One of the longest trends in appetite control has been the low-carbohydrate diet.

Many patients, when filling out their medical, dental and personal history, reveal they follow these patterns of eating. Nutrition may have stabilizing or damaging effects on the oral cavity, so as registered dental hygienists, we are in the perfect position to discuss the effects of low-carb dieting on the oral cavity, including the topic people are most embarrassed about: halitosis.

Theoretically, when shrinking your waistline, there should be a reduction in the occurrence of carious lesions. Fermentable carbohydrates, especially sucrose, are absorbed by biofilm. This process causes bacterial plaque to produce acids.1

Frequent exposure of a susceptible tooth surface to the acid causes demineralization, the initiation of the caries process.2 Progressive, intermittent demineralization of the tooth structure may progress into complete destruction of coronal dental tissues and development of pulpal abscesses.


	The etiology of dental caries is multifactorial. The chart to the left offers a visual guide. Streptococcus mutans and lactobacilli are bacteria found in biofilm that are highly cariogenic. Their cariogenic action has four aspects considered as separate effects:3

Implantation mechanism involving adhesion.

Colonization through competition with other bacterial components.    

Metabolic activity of established bacteria under the influence of food residues and oral environment.

Increased thickness of plaque and its control by oral hygiene.

Recommend to your patients the following suggestions by the Academy of General Dentistry:

		Chew sugarless gum with Xylitol or suck on sugarless mints

Advise your patients that these recommendations may help mask bad breath, but will only have a temporary effect on malodor until the source is remedied.

Saliva acts as an important protective fluid in the oral cavity. In conjunction with plaque, it contains minerals and trace elements such as fluoride, calcium and phosphorus that contribute to the remineralization of enamel. Calcium and phosphorus also are useful in the maintenance of the supportive alveolar bone.

Food residues, specifically carbohydrates, have caries promoting characteristics that allow fermentation and acid accumulation to occur in bacterial plaque.3 It enhances the four previously mentioned activities of biofilm: implantation, colonization, metabolic activity and thickness. When carbs are restricted in a diet, it limits an essential factor for the development of caries.

The Vipeholm study4 in 1954 first established the strong relationship between consumption and dental caries. It was supported by the investigation of Sreebny5 in 1982, which described the extensive reviews on the study, reaffirming its results. The literature concluded that a very low intake of sugar showed very low caries scores, and those that included a very high amount of sugar in their diets developed high numbers of carious lesions.

Dietary sucrose also may have an effect on plaque accumulation and bacterial population. The results of a study conducted by Carlsson and Egelberg6 found plaque formation during intake of sucrose was much thicker and heavier than that formed during glucose supplementation. Various studies7,8,9 have concluded a reduction in the amount of lactobacilli and/or streptococcus mutans in plaque and saliva when sucrose intake is low, and an increase in these microorganisms during a sucrose-rich diet.

Restricted carbohydrate intake also may have a negative effect on the oral cavity. It encourages the breakdown of fat stored for energy instead of glucose, a process known as ketosis or dietary ketosis. The breakdown of fats results in three different molecules called ketones, two of which (acetoacetate and ß-hydroxybutyrate) can be used for energy by most body tissues. The third ketone, acetone, cannot be used by the body and is excreted in the urine and exhaled by the lungs, causing halitosis.10,11

Smelling the patient’s breath is the easiest and most commonly used method of detection. Normal breath of a healthy patient should have no odor or a slightly sweet smell. When the odor is not limited to the mouth, but also is recognized through the nose, it can be assumed that the odor may have a systemic or non-oral origin. Chronic oral malodor is a common dental problem and may cause patients to seclude themselves from social activities fearing the shame the condition brings.2

Remember to be sensitive to your patients’ concerns. If chronic halitosis persists and the patient is no longer on a low-carb diet, refer the patient to be medically evaluated because it can and should be a health concern. The modern hygienist is in a unique role to promote oral as well as systemic health. 

Lisa Stefanou, RDH, BS, MPH, is assistant director of dental hygiene programs and associate professor at NYU College of Dentistry, New York.

Dianne Sefo, RDH, BA, is a full-time instructor in dental hygiene at the NYU College of Dentistry.

Articles

   One of the longest trends in appetite control has been the low-carbohydrate diet.

