toothfairy04952
New Member
- Joined
- Oct 11, 2019
- Messages
- 5
- Reaction score
- 2
Thanks everyone!
Last edited:
New Grad- Job decisions
- Thread starter toothfairy04952
- Start date
- Joined
- May 13, 2009
- Messages
- 288
- Reaction score
- 16
Have a CPA set up an LLC/PLLC and get them to go over how everything works with you. You can end up paying less overall as an independent contractor. Join and contact your state dental association... many of them will cover your malpractice insurance your first year out or offer steep discounts. I’d work somewhere with a mentor you like and a base pay of at least $500/day. Don’t jump at your first couple job offers if they’re not appealing you. Have the state dental association give you a recommendation for a contract lawyer and don’t sign anything without having them review it first
- Joined
- Mar 11, 2011
- Messages
- 582
- Reaction score
- 668
It's almost always better to be a W2 employee vs. a 1099 independent contractor. Owners will try and sell you on being an independent contractor because of the "deductions". They want you to be 1099ed because it saves them on FICA taxes. Under the new IRS rules, it's clear a general dentist cannot be classified as an independent contractor (this doesn't mean they can't hire you as an independent contractor, but it wouldn't withstand and audit).
If you're going to be 1099ed, you'll want to be paid about 3% more to cover self-employment tax etc.
Malpractice insurance is free during your first year through the AGD's partnership with Dentist's Advantage. Your state dental association may offer a deeply discounted plan as well. After that you'll probably be looking at $1,300-2,500 per year for malpractice coverage depending on the company and plan you pick (occurrence vs. claims made).
We'd need to know a lot more about the offers you have to give insight. I will say that DSOs are always hiring. So if you have a good offer (even if it's par time), in a good private office with a dentist you respect, it's probably worth taking it and trying it out.
You can also work part-time at one office and part-time at another but you'll need to be mindful of the terms of the non-compete.
4 clinical days is considered full-time. If you are just going to be paid on collections (without a daily base) you need to know what insurances the office is in-network with and you NEED TO SEE THE FEE SCHEDULES. You may find that you're working for nothing. Also ask who does the hygiene.
If you're going to be 1099ed, you'll want to be paid about 3% more to cover self-employment tax etc.
Malpractice insurance is free during your first year through the AGD's partnership with Dentist's Advantage. Your state dental association may offer a deeply discounted plan as well. After that you'll probably be looking at $1,300-2,500 per year for malpractice coverage depending on the company and plan you pick (occurrence vs. claims made).
We'd need to know a lot more about the offers you have to give insight. I will say that DSOs are always hiring. So if you have a good offer (even if it's par time), in a good private office with a dentist you respect, it's probably worth taking it and trying it out.
You can also work part-time at one office and part-time at another but you'll need to be mindful of the terms of the non-compete.
4 clinical days is considered full-time. If you are just going to be paid on collections (without a daily base) you need to know what insurances the office is in-network with and you NEED TO SEE THE FEE SCHEDULES. You may find that you're working for nothing. Also ask who does the hygiene.
- Joined
- Mar 16, 2005
- Messages
- 866
- Reaction score
- 134
Absolutely ask to see fee schedules for the practices. I'm in PA and our insurance fee schedules (UC/UHC, esp.) can be very low depending on your location. So it's possible that you might be producing a fair bit in corporate and not ever make it past the $500/base. Also ask to see the schedules as well. Sometimes, the schedules are not very busy and you will likely not be making any money over the base. If the schedule is busy enough, I would try to get the first one to offer some sort of bonus based on your collection vs. bonus. I believe the fee schedules in private practice are higher compared to corporate, but I might be wrong. Also, the noncompete is a little large. 5 miles/1-2 years, depending on location, is more reasonable. Ask for a "honeymoon period" before the noncompete kicks in. Usually 3 months is fair. If you leave for any reason, the noncompete does not kick in. You do not want to work at an office, find out that it's not for you and be locked into a noncompete for years.
Check if any of them offer HMO insurance. Those are bad for collection/production pay.
Just one thing to consider with the malpractice from the corporate office. There are two types of malpractice insurance. Claims made vs. occurrence. Claims made policies cover you for a certain period (typically your employment time). They do not cover any claims after that period you were practicing unless you purchase tail coverage for a period of time (PA standards are 2 years from date of discovery). Occurence will cover you, even after you've terminated the policy. Occurence is more expensive than claims made. Anyway, the digression here was because corporate offers a claims made policy and will terminate it when you leave. It can be hard to find an insurance company to offer a tail.
If you'd like, you can PM your location and the names of the corps. If they're local to me, I might be able to give you some more info about them.
Check if any of them offer HMO insurance. Those are bad for collection/production pay.
Just one thing to consider with the malpractice from the corporate office. There are two types of malpractice insurance. Claims made vs. occurrence. Claims made policies cover you for a certain period (typically your employment time). They do not cover any claims after that period you were practicing unless you purchase tail coverage for a period of time (PA standards are 2 years from date of discovery). Occurence will cover you, even after you've terminated the policy. Occurence is more expensive than claims made. Anyway, the digression here was because corporate offers a claims made policy and will terminate it when you leave. It can be hard to find an insurance company to offer a tail.
