thurston-we were all classmates and we were all employing eco-friendly practices in our personal lives and we wanted to extend that into our workplace. We decided from the onset that we were going to build practices, from the ground up, that were sustainably designed and also would function in an eco-friendly, green fashion. I’m a physician as well, and many hospitals now are being constructed via LEED [Leadership in Energy and Environmental Design] protocols but there was never any focus on private practice, which is where we wanted to make a difference and stand out, as well as hopefully set an example for the next generation of practices to come. As a business model, we wanted to demonstrate this could be a ‘win-win situation’ for everyone, for patients, for the community and for the practicing doctors. We’ve enjoyed an enormous amount of success, being able to open four offices in two years, and we’re in the planning stages for a fifth one.

DPR: Why would you encourage other dentists to take steps toward making their practice more environmentally friendly?

Well the most critical thing is it’s doing the right thing. It benefits the team and the community and the patient and, lastly, it also will really benefit the provider’s bottom line. For a few small investments there can be big financial gains and savings. This streamlines a practice and its efficiency. For example, eliminating single-use items and using metal sterilizable, autoclavable substitutes. That’s a money saver right there. Also becoming a digital practice. Digital radiography and digital patient charting saves a tremendous amount of resources, time and money.

DPR: How does a green practice benefit the patient?

Our paramount tenet is simple-what’s good for the environment is good for the patient and vice versa. But our focus is to give patients the most comprehensive, positive experience available for their oral health, and that includes incorporating state-of-the-art technology, but at the same time ensuring the technology employed is both minimally invasive to the patient and minimally invasive for the environment.

Dr. Brett Beckman, DVM, FAVD, DAVDC, DAAPM


	Immediate past president of the American Veterinary Dental Society

	His patients may be a little different than yours, but relieving their pain is just as rewarding.

	Dr. Brett Beckman’s dental patients can’t tell him what hurts, and often when their owners bring them into his veterinary practice, it isn’t because they think their pet is in pain. The family dog might be sleeping a lot more than he used to, or is leaving food in his bowl at dinner time-something he never did before. Both are signs the animal is dealing with a dental problem, maybe it’s periodontal disease or a fractured tooth. Regardless of what the problem is, once it’s fixed the beloved pet leaves his office with renewed energy, something both he and the owner love to see.

	Dr. Beckman went to school to become a veterinarian and while he said he never had an interest in working in “human mouths,” he’s always had an interest in veterinary dentistry. He performed procedures here and there early in his career, but after completing a program designed specifically for veterinary dentists, he now has an office that exclusively treats pet dental issues. He even travels to other states to treat pets suffering from dental-related pain.

	How it’s different from what you do. Dr. Beckman works with everything from guinea pigs to cats to dogs to gorillas, so he has to know a variety of different anatomies. And on any given animal, it’s not just general dentistry he’s performing. Instead, he’s thrown into everything that the whole scope of human dentistry encompasses, without any help from specialists. 

	“There is so much diversity in the anatomy of the oral cavity and so much diversity in the diseases that affect those different species, so it is very challenging from an equipment adaptation standpoint. We as veterinary dentist also are veterinary endodontists, we’re also oral surgeons. We also do orthodontics and restorative dentistry. So we do anything from removing jaws for cancer patients to root canals to periodontal regenerative therapy to teeth cleaning. We spread the gamut.” 

	
	At first glance, the treatment rooms at Zen Diego Dental Arts look more like comfortable living rooms than a place where patients come for dentistry.

	The rooms are at least twice the size of the treatment rooms most patients are used to, and the sofa and love seat add an element of comfort that most practices just don’t have. But a more cozy treatment room isn’t all this new dental spa has to offer. The office also has a European-trained master esthetician, an acupuncturist with a masters degree in Chinese medicine, and a holistic health practitioner who performs 30 different types of massage techniques.

	Dr. Chris Walinski, who is originally from the East Coast, opened the San Diego-based practice in June, and said he already has more than 400 patients. And when those patients walk in, they don’t feel like they’re walking into a dental office. It smells different, it looks different, it feels different. Patients are offered bottled water and hot tea while they wait. Relaxing music plays in the background. Family members can sit on an outside balcony and relax with a good book while they’re waiting for a loved one who’s getting treatment. The panoramic view from the 7th floor office is amazing, and just another feature that makes this dental practice stand out. 

