A radical approach to improving the quality of dentistry in the United States

The controversy.

Before I begin this post, please understand that I know this will be met with strong controversy from dental professionals. Please read with an open mind before jumping to conclusions.

The problem.

What is the focus of this “hot” topic? The 6-month hygiene recall and examination in the general dentist office.

So, why do people choose their dentist?

1.     They are friendly and “painless”

2.     They accept their insurance

3.     They like their dental hygienist

4.     They like the location and cleanliness of the office

5.     They were well-referred to the practice*

6.     They have trust and confidence in the dentists abilities to meet their goals and expectations*

*indicates less likely reasons, but more important

I believe that many people choose their dentist because of the factors above, but are unsure if their dentist can adequately screen for complex dental problems. I have always maintained that a patient will spend less dollars, have more predictable dentistry, and a better dental outlook in a quality dental office. The real cost of dentistry is redoing bad dentistry and/or waiting until a crisis that was never identified before (tooth-by-tooth dentistry).

I want to approach this topic by first addressing the standards in the dental community. If a general dentist decides he or she wants to perform root canal treatment in his or her office, then they are held to the standard of the specialist: the endodontist (three additional years of training). If a general dentist decides he or she wants to perform restorative dental procedures (esthetic dentistry, implant restorative, crown and bridge, etc.) then they are held to the standard of the specialist: the prosthodontist (three additional years of training).

So let’s take a look at the majority of prosthodontic practices in the United States. Most people don’t even know what the heck a prosthodontist is, so if they end up in their office they likely know they have a complex problem that needs to be solved.

Prosthodontists diagnose and treat complex dental problems typically utilizing a team of other specialists. They need lots of time to be meticulous with laboratory work, procedures, treatment planning, and interdisciplinary team communication.

What do prosthodontists not generally do? Check two (some three) hygienists on the top of every hour for their “recall exam.”

So, what is my issue with the dreaded “recall exam?”

It is multifactorial in nature. First, the dentist has to check 168 surfaces of teeth (192 with third molars), periodontal health, occlusal issues, head and neck musculature, temporomandibular joints, and surrounding tissues. And review radiographs. And review medical history. And get to know the patient. And…

This simply cannot be done in five minutes. This also takes away time from procedures scheduled in their restorative schedule.

It begs the question: if the experts (prosthodontists) can’t check two patients on the hour while doing their cases, how can the average general dentist who is “technically” less qualified?

I believe this is causing the decline and devaluing of dentistry in the United States of America.

The perception.

Patients think they are having a real comprehensive examination when the dentist checks their teeth for five minutes and chats about the kids and weather. It is clear that things must be missed in this exam, unless the patient has been fully restored to optimal dental health in the past. This is even worse if the first visit to the dentist is with the hygienist. Talk about a scenario that is guaranteed to lead to disaster (I do not care if you are 19 and home from college on spring break and just need your teeth cleaned… we do not know each other yet!)

This model leads to problems. It is an insurance-driven model. It makes no sense in contemporary dentistry. This leads patients into a path of complex, overwhelming problems while going to the dentist every six months thinking they are receiving “comprehensive care.”

The solution.

I think the guidelines set forth by governing agencies can solve this problem. First, I think it should be mandated that the first visit to a dental practice must be a comprehensive examination and hygiene services cannot be performed on the first appointment. Therefore, it will force dentists to take a thorough look at the problems and take time to study them before their patient returns.

I also believe that hygienists should be allowed to operate without the direct oversight of a dentist. Let’s face it: some patients will never choose health. I know there are numerous ways to show people they have a problem, but some patients just want their teeth cleaned. Well, let them have their teeth cleaned. Trust me, they will know when problems arise. Why put the responsibility on the dentist to try and psychologically make the patient aware there are problems and watch them self-destruct under our care (this leads to discussions such as "you never told me about...")? Sometimes, even the best patient communicator cannot educate someone enough to accept treatment for their problems.

What must the patient do to be a patient in my practice? Trust, appreciate, and own their own problems.

So, after the comprehensive examination, the patient now understands their risk factors (functional tooth, muscle/TMJ, periodontal, and esthetic). Knowledge is power. If they choose to neglect their health, let them. Who are we to tell you what to do with your health? Why do I need to come in and do a cursory exam for five minutes when we both have a detailed understanding of what our game plan is for the future? Why do I need to leave my restorative patient who has accepted treatment and wants optimal care for a hygeine check on someone who has been properly educated but chosen they do not want any treatment (but it is legally required)?