If you'd like, you can PM your location and the names of the corps. If they're local to me, I might be able to give you some more info about them.
toothfairy04952
New Member
- Joined
- Oct 11, 2019
- Messages
- 5
- Reaction score
- 2
- Joined
- Mar 11, 2011
- Messages
- 582
- Reaction score
- 668
A fee schedule will be a practice’s contracted rates with insurances. If your job offer is contracted with delta, you would want to see the delta fee schedule, in addition to any other insurances they are contracted with.
If the office does not want to provide this, then it would help if you were able to pull the last associates production report. If they don’t want to provide that, pull the owners. If they don’t want to provide that, probably don’t take the job without a base (if you’re taking the job at all).
- Joined
- Mar 11, 2011
- Messages
- 582
- Reaction score
- 668
Doing your own hygiene isn’t bad in a private practice depending on the fee schedule. In a corporate office is can be pretty terrible. How many columns are you expected to run at the same time in each job?
- Joined
- Mar 11, 2011
- Messages
- 582
- Reaction score
- 668
8 columns? I’d pass, that’s terrible.
- Joined
- Jul 21, 2004
- Messages
- 1,505
- Reaction score
- 2,431
8 columns is good from a production standpoint, especially if they can fill it up with productive patients.
Edit: This is what I'm talking about in my previous posts. Don't be afraid to get slammed with work. It's better to have more work than not enough... as long as you're getting paid for it.
Edit: This is what I'm talking about in my previous posts. Don't be afraid to get slammed with work. It's better to have more work than not enough... as long as you're getting paid for it.
- Joined
- Mar 11, 2011
- Messages
- 582
- Reaction score
- 668
8 columns would have to be barbershop dentistry. It’s fast, cheap, low quality dentistry where patients are left waiting for a provider who is running late pretending to do a prophy between operative patients.
In my opinion it’s better to get good, then fast. 3 columns is more than enough to collect more than 1.5M if it’s a full schedule with reasonable fees.
- Joined
- Oct 5, 2011
- Messages
- 579
- Reaction score
- 418
Yes!!! THank you! Wow there are so many people on these forums that want 2 columns 8-10 patients a day and make half a million a year. When you start out you have to WORK. You have to see a lot of patients to ramp up your production and put money in your pocket.
- Joined
- Jul 21, 2004
- Messages
- 1,505
- Reaction score
- 2,431
Essentially, a medicaid mill. If you don't have hygienists, you have to do the prophies yourself. Being slow doesn't mean high quality. Patients would rather get in and out of a procedure than be stuck with a 30 minute class II or 4 appointment RCTBUCrn.
I am the opposite. I think it's better to be fast and build your skill overtime. The more patient encounters you have, the more you build your skill and speed. You can't have more patient encounters if you're not going to see more patients in a given timespan. In terms of profitability, why limit yourself to only 1.5-2M... I would rather do a bunch of single tooth procedures to achieve the same level of production than do a few large procedures. My risk is more diversified and limited.
So I hate to say it...but I agree. I am only a student but knowing the rule of demising returns on a procedure is important. Being quick though doesn't necessarily mean you are bad and not good. It just means that you create a clinically sound environment and decent prognosis in a shorter span of time than "textbook".
- Joined
- Jul 21, 2004
- Messages
- 1,505
- Reaction score
- 2,431
All I can say is... don't be afraid to work hard and make tons of money. There's nothing shameful in doing so and I feel that today's society makes it seem like a crime to make lots of money. If given the opportunity to see 8 columns at a time, you should do so as long as you're getting paid for all of them (HMO's are notoriously bad without the upsells).
- Joined
- Jul 21, 2004
- Messages
- 1,505
- Reaction score
- 2,431
If the opportunity presents itself and you can juggle many large procedures all at once, then why not. I find it difficult to be able to handle multiple large cases at once. I would not be able to schedule 3 large cases (i.e 12-14 crown preps per patient) in the same hour with 7 hygiene. The professional liability and complexity goes up exponentially with significantly larger cases while hourly rate drops due to increased time to workup and plan a case. RCTBUCrn requires very little planning and it's pretty much on the fly thinking. Also, when things fail on large procedures (and there will always be failure at some point in our professional careers), it's more expensive and time intensive to repair (time = money, meaning more money lost). If a single tooth rctbucrown fails, worst case, pull the tooth out, put a bridge or implant. Otherwise, you can potentially fix it with a retreat, apico and/or new crown.
- Joined
- Jul 21, 2004
- Messages
- 1,505
- Reaction score
- 2,431
Efficiency is key. Adaptive thought processes during the procedure. I'll explain below:
Efficiency:
- Hot bleach/12mL luer-lock syringes: High volume NaOCl irrigation with high tissue dissolution and not having to waste time to refill multiple 3mL syringes.
- Irrigation during instrumentation: Saves time by constantly replenishing your hypochlorite, clearing debris from canal and files. Operating assumption is that hypo gets inactivated relatively quickly by inorganic/organic debris and constant replenishment during mechanical instrumentation keeps the concentration of reactive hypochlorite sufficiently high to disinfect and lubricate.
- Single file system (waveone gold): simplified armamentarium, I can use the waveone like a gates/orifice opener or for standard instrumentation. I have a piezo to trough as needed. Reading the dentinal floor/pulp map is essential
- Rubber dam: Isolates the tooth, keeps bad stuff out, good stuff in. Also standard of care. I've only had one patient ever withdraw consent for rubber dam during procedure. Had to finish with isolite. Noted in chart.
