Every dentist or team member has heard about it-even if none of us have actually done it. The patient related dental mythology of some dentist somewhere at sometime taking a knee to a patient’s chest while performing an extraction.

Well-I would like to advocate just that! No, I don’t want you to climb up on the patient’s lap and take a knee to their chest. I am talking about body posture and language when interacting with patients.

One of the most vulnerable places that a patient can be is reclined in our offices is reclined back with us hovering over them. From that position, we try to have discussions about their health, our findings and recommendations. The discussions may frequently involve unpleasant or stressful topics regarding procedures, costs and commitment. It is an awkward position to truly have a ‘conversation.’

A discussion or conversation between two people is influenced not just by what we say and how we say it. How we present ourselves physically to our patients can perhaps have one of the greatest influences. Are we facing them? Do they need to crane their necks back to look up at us, upside down only find themselves staring up at a mask, loupes and having to squint through the glare of our headlamp?

What our team advocates is having a ‘knee to knee’ conversation with our patients. The patient should be seated upright and we should bring our chair around, as much as possible to be facing them. No gloves, no mask-not even around the chin. Facing our patients at the same level puts us on the same level  from a physical aspect and removes the hierarchy of the white coated doctor hovering over them and dictating care. The equal body posture and language opens up the possibility for more comfortable and honest conversations with our patients.

When a healthcare provider takes the time to unmask, de-glove, sit in from of the patient and look them in the eyes, it conveys several things. It conveys that they are your focus, that you are willing to give them your time thoughtfulness, caring and most importantly, your respect.

Give it a try. Step out of your comfort zone and into one of comfort for the patient. We would love to hear your stories of how it works for you!

I remember the first time I heard Lou Reed & The Velvet Underground as I was sitting on my friend Rob’s couch. It literally made me sit up, turn toward the stereo and ask Rob who that was. I needed to know. The music grabbed me instantly and I was converted. The Velvet Underground was a bit before my musical time but I turned to Lou Reed’s solo career and to this day, still listen to his music regularly. I am still moved. I also remember the day he died. I had just missed a concert by one of my favorite performers the day before because I was just too busy or tired or some other excuse for not driving an hour to see her. The next day when I heard that Lou Reed had passed away, I felt like a piece of me had been ripped out of my chest and my breathing honestly felt a bit strained.

Mentors and influencers appear and move in and out of our lives. There are times that we ‘outgrow’ the influence of our mentors. That is one way to look at it. There are times that the culmination of influence of our mentors lifts us up to a higher level, purpose and calling. We do not ‘outgrow’ them but rather flourish under their influence and knowledge nurturing that it becomes time for our own evolution. Parker Palmer in The Courage to Teach speaks of phases in our growth that the need to mentored is diminished and the opportunity to mentor reveals itself. Unrealized, this juncture can be experienced as a plateau or even professional burnout. Yet, if we can turn and recognize that opportunity-to nurture and influence others, to pass on that magic that was shared with us, we can pass through that dubious plateau or burnout phase. That ‘magic’ is a gift that can grow exponentially within us and those that we influence.

As we reach the halfway point of 2016, I have seen too many of my mentors and influencers pass on this year-be it David Bowie, Russell DeVreugd or Dr. Dennis McCullough. I think of the lost opportunities I had to spend more time with Russell as I was not and do not think would ever be finished needing his guidance. If only I had made the time to get together again at the bench. I think of the missed opportunity I had to contact Dr. McCullough, introduce myself and share the impact that his teachings & philosophy  has had on my own life, my teaching and  patient care. If only I had made that call or written that letter.

I look back at those opportunities lost-if even for one more chance. Their influence remains but that piece of my chest is still missing. It has been filled though with their memories, lessons and impact. I look forward now to new opportunities realized-to pass from the receiver of their influence to the one that shares it forward to the next recipient, colleague or mentee. That is the Magic & the Loss.

When you pass through the fire, you pass through humble

You pass through a maze of self doubt

When you pass through humble, the lights can blind you

Some people never figure that out

                                                                                              Magic & Loss, Lou Reed 1992

There is a saying that has been stuck in my head since I first heard it. Sometimes I joke about it. Sometimes it comes out in my teachings as a slightly more serious discussion on occlusion and how we manage our expectations with our patients, our laboratory partners and ourselves during crown deliveries.

“Plant it low & watch it grow. Plant it high & watch it die.”

It is a twist on an old gardening mantra that I first heard, I believe, from Dr. Gary DeWood. As I recall, we were having a group discussion on the learning curve and application of occlusion. As we were learning how to take proper occlusal records as well as find laboratory technicians to partner with, there were and are frustrations. We were striving for that perfection of delivery, which on either side were reminders of our shortcomings.  Crowns that were too high or too low made us question our abilities and those of our technicians. We shared as fledgling occlusionists how we wondered & theorized what our patients perception was of our abilities as we had to grind on their new crowns after so much effort and attempts at precision in our records. What were we doing wrong? Why couldn’t we find a lab that understood occlusion?? (Even though I was just learning it myself…)

Well-last week as I heard that old saying “Plant it low & watch it grow. Plant it high & watch it die.” I heard it differently. I was reading some discussion board posts-both from clinicians and technicians. People were venting & sharing frustrations. The discussions ranged from clinical to management to specialist interactions.

“Sick and tired of having to lower expectations. Sometimes I wish it didn’t irritate me so much.”

It was then that my perspective changed. I saw or rather heard the old saying no longer relating exclusively to occlusion but rather to how we set and perceive our expectations-of ourselves, as well as of others. Our feelings of accomplishment, as well as feelings of frustration, are directly linked to how we set our expectations of the outcome.