How low-carb diets impact oral health

If you’re like most people, you’ve been on at least one diet-from Atkins to the Zone diet and everything in between. And if you’re like most people, you probably lost some weight…and then gained it back.

Many popular diets are fad diets. That is, they promise quick, dramatic weight loss with little effort. Unfortunately, if a diet sounds too good to be true, it probably is. Fad diet plans often lack variety, omit nutrients essential for good health and label certain foods as bad ones that must be avoided. Some fad diets attribute almost magical qualities to certain foods.

The reality is there are no super foods, no magical answers to weight loss and no foods that are forever off limits. The real key to success is about balancing the calories you eat with the calories you burn through physical activity.

Instead of jumping on the fad diet bandwagon again, focus instead on these tips to help you lose weight and live healthfully.
	
	Set realistic goals.  Change doesn’t mean you have to give up the foods you like. Divide big goals like, “I will eat better” into smaller, more focused ones, such as “ I will eat one extra piece of fruit each day” or “I will put one-third less food on my dinner plate.” Make small changes over time, adding a new change to the mix only when the old one becomes a regular habit.
	
	Stick to proper portions.  Most people eat portions of food that are so large, they could feed at least two people. Getting a handle on proper portion sizes can help you slim down by allowing you to eat the foods you love, just in smaller amounts. It’s difficult to visualize a half-cup or three ounces, so use these comparisons:

		A teaspoon of margarine is the size of the tip of your thumb to the first joint.

		Three ounces of meat is the size of a deck of cards.

		One cup of pasta is the size of a tennis ball.

		One half of a medium bagel is the size of a hockey puck.

		One-and-a-half ounces of cheese is the size of three dominos.

		Two tablespoons of peanut butter is the size of a ping pong ball.

		One-half cup of vegetables is the size of a light bulb.

Compare the amount you typically eat to these recommendations, and make modifications as needed.

If time is a concern in the mornings, start your day with quick breakfast options, like:

		Whole-grain cereal with fruit and low-fat milk or yogurt.

		Frozen whole-grain waffles topped with peanut butter and banana slices.

		Instant oatmeal made with low-fat milk and dried cherries.

		A whole-wheat pita stuffed with sliced hard-cooked eggs.

Eat breakfast.  Research shows that if you’re trying to lose weight, you need to make breakfast a priority. According to a study from Harvard Medical School, men and women who eat breakfast everyday are far less likely to become obese, compared to those who skip it.
	
	Track your progress.  Monitoring the number of calories you eat and keeping them within your targeted range is a key factor in losing weight. Studies show people who write down what they eat and pay attention to how many calories they are eating are more successful at losing weight and keeping it off.

You don’t have to show your record to anyone else-just keep yourself accountable to what you are eating. As long as you’re at it, weigh yourself weekly and keep track of your exercise daily. Give yourself a gold star on your calendar for every day you reach your diet, exercise or weight goals.

If you’re more comfortable with a keyboard than a pen and paper, register for a free Internet service that will count your calories for you as you log your food.
	
	Slow down. Many of us eat too quickly, don’t wait for our body to tell us we’ve had enough and before we know it we are overfull. Eating isn’t a race, so don’t try to get to the finish line too quickly. If you’re a fast eater, slow down by:

		Drinking a low-cal or no-cal beverage like water or unsweetened tea with your meal.

		Talking with fellow diners instead of focusing on how much or how quickly you can eat.

You’ll find you can probably eat one-fourth to one-third less food if you slow down, enjoy your meal and wait for your stomach to signal to your brain that you are full.
	
	Eat more watery foods.  Fiber-rich, watery foods deliver more volume to your plate and fewer calories. Try broth-based soups, fruits and vegetables, fat-free and low-fat milk and yogurt, and beans for low energy density, high volume foods that you can eat more of without all the calories.
	
	Strike a balance between food and physical activity.  Regular physical activity is important for your overall health and fitness. It helps control body weight, promotes a feeling of well-being and reduces the risk of chronic diseases. Go for a walk or hike with a friend, try a new activity like tai chi, swim some laps or find another activity you enjoy-and will keep doing.
	
	Find a registered dietitian.  For help in developing a healthy weight loss plan that’s personalized for you, contact a registered dietitian. You can find a dietitian in your area by visiting eatright.org and clicking on “Find a Nutrition Professional.”