- Irrigant activation: I use Er:Yag laser for photoacoustic streaming of irrigants. A lot of debris/organic tissue floats up from the endodontic system that that US/Sonic activators/traditional instrumentation misses.
- Qmix: Saves a step in irrigation
- BC Sealer: Efficient obturation with single cone, continuous wave, or guttacore.
Adaptive thinking:
- It all starts in caries control and whether I'm doing a crown simultaneously. In most instances, I can prep a crown before endo. As long as my margins are clean and sealed at the end and all the caries has been removed before obturation, crown prep before endo saves significant time. First question in thought process is: Do I have sufficient tooth structure to place a rubber dam clamp if I were to prepare the crown first. If the answer is yes, prep crown first. If no and I'm going to need surgical access for clamp placement, then do endo first
- Access and reading the pulp map: If something seems off in the color of the pulpal floor/orifice arrangement, must look for missing canals without perfing. Finishing bur version of endo-Z is great at removing dentinal shelfs without perfing. If you're really in doubt, take a CT.
- Instrumentation: Don't passively push your instrument without getting feedback from your handfiles/rotary files. That resistance tells you a lot about the direction of the canal and direction of your rotary instrumentation. Getting intial WL via AL gives you a lot of information of how you should angle/position your rotary so that you're not taking too much radicular dentin off to one side and prevent separation/transportation. Going with a K-file will give you tactile feedback on the direction,calcification and obstructions in the canal path. Also, for certain canal arrangements such as mandibular incisors or 1st max pre, the way that your file bends (from a non-precurved perspective) will give you an idea whether there's 3 canals in 1st maxbi or 2 canals in a mandibular central incisor.
- Biomechanical instrumentation will only get you so far. I think that you have to be able to identify whether you've thoroughly cleaned the canals. Use your senses, not just your sight or timing. Paper points need to be dry, no exudate/moisture. There should be no smell on anything, paper points or otherwise. A lot of infected root canal systems have certain smells. The pre-op smell should no longer be present. Chronic apical abscesses with exudate can be the toughest to manage. When there's a fistula, it's a lot easier because I can do a submarginal flap, enucleate the lesion, use Nd:Yag laser for disinfection/hemostasis. Sometimes I think I should just do the endo and apico simultaneously. Without a fistula or accessible communication, I may choose to open the apical constriction enough to open to push get a 30G suction past the apex and push saline simultaneously to drain the abscess, then use the nd:yag to disinfect the apex.
- Having the clinical instinct to react immediately to any and every situation that pops up is what saves you tremendous amounts of time. Gathering information throughout the entire endodontic process allows you to proceed to the next step faster. You don't have to fumble around and waste time.
During these steps, there's always time that you can jump out for a few mins to do an exam. No harm in letting the hypo sit a little extra, especially for heavily infected cases. Otherwise, if you're almost done, just finish so you can run to hygiene.
@TanMan Do people who finish a GPR tend to be better off long term in terms of how much production hourly they can manage? Does it make sense to look at this as an investment long term? Do your classmates who did a GPR tend to fair better off than the ones who didn’t if their goal was to make a larger income? What are your thoughts on this?
My god. You are a super dentist.
- Joined
- Mar 11, 2011
- Messages
- 582
- Reaction score
- 668
We probably practice very differently. Most dentists only collect ~ 750k per year and that includes around 25% hygiene. So they’re only collecting around 565k in their own dentistry. If your goal is to exceed 2M in collections and you’re not placing implants, and just doing routine general dentistry without sedation, many dentists would start to burn out quickly.
In my opinion, there’s really no need to try and exceed producing/collecting 2M in a year and producing more shouldn’t make anyone happier because your already making a ton, and making much more than most of your colleagues. At some point, enough is enough.
That aside, it is very hard to get fast first and then good later. Too many bad habits are created and they’re hard to fix. It’s much better in my opinion to get good, then pickup speed as you gain more experience. I’ve worked with too many dentists whose work is just sloppy (even though they were fast) to think otherwise.
For the op. This is a long game and your first job matters as it sets the trajectory of your career. You really need to think about what type of dentist you want to be and then devise a plan to get there. Along the way, different opportunities will come up and you should ask yourself “does this opportunity get me closer to my goal or not?”
Good luck with your decision!
- Joined
- Jul 21, 2004
- Messages
- 1,505
- Reaction score
- 2,431
I can't tell you whether a GPR makes you a better dentist from an hourly perspective, since I've never done a GPR. In my class, there were three main reasons people did GPR's: they couldn't get into a specialty program, they were GP gunners that wanted more education, or they weren't confident in their skills/education. Perhaps from a skillset and employability perspective, they could potentially make more income, but I found that I'm doing fine without an AEGD/GPR. The main downside I see to all GPR's... you lose a year. In life, timing is everything. In that one year of not starting, opportunities may not be available a year later.
A good GPR can definitely improve your skills and/or speed, a terrible GPR is a complete waste of time.
Ultimately, I believe the most important factor is the individual. Some, if given the opportunity, will rise and shine in speed and skill. Some may rise up in skill, but not speed, and some will barely improve in either metric relative to going straight to private practice. The limiting factor can either be the program or the individual. However, it's all relative. Superstar potentials need to seek the best program in speed/skill building. Mediocre individuals with limited potential might do better in going straight to private practice OR a mediocre program. They might not get much from a great program.