	“Patients don’t get these types of things elsewhere. It’s how I’ve always wanted to have a practice, but I felt like I got a lot resistance when I tried on the East Coast. Here it’s very welcome. Patients say this is what I’ve always wanted, I’ve never been treated like this. It’s a lot about the patient experience and giving them that whole ‘wow’ experience.” 

Registered Dental Hygienist in Alternative Practice (RDHAP)

	
	A flyer changed Kimberly Farrell’s life.

	When she first saw the flyer advertising the Registered Dental Hygienist in Alternative Practice program at the University of the Pacific, she was working full-time as a hygienist. But she was ready for a change, and loved what finishing the program meant. Not only would it give her independence and the opportunity to run her own business, but it also would enable her to care for special-needs patients who may otherwise go without the dental treatments they so desperately need.

	Through Smiles on the Run, Farrell goes into nursing homes and hospitals to treat patients who simply can’t get to a dental practice, or who would have to be put under anesthetic even if they could get there. She puts them at ease, gets to know them and takes the time to educate their caregivers. In the about six years since she opened Smiles on the Run, Farrell has seen so many of her patients’ mouths transform from horrific to healthy, and she’s seen a change in how they view dentistry. They’re excited to see her, and some even fight over who gets to sit in the chair first.

	“I feel like it’s kind of made my life complete,” she said. “I loved being a hygienist and loved being in a dental office, but when I started doing this I thought, ‘Oh my goodness, I found my true calling in life.’ ”

 Sports Dentistry  Dr. Alexander Della Bella Team dentist for Major League Baseball’s Cincinnati Reds and the East Coast Hockey League’s Cincinnati Cyclones    Imagine your patients walking into your practice to find a local professional athlete sitting in your waiting room.

Taking a different approach

	If you want to get the most out of your relationship with your dental lab, you have to ask the right questions.
	
	You can’t just assume that a lab uses a certain type of material or that it’s certified; you have to ask to find out for sure. And you can’t assume your new lab technician knows exactly what you’re looking for in a lab. Not only do you have to ask questions, you have to lay out your desires and expectations as a client.
	
	Not sure what to ask? Here’s a rundown of everything you need to know about the lab you and your patients depend on.
	
	

 Too often, a doctor will enter a relationship with a lab after only talking with the administrative folks who enter the cases or verify certain data, said Daxton Grubb, President of R-dent Dental Laboratory. That isn’t enough. To really get to know the lab, you need to talk with the lab owner, department manager and even technicians if at all possible. This is the time to establish relationships with key players in the lab.
	
	“If doctors haven’t really established that contact with key owners, it seems like it’s less personable,” Grubb said. “They’re more likely to outsource their products to domestic or even offshore labs without notification, or use “knock-off” brands in place of name-brands requested by the doctor. This happens frequently with products such as Valplast, Lava and denture teeth. It gives labs a little more ownership and trust if they feel like they’ve established that relationship.”

This is a question Grubb said doctors never ask, but should. Too often doctors assume labs use a high-quality material, when in fact they use a lower quality substitute. This could mean you’re not getting what you’re paying for, and your patients aren’t getting the highest quality restoration possible. Beyond that, Grubb said doctors should want to know what materials their lab uses for FDA and OSHA reasons.
	
	“If the doctor asks you what metals or porcelains you use, you’re much less likely to substitute something,” Grubb said. “If the lab never told the doctor and the doctor never asked what the lab uses, the lab is not going to feel wrong if they use cheaper porcelains.”

Ask about certification and quality systems. 

When interviewing a lab, you should ask about technician and facility certification, said NADL president Chris Waldrop, CDT, of Burdette Dental Laboratory. Certification illustrates the lab has conformed to a national standard of competency, which is an important factor for a dentist who’s starting a professional relationship with a new lab. Labs should have quality systems in place and be willing to demonstrate those systems. If they’re not willing to do this, that could indicate a problem with the lab and is a sign you might want to consider other options.

	Find out what products they recommend for certain situations. If you’re changing labs, you can’t assume your new lab uses the same products as your old lab, Grubb said. It differs from lab to lab. Ask what they suggest for inlays, onlays and single-unit posteriors. And don’t be afraid to challenge the lab and ask why technicians use what they use. Ask about the products’ pros and cons. Become knowledgeable about the products your lab uses. Take that information and share it with your team members, so they can become more knowledgeable as well.