Let Nike and iPod become your new personal trainer. With the Nike + iPod Sport Kit you can use Nike+ running shoes and a Nike + iPod Sport Kit or Sensor to allow  your iPod nano or iPod touch to motivate you mile after mile. Also, you can connect your iPod to a Nike + iPod compatible cardio machine at the gym and track the progress of your workouts.
	Visit: apple.com/ipod/nike

Web sites such as my-calorie-counter.com allow you to keep track of what you eat and your weight loss progress over time. 

Kerry Neville is a Registered Dietitian who is also a National Media Spokesperson for the ADA. Ms. Neville has been on Chicago’s FOX News in the Morning, and has been a past columnist for the Chicago Tribune’s Health Watch.

The facts behind fad diets

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

	Dental Lab Products | April 2009
	Forward Trends: Veneers

	Advanced materials, technologies, and procedures for creating esthetic, durable veneers can expand profitable revenue streams even in a tight cosmetic market.

	What a difference a year makes. In spring of 2008, the U.S. and world economies were shaky, but hadn’t shown many signs of their eventual crumbling, just yet. Then in the fall, the official word came that we had, in fact, been experiencing a recession for nearly a full year. But the worst was still to come with failing banks, falling stock prices, soaring unemployment, and growing anxiety of an uncertain future in spite of a new administration.

	Back then, the dental profession was still riding high on the economic boom that had been rolling along during the previous few years and had stirred demand for cosmetic procedures of all sorts from patients-from chairside bleaching to full-mouth revamps. Lab owners responding to a direct-mail survey in April 20081 indicated the majority (55.8%) had experienced increased demand for restorations for strictly cosmetic purposes over the past year, while more than two-thirds (70.5%) reported an increase in cosmetic work stretching back over the previous five-year span.

	In both of these categories in the 2008 survey, less than 4% said the demand from dentists for strictly cosmetic restoration had decreased in the designated time period (3.4% over one year, 2.9% over five years). Overall, the business of creating cosmetic restorations was healthy and robust for the dental lab industry. →

	Preferred veneer fabrication techniques*

	Pressing 63.2% Refractory die 31.1%  Foil 18.9% CAD/CAM milling 14.7% Other
	2.6% 

	63.5% of lab owners do not charge different fees for different types of veneers such as ultra-thin veneers.

	The global financial crisis is more than likely a key factor in how lab owners see the demand on their veneer business.

	  Past 2 years 2009** Increased 31.8% 28.1% Decreased 21.9% 20.8% Stay the same 46.4% 51.0%

	Which communication media do you receive from your dentists with a veneer case?*

	Stump shade 77.8% Photos 77.3% Diagnostic/
	provisional cast 73.5%

	What information would help improve veneer results?*

	Better prep 72.8% Photos 62.0% Diagnostic cast 59.2%

	*Multiple responses accepted.
	Source: DLP April 2009 Veneer survey.

	Though dentistry is often thought of as fairly “recession proof,” the turmoil that has affected the global economy was bound to have a trickle-down effect. “Since October, we’ve seen a little bit of a drop, and it hasn’t picked up yet,” said Keevin Shigenaka, CDT, General Manager of All-Ceramics at Glidewell Laboratories. “That’s across the board. Last month, we were up just barely 0.5%, and we were ecstatic about that.” In talking with others in the lab industry, he has heard that many laboratories are not breaking even so far this year. Without the benefit of insurance reimbursement paying for elective restorative work, cosmetic-based dental procedures, both in-office and indirect, are paid for by patients directly out of pocket and driven primarily by emotion for wants-based rather than needs-based reasons. In an economic down-turn such as now, consumers and patients tend to reign in discretionary expenditures in anticipation of potentially worsening finances. “Right now, people are holding on to their money,” said Shigenaka. “But that doesn’t mean they don’t plan to use it. Everyone’s concerned, but at the same time, how much is everyone really altering things?” Veneer placement is one such cosmetic treatment that the recessionary economic situation appears to have affected already. The latest DLP exclusive survey2 shows veneer work has tapered compared to previous years. Less than one-third (31.8%) of survey respondents indicated an increase in veneer cases in the past two years, with the remaining percentage of labs reporting either a flatline (46.4%) or decrease (21.9%).