Implants are not the end-all for profitability. RCTBUCrn still has a place in high production dentistry. Sedation isn't much better since you cannot juggle many patients at the same time. I was licensed for sedation, but gave it up due to increased compliance requirements and sedation patients tend to be a lot pickier.
I would argue never to set an artificial limit of 2M even if it's better than most of your colleagues (they are not a good benchmark, because it's a relative benchmark). That's setting yourself up for mediocrity. When I broke 2M, I thought I had hit the ceiling, but far from it. Eventually, we go past our log phase into a plateau, but until we reach that plateau, I believe that we should keep going. Coming back from a vacation made me realize that I really need to work harder so that I can be on perma-vacation. Finish fast and finish hard. It's a race because we're not immortal. It's very frustrating when you can't rise as fast as you used to.
4.5d/wk. Recently my overhead has dropped to around 55-60%, depending if you include my salary. I didn't produce these numbers overnight. It took a long time for me to get to those numbers. If I had parents who financially supported my ambitions from the beginning, I'd be done by now.
Great points. Low overhead. High profitability and speed are what new graduates should focus on. Yes implants are good but require a lot of education and training to do properly. Get good at doing RTC, crowns, fillings, extractions of all kinds in my opinion before you start learning something that will cost a lot of money, time, and overhead.
I know someone who just graduated dental school less than a year ago. She's currently an associate at a corporate clinic where she is running 7 columns. It's probably the norm nowadays. Not sure how much she's making though.
@TanMan So were you always extremely fast with good handle skill? Perhaps always the best in your class in that department? Did you just go in with mindset that I’m going to go as fast as possible and get better at skill later or where you always a manual dexterity god with Microsoft word font handwriting?
- Joined
- Jul 21, 2004
- Messages
- 1,505
- Reaction score
- 2,431
I was always fast, but I started out with average handskills. I was never the best in my class, but I didn't care enough about class to be the best. My brain is weird in that if I find little/no purpose to do something, I will not do it, or do the bare minimum just to get by. The purposefulness of dental school explains that I could do well when I found that there was a point to what I was doing; the rest of the time was just pointless. Something i learned early on is that if you dwell on something too long, you're more likely to mess it up and it's not good for the patient experience. For lack of a better term, I had "ballsy" execution during my training. I don't wait and ask, I just do it. My mindset is don't waste time and be efficient. Do it well enough so you don't have to redo it (because redos waste time and they are not financially productive). As time progressed, my handskills improved. I am far from being dexterous when I first started (macromovement-wise, very clumsy), but I improved over time. I'm still clumsy as hell when it comes to tripping over things.
There's purposeful manual dexterity and there's one that becomes innate. Eventually, when you perform dentistry enough, your innate dexterity increases without you having to think about it. That's why I believe with speed, comes skill. You have to train your mind to reflexively think quickly and adapt to any situation that's thrown your way. The only way is to have many patient encounters to be able to improve your on-the-fly thinking/analysis skills. Otherwise, you will just end up stagnating.
- Joined
- Jul 16, 2011
- Messages
- 398
- Reaction score
- 84
All of the options have some downsides
1: How many hours are you working per day? 8-6 or 9-5? Being labeled an independent contractor is legal! I have friends who practice as IC and yes it will hold up.
2: What is the payer mix? Average collections? How long will it take for you to get paid?
3: Sounds like a typical DSO offer. The alternate Saturdays might lead to burn out. you'd be working an average of 44 hours a week assuming 8 hour days
They have positives as well
If you think the you can learn how to run practice within a year I'd pick 1
If the payer mix is good and you are quick I'd pick 2
If you are unsure about either or feel neither environment will lead you to be productive or learn practice management then I'd pick 3.
- Joined
- Mar 22, 2016
- Messages
- 122
- Reaction score
- 93
Wow. How long were you taking for molar endos when you first started and how fast are you doing them now? It still takes me 2-3 hours to finish cases.
- Joined
- Aug 3, 2017
- Messages
- 1,841
- Reaction score
- 3,972
I know with DSOs ..... they notoriously overbook with 9-10-11 plus columns knowing that a certain % of patients do not show. Especially the patients with low reimbursements (Access). If I see a patient that was scheduled by the Corp call center ..... it will be 50/50 if they show up. Especially new patients. Maybe 1 in 5 will show up. I see this pattern on the general and ortho side.
My point is that 8 plus columns in a well run private practice may be different than 8 plus columns in a DSO.
- Joined
- Jul 10, 2007
- Messages
- 3,149
- Reaction score
- 3,026
No shows and last minute cancellations are very common problems in most dental practices...and not just at the corp offices. That's because dental treatments are usually not the top priority in people's lives. And the patients know that we, dentists, need them more than they need us. The reason corp offices have higher number of no show than private practices is the they have much larger patient base; they attract everybody... not just the people who work and have dental insurances.