 Recalls happen, and it’s important for dentists to know the procedure when they do, Grubb said. Ask the labs you interview how they will know which restorations are recalled, and how you will be notified if you need to bring a patient back in.

 Asking these questions over the phone or via e-mail isn’t enough for you to really get to know the lab. Visiting the lab gives you a chance to see the technology they use, and makes it possible for you to put faces with names, Waldrop said. Dentistry is all about relationship building, and that on site visit helps labs and dentists connect.

	“We’re in a people business and it’s a communication intensive business,” Waldrop said. “You want to make sure you can rely on these people. Certification gives some of that but really spending time on the front end to get to know people is important.”

	If you take the time to visit the lab and get to know the people you’re working with, they’re more likely to take ownership when they see one of your cases come in. Talk with the lab technicians if possible. Shake their hand and take the time to introduce yourself.  

. Grubb and Waldrop both said many dentists don’t take the time to come in for a tour. It could be because they don’t see the value in a face-to-face visit, the lab they work with is too far away, they think they’re too busy or they’re simply uncomfortable with the idea of it. But the dentists who do make the time for a visit learn a lot about how a lab works and what happens to the cases they send in. They learn about the technology and they start building relationships. When they finally do come in, many of them say they wish they had done it sooner, Waldrop said.

	
	That interaction, that face time is key to any business relationship, Grubb said. It makes it easier for you to make that phone call when you have questions or concerns about a case.
	
	“If you’re dealing with a lab in a local area, you need to go meet the people doing the work,” Grubb said. “I don’t see how you can rely on a lab that’s such a key part of your business if you haven’t visited the facility.”

 While you’re there, take a tour of the lab. Get a feel for how it operates, if there’s disorganization or dysfunction. Take notice of how the staff interacts with each other, Waldrop said. If morale is low or there are employees not interfacing, that could be a sign you need to move on.
	
	This also is a great opportunity to see how clean the lab is, Grubb said.
	
	“Does it look like a place you’d want a crown made to go in your mouth?,” Grubb said. “You need to make a crown like it’s going in your own mouth. If a doctor is using a lab and wouldn’t use a crown from that lab in his own mouth, he needs to change labs.”
	
	

 The lab interview isn’t just about finding out about the lab, it’s also about making sure they know where you stand on certain issues, Grubb said. If you don’t want your restorations sent offshore, tell them. If there’s a certain material you expect them to use for your restorations, tell them that, too. Don’t be shy. If you tell them up front what your expectations are, they’ll be less likely to do something with your cases that you don’t like. And the person you’re talking with should do the same during the conversation. If the lab sends restorations offshore, this is the time for that to come out.
	
	In the end, it all comes back to communication. Interviewing your lab will only make your relationship stronger, which will make you more confident in the people who work on your cases. You need to be able to trust and rely on your lab. Getting to know the people who work there and what they do will only make that easier.

	“Doctors really need to dig in and make certain they are aware of everything that’s going on with their lab,” Grubb said. “Know the people, know the materials. Don’t assume anything.”

 If you want to get the most out of your relationship with your dental lab, you have to ask the right questions.  You can’t just assume that a lab uses a certain type of material or that it’s certified; you have to ask to find out for sure. And you can’t assume your new lab technician knows exactly what you’re looking for in a lab. Not only do you have to ask questions, you have to lay out your desires and expectations as a client.

How to interview a dental lab

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	You know how important it is for lab technicians to be involved from the beginning. The more the lab technician knows and the more input he or she can provide the clinician early on, the better the outcome for the patient. After all, you are the one creating the restorations, the restorations patients are depending on to transform their smile.

	Clinicians are realizing more and more that treatment planning is a team effort, one that involves not only the doctor and the patient, but one that includes any necessary specialists-and that means the lab technician. But for that to happen, everyone involved has to communicate, has to be aware of everyone else’s role in the treatment planning process. Traditionally, communication is not something that comes easily for labs and doctors, but that is changing.