	Even though most survey participants2 believe demand for veneer cases will stay the same (51.0%) or even decrease (20.8%) this year, the design behind cosmetic materials and fabrication techniques continues to evolve. In addition, the professional marketing campaigns by laboratories like Glidewell with its proprietary Vivaneers brand or Den-Mat’s well-known Lumineers brand (which it also markets directly to patients) has brought the option of veneers as an easy smile makeover within the financial grasp of patients and provided laboratories and practices with the means to increase elective treatment acceptance.

	Veneer fabrication has transformed from the time-consuming, labor-intensive, and technique-sensitive process of refractory model or platinum foil build-up of porcelain powders by the highly trained ceramist, to the less-technique-sensitive wax-and-press processes performed by a technician with skills that can be aided by preformed or custom printed/milled wax forms, to the dental technologist working at a CAD/CAM workstation and designing veneers to be milled from ceramic or lithium disilicate blocks.

	The artistry involved with hand-building veneers through refractory or foil techniques is still popular with many high-end labs due to the exceptional custom esthetics that are achievable. Master Ceramist Michel Magne, MDT, detailed the sensitive techniques involved through hands-on demonstrations and a scientific lecture during Jensen Dental’s Thrive09! educational event in Chicago.

	“A lot of people can do a good job with refractory or foil,” said Shigenaka. “But for us in our particular situation for consistency, and because we have so many people at varying levels of talent, being able to wax and press became the default way of guaranteeing that we get a certain level of quality and consistency. Pressing is the most accurate way to get a margin. Whatever you wax up, if you press right, it goes right to the margin and there is no gap.

	For many laboratories, pressing is overwhelmingly the preferred method for producing veneers, partially due to multiple benefits afforded over other ceramic materials.

	“It’s much easier to train someone to carve a tooth in wax than it is to build and shape it in porcelain,” said Keith Miolen, Technical Director at Craftsman Dental Lab of Beacon, N.Y.

	In addition to traditional hand carving of waxes for pressing veneers, newer materials have been introduced to the market that eliminate much of the manual labor and skill necessary to form the tooth. Preformed wax patterns can greatly speed up and regulate the process, while polymer blocks can be custom designed and milled via applicable CAD/CAM systems. Laboratories also can utilize the services of outsourcing services to generate 3D printed wax patterns or purchase the software and hardware for in-house printing if working with a high volume of pressing cases.

	“What used to be in the hands of a ceramist now is in the hands of a good waxer,” said Miolen. “It’s changing the way lab owners hire and the way they structure their labs.” He added that technicians who can be trained to wax also are easier to employ than ceramists, who have years of training and experience, but who also are retiring and leaving lab owners with a difficult time finding replacements.

	In addition to veneers, pressable materials can be used to create all-ceramic single-unit inlays, onlays, and anterior crowns as well as multi-unit bridges or posterior crowns with a metal or zirconia substructure (depending on the particular material). This versatility facilitates shade matching of adjacent and opposing restorations. Pressing also affords finishing options as the technician can simply stain and glaze the pressed full-contour restoration or cut-back and layer with compatible porcelain for added esthetics.

	“If I’m doing multiple units, I just stain and glaze the anterior. But if it’s just one or two units, I will layer because I’m matching natural dentition. If I’m making all the teeth in the anterior, then I can stain and glaze and make everything match,” said Miolen. “That just makes my lab so much more productive and efficient.”

	With traditional leucite and feldspathic pressable materials there is a limit to just how thin the veneers could be pressed. The standard 0.6-mm-thick pressed veneer requires the clinician to grind the surface enamel of the tooth, which then requires the use of provisional restorations while the veneers are fabricated in the lab as well as bonding the veneers in place. Around five years ago, Den-Mat Corp. introduced Lumineers ultra-thin (0.3-mm) pressed feldspathic veneers that require minimal or no prep by the dentist, which at first caused some concern in the dental profession.

	“General dentistry frowned on the procedure, and so did Glidewell,” recalled Shigenaka. “If you don’t reduce any tooth structure, you’re adding on. It’s going to be bulky, it’s not healthy, and you’re creating a speed bump down at the gingiva.”

	However, after numerous cases were placed by Glidewell’s in-house clinician Dr. Michael DiTolla and the endorsement by Dr. Gordon Christensen of Den-mat’s Lumineers ultra-thin veneer and the no-prep technique in general, Shigenaka said Glidewell saw the no-prep veneers as a valuable treatment option and the wave of the future. “The reward factor for the patient is so great that you realize that you are doing a good service, and you are doing legitimate dentistry,” he said.