I remember when I started my very first office in 2006, I had to come in at 7am for a new patient consultation because the patient had to go to work afterward. This patient didn't show up and I wasted the whole morning. I really hate no shows and cancellations because I hate sitting around doing nothing, making nothing, and still have to pay the staff salaries and other business expenses. Now that I have more patients, I can book all my patients in the time slots (2pm-6pm weekdays and 8am-11:30am weekends) and on certain days of the month that I want (so I can have the other free days in the month to either relax at home or to work P/T for the corp to supplement my income). And I just need to hire P/T employees to come to work on those days. I intentionally overbook to compensate for the no shows and cancellations. If all patients show up and we are busy, I can always jump in to work as an extra assistant....ie changing arch wires, sterilizing instruments, taking ortho records etc. There is a big difference between working hard at your own office and working hard for someone else as an associate. When you work hard for yourself and make $$$, you feel really good. When you work for someone else, you just want to do the minimum and go home on time. When I work for the corp office, I have to bring a laptop for entertainment during the slow morning when most kids are at schools. When I work at my own offices, I usually work non-stop and I love it.
I remember when I started my very first office in 2006, I had to come in at 7am for a new patient consultation because the patient had to go to work afterward. This patient didn't show up and I wasted the whole morning. I really hate no shows and cancellations because I hate sitting around doing nothing, making nothing, and still have to pay the staff salaries and other business expenses. Now that I have more patients, I can book all my patients in the time slots (2pm-6pm weekdays and 8am-11:30am weekends) and on certain days of the month that I want (so I can have the other free days in the month to either relax at home or to work P/T for the corp to supplement my income). And I just need to hire P/T employees to come to work on those days. I intentionally overbook to compensate for the no shows and cancellations. If all patients show up and we are busy, I can always jump in to work as an extra assistant....ie changing arch wires, sterilizing instruments, taking ortho records etc. There is a big difference between working hard at your own office and working hard for someone else as an associate. When you work hard for yourself and make $$$, you feel really good. When you work for someone else, you just want to do the minimum and go home on time. When I work for the corp office, I have to bring a laptop for entertainment during the slow morning when most kids are at schools. When I work at my own offices, I usually work non-stop and I love it.
Last edited:
- Joined
- Jul 21, 2004
- Messages
- 1,505
- Reaction score
- 2,431
I don't recall how long I used to take. Maybe I noted it somewhere along my old posts. I don't think there's a set time that it takes me, based on today's schedule, I'd say 20-30 mins. Hard to say exactly since I often combine steps of crown prep and endo. For ultimate efficiency, I recommend doing the crown prep whenever possible. Sometimes, you cannot do the crown prep first if you need surgical rubber dam access or many times on a terminal molar due to HOC being too high and unable to get the dam on without significant buildup or gingivectomy.
If you're looking to become more efficient in your molar endos, you really need to break it down step by step and see what is taking you so long. 2-3 hours is way too long to have a patient open for a root canal. I might have a patient on a 2-3 hour block but that's for molar RCTBUCrn, but that's with 2-3+ additional ops patients in the same block. Most of the time, I'm just waiting for the crown to mill and bake. I have thought of doing no-bake crowns to be more efficient, but I want something that's going to last a long time for my patients. No bake Celtra-Duos or resin based crowns are not very good for terminal molars, bruxers, etc... and I find their polishing ability to be inferior to emax.
When you are forced to do the endo first, plan to make the crown immediately after the endo. As soon as you finish the endo, go prep the crown.
Looking at the steps:
- Anesthetic: Must be profound, fast, and long lasting. (Takes 1-2 mins)
For upper molars, use prilo/septo, I use PSA, infiltration, MSA (for 1st molars). If they still feel something, approximate the palatal root, inject palatally (like a gpal) + PDL. Prilo is fast acting, but not very profound. It sets up the stage so that the Septo blocks don't hurt so bad), but you need septo for the profound anesthesia
For lower molars, use septo (with optional marcaine). IA Septo, (if you use marcaine, aim high). You know you hit the IA if you're almost in with the 27G long and they jump a little, aspirate and inject after advancing an extra mm past that "shock point". You know you hit the lingual if you're about 1/3-1/2 and they feel a shock. Keep going a little more. In addition to IA, I do LB, mylohyoid, and PDL. LB so that the clamp on buccal doesn't hurt, mylohyoid to cover accessory innervation especially on 2nd man molars, if they have a prominent lingual concavity, approximate the apex of the 2nd molar, bend a 30G x-short and hook the septo underneath. Do not bend a 30G more than once, otherwise, it will break off the hub.
-Caries Control and Wall reconstruction (Usually takes a few mins). This is where strategy plays a big role. This is what takes an annoyingly long time, especially for severely broken down teeth with gingival hypertrophy. You need to think about how you would approach this to meet your primary objectives (be able to rubber dam easily and get good isolation. Ideally, you want to be able to rebuild any walls of your proposed access/orifice without touching the gingiva since bleeding will contaminate your bonding interface. I flatten the surface with a 909 bur. I want to see the dentin to visualize any fractures hidden underneath and get a flat reference point (takes a few seconds)
So, lets look at the worst scenario:
Gingival overgrowth, close to alveolar bone - This is the worst case scenario, time consuming to rebuild, must act very fast... remove the caries with your bur of choice (you have to be ready to rebuild your wall asap), if you're not able to, you need at the very minimum, solid and carious free margins. You can leave decay on a non-affected wall until you've built up your 4 wall minimum, remove caries afterwards, and rebuild the wall with buildup material once more. If the decay is so extensive that you cannot matrix, then you need to freehand but maintain hemostasis/moisture control as much as you can. The bad thing about matrices is that the way they impinge on inflammed gingival tissue, it can exacerbate the bleeding and sometimes make it more difficult to achieve hemostasis. So... once you've removed the necessary carious tooth structure, look at your gingival tissue/alveolar bone. I like using a sharp surgical round bur on a dry high speed to perform a cauterizing gingivectomy and CL prn. If the tissue isn't so inflamed, it will not bleed. Alveolar bone will almost always bleed. This is where 1:50 epi comes in, along with viscostat/laser/heat cautery. Once you inject 1:50 epi + other hemostatic agents, you have a minute to build that wall.