So-how does that translate or relate to the old saying? Well, when we set our expectations and goals as too far beyond our abilities or ability to achieve, all that we experience is failure or an inability to reach our desired outcome. This can beat down our confidence and our conviction. Our goals can die. It is seen and feels like failure. In defeat, we lower our expectations.

Does that mean we should not strive to improve & just lower our standards and outcomes? No-of course not. When I think of “plant them low and watch them grow” I think of setting realistic steps, milestones and waypoints in our journey & commitment to improvement. This allows us small successes yet continual improvement.

Plant your goals SMARTly:

Specific-know what you are trying to achieve

Measurable-know when you have reached that goal

Achievable-know that it is something that can be done

Realistic/Relevant-know that it is a goal that is appropriate for you

Timely-know that it can be accomplished within a set time frame

If you can change your perspective on planting your goals, you will have a better chance to see them flourish in the near future and grow in the seasons to come. Thank you Gary for the lesson-it just took 15 years to sink in!

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“First figure out what you want it  to look like, then figure out how to make it fit.”

That is the current mantra of modern treatment planning in dentistry. It clarifies a methodology down to something so basic and easy to follow. The application & rationale certainly require a bit more explanation and exploration.

There is simple rationale for starting with the upper single central incisal edge in our treatment planning. The midline and incisal edge together are the cornerstone of the smile. From an aesthetic standpoint, if we start anywhere else, we risk loss of space, symmetry and starting the whole process over again. Eventually we may or will get there-maybe and with lots of effort and potential repeating of the process.

This has been exemplified through Dr. Frank Spear’s FGTP (Facially Generated Treatment Planning), more recently Dr. Christian Coachman’s DSD (Digital Smile Design) but really goes all the way back to the Hanau Quint and the fundamentals of denture setups.

This rationale however goes past aesthetics and can also facilitate efficiency in planning ‘fit’, while maintaining the aesthetics that we achieved in the ‘looks’ planning stage.

In general concept and application, this is the rationale and flow:

The maxillary incisal edge placement is designed in location through aesthetics and phonetics. In fact, phonetics becomes the first component of ‘fit.’ If we like the looks but the patient cannot talk, that really is fit issue that must lead to altering of that sacrosanct edge. It may only be a bevel or labial~lingual inclination. In some cases it may be length. After that has been accomplished-the melding of aesthetics and speech, any changes made to the maxillary incisal edge are at the expense of the aesthetic goal. Consider the edge placement at this point sacrosanct.

Next-we truly move to fit. Traditionally this has been the occluding contact of the lower incisal edge against the palatal surface of the maxillary central incisor. There are pitfalls in this approach that I will get to but let’s first explore a different approach-which is the outside~in approach to occlusal design & equilibration.

The second step involves matching the mandibular incisal edge to our desired maxillary incisal edge.  Porcelain is said to live and die on the incisal edges…and the transition to and from those edges. That is an issue of distribution of forces along a flat receiving area and the resistance encountered getting to and leaving that receiving area. So matching the lower incisal table to the existing maxillary table that we designed provides that distributed, axially loaded force (as much as possible) of parafunction.

From that edge to edge position, we move ‘outisde-in’ off of the incisal table and towards MIP. The next contact that we encounter/transition to is over the inciso~lingual edge of the maxillary central-also called the ‘leading edge.’ This is possibly the most overlooked occlusal contact area but arguably the most critical when we look at porcelain failure.  If that transition is not smooth or if the contact area in that transition is to concentrated on one small area, failure can and will occur. The leading edge then is matched to the  leading edge of the mandibular central incisor-which is the inciso~facial edge or bevel.  It has been my experience that spending time & attention to refining the tables to this edge transition will significantly reduce you porcelain chipping and fracture.

From that edge transition, we can continue the outide-in journey along the palatal surface of the maxillary central incisor and finally to the leading edge of the mandibular incisor defining the MIP occluding contact.

The maxillary incisal edge defines the mandibular incisal edge.

The mandibular & maxillary leading edges are defined and matched.

The transition between incisal tables & leading edges are refined.

The excursive  contacts are maintained outside-in which finally defines the MIP palatal contacts.

So-returning to the comment at the beginning of the blog about the pitfalls of starting ‘anywhere else’, lets talk about starting this process from the MIP contact or ‘inside out.’

The mandibular leading edge is matched to the MIP contact-sound good.

The mandibular leading edge defines and refine the excursive contacts as we move toward the maxillary incisal edge. Looking good.

The mandibular leading edge reaches and defines the maxillary leading edge-still seems to be working.

Then we get to the tables. As we transition to matching the mandibular table to the aesthetically defined maxillary edge, do they match. If not what do we do? Do we change the maxillary edge? Well-that could change our desired aesthetics. So-that would lead us to adjusting the mandibular table.  Does that adjustment affect the mandibular leading edge? If that is the case then all of the work we did in our inside-out excursions may or will need to be redone. Back and forth the process goes. Inefficiency.

Of course-there is also the possibility in the above scenario that we began with ‘fit’ and did not even set that maxillary edge first. Then we would be performing that inside-out occlusal design first then our incisal edge would either be compromised by the plane of the mandibular incisal edge. Or-we go through the whole inside-out process, then we set the maxillary incisal edge. Again-all of  other contacts  would likely need to be altered.

I hope that this helps clarify or at least shed some light on the advantages of an outside-in approach and the sacrosanct nature of the aesthetic maxillary incisal edge.

I would like to thank Dr.’s David Latz, Frank Graziano & Steve Ratcliff for sharing their knowledge, insights & passion with me on this subject back in the day at The Pankey Institute. It was truly a critical crux point in my journey.

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