	According to Shigenaka, Glidewell ceramic engineers set out to develop their own pressable ceramic capable of pressing to 0.3 mm for no-prep veneers and eventually came up with a leucite-reinforced feldspathic porcelain that is a variation of a layering ceramic and available in a range of opacities. “That became our entry into the market,” he said.

	Like Den-Mat (as do several other labs), Glidewell markets its own Vivaneers brand direct to dentists as a no-prep, non-invasive smile makeover option. However, Glidewell also developed the material for labs to use for in-house veneers known as Prismatik ThinPress, and just recently Ivoclar Vivadent launched IPS e.max Press lithium disilicate material in both low (LT) and high (HT) translucencies for ultra-thin veneers. In addition, Pentron Ceramics now offers Press.tige pressable material for ultra-thins, which Miolen has been using for several months.

	“A material that can be pressed this thin makes my lab more productive because now I can incorporate more waxups into my rings as well as press the thin cases,” said Miolen.

	According to the DLP veneer survey, 40% of lab owners have added ultra-thin minimum-prep veneers to their services.

	Miolen added that because it also can be used to press full-contour units, he has been able to up-sell cases where the dentist has prescribed a single restoration but where adjacent teeth are asymmetrical or out of arch form and could benefit from a thin veneer with no preparation.

	“I’m actually calling doctors up promoting more veneers on cases where they do not prescribe a veneer. All I have to do is press it and send it,” he said. “It idealizes their smile, and the doctor doesn’t have to prep. I now aid the doctor in treatment-planning a better smile for the patient.”

	Eddie Corrales, Owner of Downtown Dental Designs in San Diego, confirms the add-on benefits of pressing ultra-thin veneers as an adjunct to non-veneer cases. “That’s something that I, and a lot of good technicians, have a good eye for-the improvement of the case,” he said. However, he does recommend that such case upgrades be limited to good clients to ensure payment.

	Shigenaka mentioned that Dr. DiTolla frequently uses no-prep veneers in his practice for certain cases to fill out a smile, which benefits the laboratory, practice, and patient.

	“From the lab’s perspective, it’s a great tool to generate revenue and to get a higher success rate on the restoration because it just blends everything better,” he said. “For the doctor, you’re offering the additional revenue stream. The patient is more likely to go for it. [The clinician] can give a really great price [because of the lack of additional prep time], and feels like he’s getting a deal.”

	More commonly used to mill substructures for zirconia-based crowns and bridges, CAD/CAM technology also has applications in the production of veneers, beyond the milling or printing of wax/resin patterns for pressing. Although pressables command the heft of use for veneer fabrication, a healthy 14.7% of lab owners responded to the DLP survey that they use CAD/CAM to mill their veneers.

	Bill Atkission, Owner of Bill Atkission Dental Ceramics in Oceanside, Calif., has been using Vident’s Mark II feldspathic blanks on the Sirona inLab system to mill anterior veneers since 2006, prior to which he was pressing.

	“I prefer to do these and talk my doctors into doing them,” he said, though he adds that the milled veneers aren’t suitable for all cases, such as patients with heavy bruxism.

	In addition to Vident, Ivoclar also offers millable blocks for use in the inLab CAD/CAM machine in the form of IPS Empress CAD leucite-reinforced glass-ceramic and the IPS e.max CAD, though they are indicated only for standard (not ultra-thin) veneers.

	Atkission indicated he hasn’t had the opportunity to mill the newer IPS e.max CAD HT blocks (which were just launched this year), but said he would likely use them in cases that require the additional strength of the lithium disilicate material.

	One minor downside to milling veneers is there are no blocks specifically shaped and sized for the thin restorations. Using a standard block results in wasted material and extended milling time because only one veneer can be milled at a time.

	Shigenaka says that Glidewell does a certain percentage of its veneers through CAD/CAM with consistent results that require minimal hand finishing. “As the materials become more usable and more practical, that’s really going to increase,” he said. He added that for single veneers, he’s more likely to press.