- So depending on the path that you've taken, either you're prepping for a crown (which we can all do) or endo. If you're prepping for a crown, I like to have serrated clamps ready to retract the gingiva and let the clamp slide below your margins in preparation for endo. If not prepping for a crown, 14A works best for most molars. Use cheap flowable composite around the clamp for added retention and better moisture control.
- Access (should take a minute): I only put the rubber dam on once I have access to the pulp chamber. The reason is that I am less likely to lose orientation and perf. So, make your access, once you feel the jump into the chamber, go put your rubber dam on. Use a non-end cutting endo-z bur to laterally open the orifice. Look in there, I like to start on the orifice that's usually the largest, either P or D canals. From there, I can map where the others are based on the pulp floor. Rinse pulp chamber debris with hypo
- WL (with AL - if not calcified, should take 1-2 mins, if calcified, might take 2-10 minutes). 10 file works in most cases, if not, use a WO Gold to open the orifices up. Do not use that file to file down, get a new file after opening up the orifices. You will notice it will most likely be unwound.
- Instrumentation (few mins): Most 2nd molars will require 21mm files, everything else will be 25mm except for canines which are usually 31mm files. Your staff needs to be proactive in this stage. At this stage, I will instrument to the WL with my WO Gold. I use my right hand to instrument and my left hand to irrigate with hypo. Your staff is very important here because you need to tell them that no hypochlorite must leave that orifice, you must suction it out while I'm instrumenting/irrigating. You will be surprised at how much dentinal debris you pull out. People ask, where to aim the hypo? Right at the orifice you're instrumenting and the flutes of your files. You know that most of the canal is clean when the flutes of your files no longer have debris, the hypo is clear and non-bubbling, and the file slides down a lot more easily. The next step after cleaning all canals is to activate your hypochlorite,edta,chx irrigants. I use Qmix, so it's just hypo, sterile water, qmix. Although you've cleaned the main canal into the apex, there's lots of branching in the root canal system and traditional instrumentation just won't reach. I activate using an Er:Yag laser, I'll use endo activator on anteriors with large apical openings since less chance of extrusion. This will allow you to clean lateral canals and any secondary anatomy on the last apical 3mm of the root.
- Final length check: Pre-measured cones by your assistant, verify that they are your instrumented WL, take PA. If good, obturate, if not, you need to go back in and reinstrument.
- Obturation: I like to place paperpoints and airdry to create a drying capillary effect. Can't cause air emphysema because it's blocked by paper points. You can use single cone with BC Sealer, Continuous wave obturation or GuttaCore. Pick your poison. For speed, take single cone with BC Sealer, squirt into the canal, coat your cone, push, and sear. I'm old school in that I like my glick and a torch for searing. Way faster for me than using elements.
- Buildup (1.5 mins): Bond, GI, Composite dual cure material
So... think about what you're doing right now, and figure out if you can incorporate these techniques.
Yep, that's what I do. We try to book 13 columns and take all walk-ins even if I'm completely full. The objective is to clear as many rooms as possible to bring in the next batch. Most of the time they won't all show up. When it does, it's a bit chaotic, but I just gotta keep going.
@TanMan, The way you approach dentistry is lightyears beyond my internal mental process.. seriously hats off to you. My question is...what happens when things don't work out? Happens to me in endo a lot - do you ever have trouble locating all canals? Do you refer extremely calcified teeth/dilacerations? Do you use a scope? Where do you draw the line between referring and doing it yourself? I have no doubt you are as fast as you say, and do great work, but there are really hard endos out there...at least for me... What do you do when you come across a hard one?
Last edited:
- Joined
- Aug 3, 2017
- Messages
- 1,841
- Reaction score
- 3,972
S
schmoob
Have you had any issues with parasthesia using septo for IA? *knock on wood*
- Joined
- Jul 21, 2004
- Messages
- 1,505
- Reaction score
- 2,431
Extremely calcified teeth, I can still access. I can sometimes have a difficult time locating all canals, but with time, you will be able to tell if something "looks off". Dilacerations are a different story and I've had problems with them before to the point where I'll send them out. Unfortunately, ideal v. real world, patients are seeking the cheapest care and I've seen "treated" dilacerations with perforations from a local chain that supposedly has an endodontist that comes once every few weeks. However, once the care is done and I have to see the patient again, I tell them to go see that chain endodontist for the followup (without throwing the endodontist under the bus) and they can never get an appointment with the chain endo again. Unfortunately, a lot of those that I get back end up needing an extraction.
When I come across a hard case, I just keep working at it. You don't have a choice once you open it up and I believe that this is how you build your dental instinct. Pushing your limits, knowing what to do, consciously and subconsciously thinking about what to do when you're stuck somewhere. Take every case you can and learn from it. Eventually, everything will be easy (or easier).
I do not use a scope. I am able to find most canals with tactile sensation from an endo explorer/non end cutting bur.