My job is to educate and guide, not to mandate. If someone wants their teeth cleaned, that is fine with me, but don’t put the responsibility on me to come in every six months for a “check” when we have laid out the framework for optimal health and you have chosen to decline it. Quite frankly, I would rather you have your teeth cleaned elsewhere and come to me if you have a complex problem that needs solving.

The paradigm shift.

It is time to move away from this model. I don't care what your insurance company says (trust me, I really don't). I strive my best to model a prosthodontic practice, but I am stuck with the dreaded hygiene exam. Of course, I invite patients back for a comprehensive examination when changes arise, but some simply will never cross the abyss. For that, they do not need my services. For that, I do not need to interrupt my goal of providing exceptional restorative dental care for my patients.

If the experts don’t do it, why should the less qualified be required to do so? All this does is decrease the quality of care in the office.

I finally said it: the six-month hygiene exam decreases the quality of restorative care in the average general dental office.

Can we (please) re-think dentistry of the past and strive to be better and more thoughtful?

Dentists and patients, I believe, would benefit greatly.

Matthew Kogan, DMD

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So what should truly be covered in that five minute exam? Tooth position, tooth arrangement, tooth color, tooth wear, gingival displays, gingival levels, papilla position, contact length, decay, cracks/craze lines, fractures, erosion, failing restorations, missing teeth, missing teeth which need replacement, teeth that will need future attention, gingival inflammation, gingival recession, bone loss, gingival hyperplasia, bone hyperplasia, pathology around roots, pulpal inflammation, abnormal radiographic (x-ray) findings, temporomandibular joint sounds, temporomandibular joint pain, muscle pain, tooth wear, tooth fracture, tooth mobility, malalignment of teeth and... what did I miss (at least the weather)?

To that I say: "Good luck."

[More to come on this topic soon...]

Facially generated treatment planning.

It appears that my blog, which potentially generates zero readers (no offense taken there), is taking the route of going “quarterly.” That was never my intention, but (un)fortunately I have been extremely busy and haven’t had time to put my thoughts on digital paper. So, I wanted to write some quick thoughts before I start my day.

It is more important for a physician to know what kind of patient has a disease than it is to know what kind of disease the patient has.
— Sir William Osler

I have had a few topics on my mind lately, but one thing I want to focus on in particular is treatment planning in dentistry. While this may seem like a boring topic, I think it is extremely important for both the practitioner and the patient.

Obviously, I am not going to go into a diatribe regarding my own personal opinions of the data gathering and treatment planning process, but I will say that I believe this portion of the examination needs to be thorough, accurate, and thoughtful. Generally, it should be more than five minutes long (I truly believe it can take up to four hours to properly examine the dental structures and take any necessary records). 

Last week I attended a casual study club meeting with three other colleagues. Each of us brings a unique perspective when it comes to case presentation and treatment philosophy. While one member of the group was presenting a case (pictures of teeth, gums, etc.), another colleague mentioned, “Isn’t it amazing how we don’t even look at the teeth anymore? The teeth are the last thing we look at.” He was exactly correct.

In the days of old, the restorative dentist simply checked your teeth. No cavities. No periodontal disease. No problem. “See you in six months.”

This is archaic. 

To be blunt, the teeth and gums are part of the face. And this particular part of the face is responsible for all of your emoting capabilities. Kissing, smiling, laughing, eating, etc… you get the point. How can we not plan your mouth and smile in relation to your face?

Once we determine the aesthetic needs, if any, of a patient’s smile, we can then begin to formulate a plan. Of course, we must first know our patients circumstances, temperament, and objectives. Assuming this patient has assumed responsibility for their own health, trusts, and appreciates, we now have a definite path on which to plan for. Every patient has the right to be educated on an optimal plan for their oral health, regardless of their motivation and abilities today. I wholeheartedly believe this. 

If I accept you as you are, I make you worse; but if I treat you as though you are what you are capable of becoming, I help you become that.
— Johann Wolfgang Von Goethe

Some doctors in my interdisciplinary team (specialists) tell me that patients need to be “ready to hear it.” Essentially they are saying that they (the patient) have experienced reactive-type dentistry for so long, that they need time to hear a complete plan for their entire mouth. I disagree with this notion, because I feel that it provides no benefit to the patient or myself. If we discuss a plan towards specific goals that has a definitive end point, we now have a clear and conscientious path to follow.

Personally, I like visualizing the end before I begin. It makes me more comfortable. It makes our relationship better. If that is a turn-off, then there are many practitioners who will schedule you with their hygienist and check your teeth alone for two minutes and probably reply with something like: "See you in six months."

A handyman or an architect.

As dentists, we have decisions to make. It is very easy to be a handyman. People are used to this. Come in, scrape your teeth, and if something breaks, we will fix it. Oh, and if that breaks, we will blame the material or the laboratory and put in a “stronger” material (next blog entry - Maybe we should ask: “Why did this break?”). 