	Today, there are technologies, some dental specific and some not, that can help bridge that communication gap. These tools ensure you get involved in the process sooner and that, in the end, the patients get the result they’re looking for without needing to come back to the dentist’s office over and over because their case needs a remake. With the advanced treatment planning tools available today, that shouldn’t be happening. Even as cases become more complex, treatment planning has become more predictable-when the right tools are used properly. From digital impressions to Web-based communication to cone beam technology, the tools are there to make treatment planning more advanced than ever before. You, and your doctors, just have to be willing to use them and embrace the emerging digital workflow.

	“From the very beginning, it’s a team effort. In my position, I want good accounts and good dentists to grow my business. To do that, I can’t let doctors have bad experiences, whether they’re my fault or not,” said Daxton Grubb, President of R-dent Dental Laboratory. “My job is to minimize that. It’s important for us to get involved earlier so we don’t have to call a doctor after they have already sent us a case and tell them we need them to get the patient back in for additional bites, pictures, models, etc. Doctors count on us to minimize their losses as well. The sooner we can get in on those cases so they understand what we need, the better.”

	The right treatment planning tools can help ensure you’re involved throughout the process and that everyone is happy with the final outcome. Here we break down some of the latest advancements to help make that happen.

	It happens all the time. You get a case in and the doctor wants you to use a certain material, but didn’t provide you with the information you need to make that happen. You have questions about shade, or maybe you’re working with an impression that isn’t as good as it should be. You need more information, and no matter how many messages you leave, the doctor won’t call you back.

	That lack of information makes it difficult for you to do your job, but there are ways for you to get that information on the front end. Joe Procopio, President of Pro Esthetics Dental Laboratory, and some of his dentist clients use 

’s Web-based prescription form Intercom to make sure all the information pertinent to a case is communicated from the very beginning.

	How does it work? The doctor fills out the prescription right in the operatory, while the patient is there, Procopio said, and unless the doctor fills out all the information on that prescription, he can’t advance to the next step. Once everything is filled out, the doctor sends the prescription to the lab via e-mail.

	This user-friendly program really has streamlined the treatment planning process, Procopio said, and has eliminated a lot of follow-up calls and trying to guess what the doctor and the patient really want.

	“Everything is on there,” Procopio said. “If we’re doing an IPS e.max or an IPS Empress or a metal-free restoration and the doctor chooses that option on the form, he has to give me a stump shade, which really helps us. A lot of time that’s a forgotten part of a metal-free restoration, but it helps us determine how to exactly make that crown.”

	Whenever laboratories have to make follow-up calls because of incomplete information, opportunity costs begin to rise, said Andreas Schumacher, MBA, MS, Marketing Manager,Technical Division, for Ivoclar Vivadent. Not only that, patient satisfaction declines if a case is delayed or not prepared as desired because of insufficient case information. Intercom addresses both cost drivers, forming an even stronger partnership between the lab and dentist founded on cost-effective, quality patient care.

	Many doctors also use Web-based software to keep everyone informed about what’s going on in a case, said Dr. Christopher Ramsey, a practicing cosmetic dentist in Jupiter, Fla., and Dental Products Reports’ Cosmetic/Restorative Team Lead. Through Web-based software, companies such as 

 make it possible for the restorative dentist, specialists and the lab technician to go to one place for the most up-to-date information about a case, information that’s updated from everyone involved. That’s a great way to keep the team informed, especially when you’re dealing with a complex cosmetic case.

	Making a phone call to your dentist isn’t the only way you can talk about a case these days. Doctors are busy people, but it doesn’t take them that long to send an e-mail or a text from their smartphone, Grubb said. If your doctor can e-mail or text you a picture of the patient while the patient is still in the chair, you can communicate instantly about where to go with the treatment plan.

	“Anything that can put us there, whether it’s a picture, webcam or whatever,” Grubb said. “Any good lab technician, when they have an understanding of where the doctor and patient wants to go and everybody is on the same page, most good labs and dentists can accomplish pretty much anything they want. When you skip steps or make assumptions, that’s when we open the door for issues and set ourselves up for failure.”

	Skype video calling is a tool Edward Corrales, of Downtown Dental Designs, likes to use to enhance communication, especially when he’s about to work on a large cosmetic case. In a sense, Skype puts him in the operatory with the doctor and the patient, even though they may be on opposite coasts. He can see and even talk to the patient, which gives the lab a huge advantage when it comes to understanding the outcome that patient is after. Beyond that, patients feel more comfortable going forward with the case. They’ve now met and talked with the person who’s ultimately going to make the restoration, and they’re impressed with the effort the lab is making to get to know their case and their needs.