Maybe, but I don't think what I'm saying is beyond common sense. Also, takes time to build yourself up in the lecture circuit. I like what I do, and if I were to help other dentists, maybe I'd do a dental tourism type of deal where I travel to destinations, help local dentists learn techniques and see the sights too. I'd have the freedom to do that if I was fully funded for retirement.
Never.
Most dentistry that is really fast is also poor quality. This board may be biased because it's student doctor network; however, quality dentistry tends to take a consistent amount of time among experienced dentists. That's because after you've been working for a few years you develop systems and become efficient. Beyond that most dentists are just marginally faster or slower than one another. It''s not as though there is a super group of fast dentists that have figured out some magic to be 2-3x faster and do the same quality. No, usually the quality is worse. Once you start seeing patients who have gone to mills and been worked over with fast poor quality dentistry you will see what I'm talking about. Don't fall prey to magical thinking.
Last edited:
- Joined
- Jul 21, 2004
- Messages
- 1,505
- Reaction score
- 2,431
There is some truth to what you are saying. I wish I could be as fast as some of my former colleagues at corporate where they could do 10 minute molar endo, but I can't because the quality of work is really bad. There is definitely a way to be faster, and sticking by certain ways taught by schools, gurus, etc.. can make you consistent, but that doesn't mean it's the only way (nor the best way). For me, this line of thinking is dangerous because as a practitioner, you are constricting yourself to what you may believe that slower is better. Being slow can mean a few things, either you are purposeful but lack the confidence to quickly execute, believe that speed is the devil, or you're trying to figure out what to do next.
The subjectivity of dentistry and the criteria of quality varies significantly depending on clinical circumstances. My preps aren't going to win tucker gold club of the year awards, but they are acceptable in that they follow the basic principles. Sufficient retention, closed margins, caries-free, durable, functional, esthetic, and all the things that are going through my mind as I evaluate my restorations/endodontics. My argument for going too slow is that you are more likely to do more damage, the more you dwell on the tooth. For crowns, get the prep to draw, all caries out, sufficient reductions, good isolation/hemostasis, clear margins, etc... what we do is not rocket science.
For example, if you were to stick by what dental school taught you and nothing else... you would make virtually no money by the virtue that dental schools were designed to make you safe enough to work on patients, but not necessarily productive enough to make money. Think of dental school this way, it's like running Windows on Safe mode/S mode... yes, it's safe(r), but you're probably not going to get much done either. It's a fallback to when everything else fails or you can't/don't want to venture out of your comfort or safety zone.
So... to sum it up, I don't think all dentists are made the same, they do not reach that same +/- few minutes plateau for each procedure, and quality is subjective. Follow the dental principles you learned and find a way to execute the procedure quickly to meet said principles. Always keep thinking outside the box, thinking of why you're doing what you're doing and how you can improve each step in terms of quality and speed. We will always be students as long as we continue to practice dentistry, always learning, never stagnating.
Also, cool recall case came in today for 1 year f/u:
- Joined
- Aug 3, 2017
- Messages
- 1,841
- Reaction score
- 3,972
But I thought schools like Midwestern Univ. Arizona was graduating SUPER GPs.
But I thought schools like Midwestern Univ. Arizona was graduating SUPER GPs.
Is this a new meme and/or true?
I thought that school was just really expensive
- Joined
- Aug 3, 2017
- Messages
- 1,841
- Reaction score
- 3,972
Generally speaking ... I do agree with @yappy re: speedy dentistry as related to quality of treatment.
You can get away with speedy orthodontics because you've got 18-24 months to finish the treatment. Busy days ..... speedy ortho appts. Slow days ..... I'll bond 2nd molars, reposition brackets, take progress records, etc. etc. spend more time with the patient. Lots of opportunity for speedy tx in ortho with no concern about poor outcomes because at some point .... you will have TIME to properly treat that patient. Ahhhh. The life of an orthodontist.
Now general dentistry is another animal. Most procedures are one and done. You have X amount of time to perform the procedure. Bringing a patient back to finish a typically one appt procedure is probably rare in dentistry.
My personal dentist (prosthodontist) sees a limited number of patients in a day. I like the small waiting room with fewer patients. Yes ... I pay more for the procedures. Most "discerning" patients will relate better quality with less speedy appts.
Of course ... there are examples either way.
That's the beauty of dentistry. You can pick your poison.
You can get away with speedy orthodontics because you've got 18-24 months to finish the treatment. Busy days ..... speedy ortho appts. Slow days ..... I'll bond 2nd molars, reposition brackets, take progress records, etc. etc. spend more time with the patient. Lots of opportunity for speedy tx in ortho with no concern about poor outcomes because at some point .... you will have TIME to properly treat that patient. Ahhhh. The life of an orthodontist.
Now general dentistry is another animal. Most procedures are one and done. You have X amount of time to perform the procedure. Bringing a patient back to finish a typically one appt procedure is probably rare in dentistry.
My personal dentist (prosthodontist) sees a limited number of patients in a day. I like the small waiting room with fewer patients. Yes ... I pay more for the procedures. Most "discerning" patients will relate better quality with less speedy appts.
Of course ... there are examples either way.
That's the beauty of dentistry. You can pick your poison.