I strive to be the architect. Let’s blueprint a plan to fix things, and fix things right. While we are at it, let’s do the very best we can do. The very best. Let’s replicate nature as best we can. Let’s try to fabricate custom restorations that are simply... beautiful. 

This is restorative dentistry. 

It is time to think like architects. 

We are not handymen.

Home.

Over four years ago, I began the journey to become the best restorative dentist I could be. Now, as I finish the continuum at The Pankey Institute, I am grateful for the person and professional that I have become, the great mentors and friends who have influenced me along the way, and the relationships with all my patients who put their trust in me to provide them with exceptional care.

When I first came to The Institute, I was simply traveling to Key Biscayne to learn.

Now, traveling to Key Biscayne simply feels like traveling home.

The core reason for it all was beauty. Walking was a divine delight. Everything was rewritten. New things were possible with the human form. It went beyond equilibrium. He felt for a moment uncreated. Another kind of awake.

About Dental Insurance...

Rapid, confusing changes in the insurance industry are causing all of us in American society to reflect on and decide how we both give and receive healthcare. In the past few years, I have deeply contemplated the meaning of these changes relative to my mission to render the best dentistry I am capable of in an environment which truly cares about each and every one of you. With this in mind, let me share a few thoughts with you.

Before we get into the heart of the issue, I want to explain that I have lived on both sides of this issue. When I first started practice, I was contracted with numerous 3rd party insurance carriers. My dissatisfaction came from the inability to provide individualized and personalized restorative dental care at the highest level for my patients. These discount plans do not afford the opportunity to make choices as a team with our patients, and limit the amount of time we can spend with our patients. For example, a comprehensive new patient examination in my office takes a minimum of 1.5 hours. This equates to 3-5 minutes in the "average" insurance-driven dental practice. It is for scenarios like this that I found it unacceptable to partner with 3rd parties whose mission clearly states that their objective is to make the largest profits possible, with no mention of patient care at all. 

What is insurance? Insurance is defined when a 3rd party takes the risk and responsibility for a catastrophic loss. Unfortunately, this makes “dental insurance” a misnomer, and in my belief, is communication malpractice to the patient and consumer.

Insurance companies are in business to make money. They are not concerned with caring for your teeth or health. In fact, it is the insurance company’s best interest if you do not seek any healthcare. That way, they earn money on your premium dollar without having to do anything for your health. Seminars and newsletters to dentists are filled with stories of insurance companies’ tactics in delaying payment to dentists and denying needed treatment to patients.

In recent years, the insurance industry has moved rapidly in ways which interfere with or destroy the doctor-patient relationship, which I hold has one of the few remaining sacred things left in modern life. In fact, I believe that my devotion to each and every one of you is one of the key factors which makes our practice special, and is also why you have chosen us and remained with us.

When dental insurance came into the consumer market in the 1970’s, an individual’s maximum annual benefit was $1,000. I find it amazing that, although premiums for these policies have risen dramatically, the maximum benefit has remained the same. In other words, what was a very generous benefit some 30 years ago, is a very paltry sum now. Think of what $1,000 bought in 1970 compared to today!

We want you to receive the maximum insurance benefit to which you are entitled, and will work very hard to assure this; however, we realize that an insurance policy is a contract between you (or your employer) and the insurance company, subject to rules and regulations which we cannot control. We will also never make any healthcare decision based on the edicts of any third party, which puts profits ahead of human well-being.

Unlike medical insurance, dental coverage was never intended to be all-encompassing. With this in mind, please understand that even the best dental policies today cannot be viewed as anything other than a payment assistance program with some very severe limits. Please know that my team and I are devoted to your well-being, and will help you make decisions which will preserve the health, comfort, function, and aesthetics of your mouth regardless of what any for-profit third party has to say. We will do all we can to assist you in paying for what we consider to be excellent care; however we will not compromise on the nature or quality of our treatment of any human being.

In summary consider the following points:

  1. Did your insurance company examine your oral health before giving you the plan?
  2. In 1967, the annual limit was $1,000. That equates to nearly $7,000 today. So, in a 5-year period, you could get well over $30,000 in treatment completed. Today, the annual limit is still $1,000. Therefore, it is impossible to get everything you need paid by insurance.
  3. I promise you, I will never be guided by your insurance plan. Let’s talk first about what dentistry you need, then how you can pay for it.
  4. Insurance is a method of payment, not a method of treatment. We are always going to look out for your best interests first.
  5. We firmly believe that any patient will spend less dollars in a quality dental practice over the course of a lifetime than in an insurance-driven, high production office.