	Den-Mat produces the Lumineers with Cerinate through pressing, though Den-Mat Director of Marketing Kim Ferrari said another Lumineers  veneer option is a milled lithium disilicate. In addition to using CAD/CAM to produce the veneers themselves, Den-Mat also incorporates the technology to generate an innovative tray delivery and placement system called LUMITray as well as a tooth-preparation guide called LUMIKey. “It’s actually better for the dentist getting into thin veneers,” said Ferrari. “We take the technique sensitivity out if it. It’s a hard material that won’t let you overprep.”

	While clinicians have the option of milling veneers at chairside on Sirona’s CEREC machine or the E4D chairside CAD/CAM system distributed by Henry Schein, the technology has limited appeal for the majority of practitioners due to the hands-on processing steps involved-such as the detailed staining, glazing, and polishing-to create natural-looking single-visit restorations. However, the CEREC system starts with a digital impression that can be electronically sent to a laboratory for veneer design, milling, and finishing. Other intraoral capture devices, like Cadent’s iTero or 3M ESPE’s Lava C.O.S., as well as extraoral scanners, like Zahn’s Dental Wings or Nobel Biocare’s brand-new NobelProcera, that can scan the internal aspects of a poured impression tray and generate a digital model, offer labs and practices a model-less option for veneer cases, which shortens turnaround time.

	“Everyone’s fascinated with this kind of technology, but I think the vast majority of labs are still doing it the traditional way,” said Shigenaka, though he cautions that laboratory owners “should know that CAD/CAM or pressing maximizes their efficiency.” 

	Keith Miolen of Craftsman Dental Lab illustrates a veneer case using Pentron’s new Press.tige pressable ceramic. Click here.

	1. The DLP April 2008 Cosmetic Survey was direct mailed to a random sampling of 1,000 lab owners in the United States in February 2008. Statistics were tabulated from 159 returned surveys, for a response rate of 15.9%.

	2. The DLP April 2009 Veneer Survey was direct mailed to a random sampling of 2,730 lab owners in the United States in February 2009. Statistics were tabulated from 195 returned surveys, for a response rate of 7.1%.

 Dental Lab Products | April 2009 Forward Trends: Veneers  New Face of Veneers  Advanced materials, technologies, and procedures for creating esthetic, durable veneers can expand profitable revenue streams even in a tight cosmetic market.  by Richard Palmer    Photo: Den-Mat Corp.

New face of veneers

	Your team members can’t just answer the phone. They need to connect with the patient. Here’s how.

	Calling a new dentist for the first time can be, for many, an act of courage. This is especially the case when the caller is responding to, for example, a mailed invitation because then, in addition to the usual trepidation, there may be other concerns-such as ‘what’s the catch?’ An appreciation for the caller’s mindset and emotional state can go a long way preparing the Team for handling these calls appropriately.
	
	A dental marketing consultant’s job essentially boils down to getting the phone to ring. I learned early in my career that what happens after the phone rings is every bit as important as getting it to ring in the first place. Until they find a way to actually deliver dentistry over the Internet, the telephone will continue to be the main gateway people use to learn about your practice. This means the front office team can literally make or break your marketing plan.

	Another example of exuding enthusiasm among team members is to ask yourself how you would rather be greeted if you were to call your office.  Would you rather hear: “Dental office” or “Thank you for calling our dental office, this is Danny speaking.  How may I help you?”  While you can tell, just by the words, which is the preferable introduction, it’s how the words are spoken that really makes the difference.  
	
	Specifically, project, enunciate and vary the tone of your speech.

	In a 2007 survey commissioned by American Dental Marketing, 78% of dentists indicated their biggest dentistry marketing challenge is getting their team to properly field telephone inquiries from prospective patients (converting Web site visitors to patient appointments was second, and getting prospective patients to call at all came in third). But there are ways to improve your staff members’ phone etiquette, from changing the tone of their voice to thinking more about what they’re actually saying.

	Professor Albert Mehrabian’s research at UCLA determined that three components comprise our communication:

		The visual component (aka body language). The motion and expression of the face and body.

		The vocal component. The tone, resonance and projection of the voice.

		The verbal component. The actual words spoken.

	When measured, the effect of each component on the believability of the message showed:

		The verbal component contributed just 7%

	These findings make it clear why telephone etiquette, combined with the appropriate choice of words, is essential in diminishing the telephone’s “visual gap” and enhancing the believability of the message (as well as that of the messenger).