	Webinars and online communication services such as GoToMeeting are other options that can get you closer to the doctor and the patient, said Daniel Llop, CDT, President and CEO of nSequence Center for Advanced Dentistry. Gone are the days when the dental lab technician is the last one included in treatment planning, and these technologies make that possible. You no longer have to try to guess what the patient looks like or be left in the dark about the details of a case-you have to remember you’re the one making what the patient is paying for.

	“Patients buy teeth. Not radiographs, not bone grafts, not implants, not sinus lifts. Patients want to be esthetically and functionally restored with the least amount of chairtime and they want it to be feasible and they want to be out of pain,” Llop said. “And so by digitizing treatment planning and bringing all the professionals together in one digital room using GoToMeeting or webinars, there is a certain professional accountability that is achieved and an information exchange, therefore advancing the interdisciplinary knowledge within the professional community. Any time that is done, dentistry advances.”

	No matter the method you use, the communication has to be there for you to feel connected to a case. If all you get is a box with a less-than-ideal impression inside and a note from the doctor to “make it work,” you’re not going to feel very vested in that case.

	“It will get done but not that well because we don’t feel it. We’re not really involved. We don’t feel it in our hearts to really give 100 percent because we don’t see the final result in our mind of what everyone wants to achieve,” Corrales said. “When you do a diagnosis with a doctor via Skype or otherwise, when you see a wax up and then design it in the computer or wax and press you just did the case three times in your head, and that really helps you out with the final result.”

	This technology represents another huge step forward in treatment planning and communication. Doctors can send all the information from the digital impression to the lab technician while the patient is still in the chair, Procopio said. The lab tech can then say, “This is great,” or, “Hey, we need to take a new scan; I can’t make the restoration with the prep you did.” Knowing this up front saves everyone involved time and money.

	The ability to see that prep in real time is huge, Grubb said, and helps eliminate a lot of problems that can come up along the way, whether you’re talking about a cosmetic case or regular dentistry. Too often, labs get impressions that the doctor thought looked OK, but they don’t always see the same thing once the lab pours the model. The digital impression gives the lab technician the ability to communicate about things like clearance, prep and margins so they can get it right the first time. These systems also provide a fully accurate bite, Grubb said, and there’s no question about whether the patient bit down properly as there always is when impression materials are involved.

	Not a lot of doctors are using these systems now, but the numbers are growing, and industry experts expect that to continue. And until they catch up, if you have the capabilities to work with digital impressions, it makes your lab more attractive to other dentists, even if they’re not quite there yet, Procopio said. It puts the lab in a different light, as a lab that’s on the cutting edge and that is willing and able to go that extra step to ensure patients receive the best restorations possible.

	Making sure everyone is on the same page can be difficult when dealing with complex implant cases. There are advanced implant systems that makes it possible for everyone involved to look at the case in 3D, Grubb said. In his lab, he uses 

’s Atlantis implant system and says the 3D images of the patient’s anatomy gives them the ability to toss and turn the image and look at the abutment and the proposed restoration.

	Known as Facilitate™ computer-guided implant treatment, this software helps ensure accuracy and provide more control over the esthetic outcome. And because it’s something that can be sent to all the specialists involved, it helps connect those specialists and ensure everyone is on the same page when it comes to the treatment plan.

	“Atlantis is an excellent product because you can virtually do the restoration before you ever fabricate it,” said Dr. Bob Hewitt, a retired dentist who works with Grubb at R-dent Dental Laboratory. “The opportunity is overlooked so many times.”

	Cone beam 3D imaging takes the guesswork out of implant placement, said Dr. Hugh Flax, President of the American Academy of Cosmetic Dentistry. This technology enables the clinician, lab technician, surgeon and even the patient to see any issues you might be dealing with before it’s time to place an implant. It shows you if there isn’t enough bone and helps you map out a plan that includes exactly where the implant needs to be placed.

	Simply put, it makes treatment planning more predictable, said Elvin Carrero of 

. Having all the information you need and creating a surgical guide before you go into surgery is huge because everyone knows what to expect.