- Joined
- Jul 10, 2007
- Messages
- 3,149
- Reaction score
- 3,026
For practices that have busy schedule and continue to get a lot of word-of-mouth referrals, the owners of these practices must have long good track record of doing excellent dentistry over the years. People don’t keep on coming back to see the same dentist if they continue to have pain after the RCT or a crown comes off in less than a year. So before criticizing a colleague for doing low quality work (without knowing anything about him/her, without looking at his/her work), one needs to look at him/herself in the mirror first.
Doing things fast doesn't necessarily mean low quality
Doing things fast doesn't necessarily mean low quality
- Joined
- Aug 3, 2017
- Messages
- 1,841
- Reaction score
- 3,972
My wife doesn't agree.
S
schmoob
- Joined
- Jul 21, 2004
- Messages
- 1,505
- Reaction score
- 2,431
"Discerning patients" + PPO = lower productivity. It works in an FFS setting, but not a PPO/FFS hybrid. "Discerning patients" are usually patients that have a million questions, extremely exacting/picky, and require a lot of time. If I was paid by the minute, then by all means, I can be here all day. Unfortunately, dentistry is paid on procedures/outcomes, therefore, time is a valuable commodity. Every practice is different, and it's up the patients to find the office that best suits them. This is what I commonly refer to as "practice evolution". A practice evolves to accept patients that are compatible with the attitudes/mentality of the dentist(s) in the practice.
Is it better to leverage more in dentistry? Or is it too risky for expensive practices? $ 1 million or more.
- Joined
- Jul 21, 2004
- Messages
- 1,505
- Reaction score
- 2,431
I'm all for starting a practice from scratch, much to the antagonistic reactions of most everyone else. I started cheap and ramped it up to profitability pretty quickly. Buying a practice can work, but I see it as a slow means of making money, along with all the other headaches that come with buying a practice. If I were to look into a practice, I'm not buying the furnishings, equipment, and physical/tangible assets, I'm buying the future cash flow. The problem I have with buying a practice is that the potential future profits are typically "priced-in" to the selling cost, reducing my profits even further. All the problems that come with buying an office include: transition from the old owner, "seasoned" staff that are stuck in their ways (and the state liabilities associated with terminating them), older equipment, patient pool that's most likely depleted of procedures if they practice was efficient (and vice versa, the difficulty of converting treatment from a dentist that watches everything and the suspicions that arise from that, and so on....
So, when I look at a practice, I just see it like buying a bond, but instead of sitting and letting it grow, you have to put labor inputs too. I think it makes sense when the sale value is really low where it's cheaper than buying all the equipment, and either flipping it for resale or doing a turnaround. However, that's still a lot of labor involved, relative to starting new. There's a bunch of threads from last year regarding startup v. purchase. I'm all for start cheap (100k+), put what you save into advertising, grow into multimillion practice.
I'm all for leveraging, but you need to make sure that your returns/debt load are not excessive to the point where your cash flow is severely hindered. Cash is king, if you got free/zero interest money with no strings (unsecured line of credit), leverage all you want. Otherwise, you need to see how much you can leverage until the debt load affects cash flow and future expansion plans. If you're looking to buying a 1MM+ practice, they should be collecting at least 1.5MM. I don't care if they have the fanciest gadgets or nicest looking office. I'm buying cash flow, not the physical/tangible assets. Of course, the physical assets must come with the practice in order to sustain the cash flow/production, but the salvage value of those assets are typically nil.
@TanMan Thanks for answering all these questions. This has been very interesting and insightful. How much money do you think is appropriate in proportion to the amount of revenues that you bring in a month? 10-20? Is there a point where you should reduce your number on that after a while? Also how can you tell what kind of market penetration you are getting? Also what kind of socioeconomic area are you practicing? What are the pros and cons of practicing in a wealth area vs a poorer area besides wealthy people being more likely to sue you?
I appreciate all of this information!
I appreciate all of this information!
- Joined
- Jul 21, 2004
- Messages
- 1,505
- Reaction score
- 2,431
Are you talking about 10-20k/month? or 10-20%? My comfort level is producing 300k/month right now, but I think that depends on each person. Some people are content with only producing 100k or even 80k. If you're talking about take home, I'm content with 100k/month net. Only time you need to reduce is if you can't handle the production level or if your quality is decreasing to the point where your redos increase significantly.
Market penetration can be determined by zip code, wealth distribution, radius from office, etc... I'm in a middle/upper middle class suburban area. Pros of wealthy area is that finances tend to be less of a barrier, but typically the barrier is moreso from the individuals themselves. Also depends on the culture of the wealthy in the area you're practicing. If these are entitled new money types, they usually fall into two categories: either they didn't work for the money and freely spend it (but they are impatient on getting things done asap) or those that usually have handed things to them and expect you to do the same. I'd rather have the former, because I can deliver on speed, rather than have to cater to people who believe they are entitled to freebies due to their status. Poorer areas have the problem of affording dental care. Finances are the primary barrier to acceptance, but this can be negated if the credit market of the poorer areas have not been tapped out as long as you can find a third party lender that can shoulder all the risk. Eventually, if too many default, the credit markets in that area will shrink, but if you were first in and first out, there should not be a problem. I like middle/upper middle more (where I'm practicing), since finances are not so much of an issue, without the difficulties of wealthy patients. Older wealthy patients have most of their teeth worked on already, middle aged wealthy patients tend to tighter with their money, but that's the same with low fixed income elderly patients too.