	In my writing and speaking about Internet-generated inquiries, I often make the distinction between trigger pullers and tire kickers. Trigger pullers are people who have already chosen to take action. Prospective patients usually fall into the category of tire kicker. Someone calling you for the first time needs to be treated differently than someone who is familiar, and comfortable, with the practice. The tire kicker likely knows nothing about you or your practice. As noted earlier, the challenge becomes even greater when the caller os responding to a special offer, because they may be even more skeptical.

	In other words, a caller may ask, “How much does a crown cost?”  But what they’re thinking and feeling is: “Can I trust you?” and “Will you treat me better than my last dentist did?”  

	Because today’s tire kicker is tomorrow’s trigger puller, the growth of your practice literally depends upon how carefully and professionally you treat these callers. You can, simply with the empathy, enthusiasm and technique you deliver, convey that yours is a dental practice unlike anything the caller has experienced in the past. But, for this to occur, we must be on guard against a mental trap.

	It’s important for your team to really think about what they’re going to say when they take a patient phone call. For example, I attended a lecture where we were asked to indicate our preference between the following workshop titles…

		Proposed Title I: Sexual Harassment in the Workplace, and Dealing with Racism

		Proposed Title II: Men and Women as Allies and Friends, and Celebrating Pluralism

	Both titles promise the same thing, yet it’s obvious which is preferable. The brain hears all the words, but it also feels some of them. Some people will react negatively, perhaps without even knowing why, to the words ‘sexual’ ‘harassment’ and ‘racism’ because for them, these are emotionally charged words. So always choose your words carefully and, if a word can be misinterpreted, don’t use it.

	The self-fulfilling prophesy trap refers to certain attitudes and beliefs that can cause what you least desire to come to pass. For example, some dental offices place a call tracking sheet near the telephone. There are boxes at the top of the sheet that the team member uses to identify the ‘kind of patient’ calling the office. One of these designations is often “Price Shopper.” If a caller asks how much a procedure costs, an X goes in the box marked ‘shopper.’ The team member understandably feels he is doing his or job by saving the practice a lot of time and aggravation by getting rid of the price shopper.

	Unfortunately, neither the doctor nor team member realize that, when we label someone as undesirable, the quality of the communication changes. The call can become more of an interrogation to see if the caller is worthy of the practice than conveying to the caller the unique benefits of joining the practice. This is particularly unfortunate because, in all likelihood, the caller simply asked for the price because he did not know what else to ask.  

	Now that we’re free of any prejudgments about who is calling us, the next step is to understand how to quickly and effectively connect with the caller. And by connect I mean convey empathy, exude enthusiasm and get the caller to agree.

	To convey empathy, you must not only feel for another person; you must also let that person know how you feel. People don’t care how much you know until they know how much you care.

	For example, if someone calls a dentist because his tooth hurts, would he rather hear: “What kind of insurance do you have?” or “I’m so sorry to hear you’re in pain. Can you come see us right away?”

	The next way to connect with the caller is by exuding enthusiasm. Because we know most communication is visual, we understand the importance of making up for the loss of that visual component by emphasizing the only two components left to us on the telephone, namely, the verbal and vocal components. This means enunciating and selecting words that are clear, easy to understand and have the appropriate impact.   

	I have my coaching subjects simulate a telephone conversation with their fellow teammates as observers. We then take turns evaluating each others’ performance. One of the most commonly cited observations is the caller seeming ‘flat’ during the simulation. Why? Being perceived as genuine and enthusiastic over the telephone actually requires us to exaggerate our communication a bit. Because this is unnatural, it’s also uncomfortable at first. As with most things, a little practice and positive feedback are all your team needs to exude enthusiasm over the telephone.

	The final key to connecting with callers is to get them to agree. This could mean agree to hear more about the practice, agree to make an appointment, agree to pay their bill on time, or any one of countless other desirable actions you want callers to take.

	Perhaps the easiest way to accomplish this is to place yourself in the questioning seat. This is because whoever is asking the questions controls the call (note that, by control, I do not mean manipulate. People are best served when the expert is in control). A simple way to get and remain in the questioning seat is to answer any difficult question with another question.

	For instance, if someone calls your practice and asks “How much do you charge for a crown?” You might answer, “I can help you with that. My name is [your name]. With whom am I speaking?” By that simple, but highly effective, sleight of word, you have just regained control of the conversation.