	“You can actually get the prosthesis made before you go into the surgical setting because of the cone beam CT scan,” Carrero said. “Now, you have the surgical, restorative and lab component. The triangle. All parts are communicating before we go into a surgical setting. This is our treatment plan, this is the prosthesis we’re going to make, and this is where you need to put your implant. It’s giving labs the information they need to get their job done.”

	So why isn’t every doctor using this technology in practice? It’s a great planning tool, but it’s an expensive one. That’s where Carrero comes in. His company is one of the mobile imaging centers that brings cone beam to dental practices. He has a large customized van equipped with cone beam technology; what he describes as an extension of a practice. He visits practices in Tennessee and Kentucky and takes the scans on the property, making the process more convenient for the patient and the doctor.

	With this becoming a viable option for many dentists, you may see these types of scans more often for more predictable planning on your end.

	When treatment planning, presentation wax ups can be a huge help to the dentist, Dr. Hewitt said. Dentists can take these lab-created visual aides and present the cases to their patients, showing them what can be done as far as rehabilitating their smile.

	But that’s not all a wax up can do. When you get that approved wax up back, you have a better understanding of where the doctor and patient want to go. At R-dent they can take the wax up and scan it into their software, Grubb said. Instead of going in and saying they’re doing a Lava bridge, they’re going in and building the framework by looking at models and doing a visual fabrication. They’re actually scanning that wax up and building the framework within the wax up, giving them what Grubb describes as the perfect framework to build the wax up from.

	“It’s just another way to bridge the gap for big cases. When we’re doing big cases it’s so easy for the doctor to send in a case and say ‘I want this,’ and there are so many ways to go with that,” Grubb said. “The more we can have a better understanding of what the doctor and the patient want-doing models, doing wax ups, doing temporaries from wax ups, us using the technology we have once we get the information back-I can’t imagine doing a cosmetic case without going through those steps now. Nobody understands where the doctor and patient want to go if you don’t.”

	Grubb’s lab also includes silicon putty matrixes with these presentation wax ups for doctors to use as a prep guide and another one to use for temporaries. All too often, a lab will do a cosmetic wax up, the doctor will show the patient the wax up as what the lab can do, raising the patient’s expectations. The doctor does the prepping, makes the temps, and then the lab realizes the doctor didn’t give enough clearance to match the wax up, and that means the patient is disappointed with the result. Providing the doctor with a prep guide helps avoid this scenario.

	“We give them the right amount of clearance and have the preps angled so the restoration will fit onto the preps,” Dr. Hewitt said. “If we make the restoration, and the restoration breaks because they didn’t give us enough clearance, then they think it’s our fault. I’ve been on both sides of it. I practiced dentistry for 40 plus years, and now I’m here, and I’ve seen stuff come in here that’s just astounding. You can tell in some instances it hasn’t been planned out. Then the lab is to blame, the finger is pointed at them. So many times it’s not the lab’s fault, but we have to eat that remake because the right restoration was not used in the right place.”

	Digital treatment planning is nothing new for Corrales who has used 

’s CEREC for six years. Because of what’s happened with CEREC and CEREC Connect, his lab is digitally receiving cases from doctors all over the country. They receive the files from a CEREC machine, upload them at the lab and do the restoration digitally. They can do single restoration bridges out of any material they want, as well as large veneer cases, diagnostic wax ups and even implants.

	Corrales also remotely accesses doctor’s CEREC computers to see their work, making the treatment planning process that much easier.

	“I can design their work on their computer, or I can retrieve their work from their computer and send it to myself for me to finish,” he said. “It’s pretty amazing what we can do. I think we’re the only ones doing that, but I’ve been presenting that concept for the last year. More and more labs will be able to offer that service, where you are designing or revising people’s work. It’s more of a service, and you’re saying to the doctor ‘I’m here for you whatever happens.’”

	Of the doctors who use this technology, only a very small percentage are excellent at it, Corrales said, opening up an opportunity for labs. They depend on you to speak the CAD/CAM language and to share your knowledge about the technology. Many of these doctors just know how to press the button to mill it, send it out and submit it. They don’t realize what all is possible with this technology. If you educate and market yourself the right way, these dentists will turn to you for your expertise.

	“The best part is patients know about this technology now, through TV and magazines. CAD/CAM technology is here,” Corrales said. “I’m in the middle of it. I love it all. And yes I’ve had scary times here and there. You need to find your niche within the technology. You’d be amazed how much money there is to be made.”