	Part of succeeding in business (and life) entails being an effective communicator. Because so much communication is conducted over the telephone, those who master the art of telephone call etiquette are poised to excel.  

	So, stay out of the self-fulfilling prophesy trap, exude empathy and enthusiasm, and practice your skills, and soon you and your entire team will be master telephone communicators.

Daniel Bobrow, MBA, is president of the American Dental Marketing Company, a dentistry marketing and patient communications consultancy. He is also Executive Director of Dentists’ Climb for a Cause™. Readers interested in learning more about integrated marketing and patient communication products, systems and services are invited to contact Mr. Bobrow at 312-455-9488 or DBobrow@AmericanDentalMarketing.com or visit AmericanDentalMarketing.com.

   How’s your phone etiquette?  Your team members can’t just answer the phone. They need to connect with the patient. Here’s how.

Marketing Insider: Phone etiquette

	Example of direct mail campaign tracking program

	There are many elements to a marketing plan you can track with TTN (tracking telephone numbers). Here’s a sample marketing plan and how you can track the results.

	Twice monthly placements in a local newspaper: if you only run one ad, acquiring an additional Tracking Telephone Number should be sufficient to gather the necessary data.

	Direct mail to current and new residents as well as direct mail to area employees. Because the practice is deploying two distinct direct mail tactics, it’s important to distinguish between the responses. Acquire at least two tracking telephone numbers, one for each strategy. You may also want to acquire more than two TTNs for ‘a/b testing,’ which involves changing a variable, such as the headline, to see if there is any significant difference in response.

	A Web site, including paid and organic Web marketing. Your Web site should have a TTN prominently displayed near the top of each page. It should be in text, not graphics, format. This helps search engine robots (bots) identify yours as a local business which, in turn, helps you rank higher when Web surfers are looking for a dentist in your area.

	If you are invested in SEO (search engine optimization) and PPC (pay per click) strategies, consider using JavaScript rewrites. These permit a different TTN to appear on your Web site as a function of how the visitor got there.  For example, if people use Google to find you, they’ll see one TTN. If they use Yahoo they’ll see a different TTN. If you use a drip marketing campaign that is intended to communicate with prospective patient leads who’ve visited your Web site and have signed up to receive your communications, you’ll also want to track these captures. This can be done by using an online tracking portal.

	Be sure some form of analytics is included with your Web site, and that you have access to and are familiar with its use.  Most Web hosting services include an analytics service, so you should be able to ascertain detailed information about who is clicking through, when, from where, and through what pages. This feedback is indispensable in learning what visitors find interesting as well as what they do not, which in turn permits you to make improvements to your Web site and Web-based marketing.

	Automated email-based communications with patients of record (what we call Patmetrics©). Tracking the benefit of your internal marketing efforts can also be enhanced by using TTNs. But because you already know who these people are, you may or may not care about tracking to that degree.  For instance, if you measure average patient production (by dividing total production for the year just ended by the number of active patients) just before you implement your new tactic, then perform the same measurement one year hence, any increase in average patient production will at least be partly attributable to the new tactic. Because the cost to implement such strategies is usually relatively low, any increase should justify continuing the tactic.  

	If you want to be more precise, calculate response rate by assigning a unique landing page containing your “Special Patients Only” offer, then monitoring the number of click-throughs to the landing page, and dividing that number by the number of patients contacted.  To calculate your closing ratio, or how many patients accepted the offer, divide the number of patients who paid for the offer by the total number contacted.An annual cause-related event. Cause-related marketing continues to be one of dentistry’s least used practice building tactics (see Marketing Insider: Cause Related Event Marketing).  Tracking the efficacy can be easily accomplished by setting up a unique event registration page for your event* and having the link to the Registration page placed on your practice’s home page.  Following the event, compare who on the attendee list (who is not already a patient) becomes a patient.  Be aware, however, that as with all marketing tactics, there may be a considerable time lag between the exposure and the response.
	
	*Event Registration and Fund Raising Pages are offered free to ClimbForACause.org participants, courtesy of American Dental Marketing. Alternatively, you can dedicate a landing page on your Web site exclusively for this purpose.

        Example of direct mail campaign tracking program  There are many elements to a marketing plan you can track with TTN (tracking telephone numbers). Here’s a sample marketing plan and how you can track the results.

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Marketing Insider: Phone etiquette

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