	Today, lab technicians are recognized as professionals, as specialists in the dental field rather than third-party vendors, Llop said. General dentists and specialists are realizing the plethora of information lab technicians have accumulated over the course of their careers, and that they’re a valuable resource in the treatment planning process. And the more education you have, the better. Learn about the other dental specialists by working with them and also by attending the courses they attend, Llop said.

	“Dental lab professionals need to understand they’re going to be called on by the specialists in the dental community to become professionals quickly, so if they have not taken it upon themselves to be educated in all the specialists of dentistry, then they will quickly fall by the wayside,” he said. “As digital dentistry catches fire, these people are looking for educated dental technologists to become part of regimented treatment planning sessions.”

	As more and more products and technologies become available, doctors are relying on their labs today more than ever. The options are coming out faster than they can keep up with, so they need to have a lab they can turn to when it comes to treatment planning and beyond. You need to be that resource.

	Dr. Flax, who is thinking about adding digital impressions to his practice, plans to talk to his lab as part of his research. Grubb recently received a call from a dentist client looking for purchasing advice on the same systems. That’s the type of relationship you should have with your dentists. You should be the person they turn to for that kind of advice. That type of relationship is what leads to better treatment planning and, in the end, more successful cases.

	And with all the advancements and the knowledge base lab technicians have, that’s starting to happen.

	“What if you woke up one day and all the lab technicians were taken off the face of the planet?,” Llop said. “That would be a bad day in the dentist’s office. The dental lab technician is a vital professional who serves as a vital component to advanced treatment planning in this new paradigm in dentistry. And that’s digital dentistry.”

 You know how important it is for lab technicians to be involved from the beginning. The more the lab technician knows and the more input he or she can provide the clinician early on, the better the outcome for the patient. After all, you are the one creating the restorations, the restorations patients are depending on to transform their smile.

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	In his new book, Teeth in Mortal Combat: How to Unleash your Basic Instinct for Survival, Dr. Sawicki argues that enhancing the Qi, or life energy, of the mouth may boost jawbone mineral density, increase blood flow to the brain and improve overall balance and muscular strength. This idea of strength and the purpose of the mouth in relation to the rest of the body’s survival has been neglected over the years, which is something he hopes to raise awareness of with his book. 
	
	We recently talked with Dr. Sawicki about his book and the role teeth play in activating primitive instincts. Here’s what he had to say.
	
	

 Can you tell me a little about your new book and why you think it’s important for dental professionals to read?
	
	

Through my practices of dentistry and martial arts I discovered compelling evidence regarding the vital importance of teeth to human survival, and learned that by strengthening the Qi (vital life force) of the oral cavity one can significantly boost jawbone mineral density, protect teeth from occlusal stress fractures, restore and enhance periodontal health, alleviate TMJ dysfunction, increase blood flow to the brain, improve overall body balance and muscular strength, and accelerate thought processes. Training the teeth, tongue and jaw increases salivary flow, which releases a surge of insulin thereby increasing heart rate and sending glucose and oxygen to the brain to help us learn faster and retain information longer. Cerebrospinal fluid flow to the prefrontal cortex is facilitated, thereby strengthening the body’s natural protection against addictions.
	
	The mouth remains a potent, albeit unused, weapon of self-defense today. It is a reservoir of powerful Qi that can be used to access and strengthen the body’s chakras (vital energy centers) to ensure a long, healthy and prosperous life. Teeth in Mortal Combat: How to Unleash your Basic Instinct for Survival illuminates the importance of teeth not only as a weapon, but as a key to boosting one’s overall health and fitness as well as understanding our place in the cosmos.
	
	I believe this information is invaluable to dentists. As the future “Masters of Holistic Health,” we can use our levelheaded common sense and influence to instruct our patients-both young and old-on the value of maintaining and enhancing tooth function beyond ordinary use into the realm of the extraordinary: 32 precious pearls of life that immeasurably affect one’s happiness and enable the fulfillment of one’s destiny.     
	
	

 In his new book, Teeth in Mortal Combat: How to Unleash your Basic Instinct for Survival, Dr. Sawicki argues that enhancing the Qi, or life energy, of the mouth may boost jawbone mineral density, increase blood flow to the brain and improve overall balance and muscular strength.