Please feel free to discuss this issue openly with my team or myself.

Click here for a .pdf of this article

Minimally invasive adhesive dentistry.

I want to share a short case with everyone to show the possibilities in restorative dentistry today, and why it is so important to have trust in the care, skill, and judgment of your restorative dentist.

Much of the dentistry being performed continues to lag behind the current possibilities and technologies that are available today, and this almost always proves to result in a detriment to the patient. Granted, procedures of minimally invasive adhesive dentistry require intense planning and certain technical ability, but success can be predictably achieved in numerous clinical applications. Each case must be individualized and personalized based on someone's unique needs, circumstances, and objectives.

I have a great patient who came to me with the chief complaint of missing a tooth on her lower left side. The tooth had a history of needing root canal treatment and a full coverage crown, and eventually the tooth fractured. The dentist decided to remove the tooth without any consideration or discussion as to how he would replace it in the future.

Well, a few years later, this patient wanted her tooth back (understandably so). She is a young, attractive woman who will need many more years of using her teeth. However, things were now much more complex because of decisions that had been made (or not made) up to this point in time.

When the tooth was extracted, the dentist simply allowed the area to heal without anticipating the future replacement tooth. Subsequently, we lost plenty of healthy bone and soft tissue that could have been extremely helpful to make placing and restoring this area with a dental implant simple and predictable.

But, this was not the case. After obtaining a C.T. scan and consulting with our surgical colleagues, we determined that the ability to place a bone graft and implant would have an unpredictable outcome due to certain anatomical restrictions. Additionally, the time-frame to complete (not a factor in my decision-making) was significantly longer. 

Long story short, this particular patient was not interested in waiting. She had made up her mind that she did not want to go the route of a dental implant, and I had to respect that choice. She was fully informed of the pros and cons of both potential treatment options.

After adamantly telling me she was not going to have a dental implant placed, I had to figure out other viable options for her that I was comfortable with. The traditional option of a "bridge" (fixed partial denture) requires removing excessive amounts of healthy tooth structure from two teeth that were, for all intents and purposes in this case, perfect. This was the last thing I wanted to do. In fact, it is always a goal to do the most minimum amount of dentistry we can to achieve exceptional and predictable results.

So, we made a decision to fabricate an extremely thin glass-oxide ceramic restoration that would adhesively bond to this patient's healthy enamel. Thus, I was able to do very little dentistry on her adjacent teeth, and still create a restoration that is functional (chew whatever you want on it), and beautiful.

All of us were extremely happy with the result, and I could not be happier to have preserved the maximum amount of this patient's healthy tooth structure as possible instead of doing a traditional "bridge."

This was a fun and gratifying case to wrap up before the weekend. It continues to excite and amaze me what we can achieve when things are done in a meticulous and well-planned manner.

I have attached case documentation photographs below. I hope you agree that the result is pretty exceptional!

Note: Please understand that anything and everything I post to my blog or my website is entirely my restorative dental work and my digital dental photography that is done on my incredible patients. I thank them for their trust and their willingness to allow me to share their stories and experiences with others. 

You don't "have TMJ."

I was well aware that the biggest drawback to creating my blog was the fact that I would actually need to update it with new entries on a somewhat periodic basis. However, it's not everyday where I feel inspiration to share my thoughts with you (no offense, of course). That being said, it has been awhile, but I am glad to be back. I hope that everyone is having a safe, relaxing, and enjoyable start to their summer. I spent the first week of June in Lexington, Kentucky participating in the one and only Dr. Jeff Okeson’s mini-residency program on Orofacial Pain & Temporomandibular Joint Disorders. Dr. Okeson is the author of the “bible” of TMDs and Orofacial Pain, so learning from him was a true honor and incredible experience.

It is usually during these week-long explorations where I find time to reflect and discover potential inspiration to share my ideas with the world at-large. The program had approximately thirty participants (ranging from anesthesiologists to oral and maxillofacial surgeons) from all over the world (Norway, Australia, etc.), so I felt lucky to be just a short five hour drive away from the UK campus.

Anyway, enough of all that, let’s get straight into it. I am going to do my very best to stay focused on the topic at hand (I have a lot on my mind). But, before we begin, allow me to give a quick “shout-out” of inspiration to Mr. Mark Twain, who will be our tour guide for this entry.

How we learn.

"A full belly is little worth where the mind is starved." -Mark Twain

Certainly, I learned lots of invaluable information that continues to layer advanced, evidence-based science that I continue to incorporate in my practice in order to provide my patients with optimal, individualized, and personalized care. The residency taught elements of restorative dentistry, pain management and control, advanced sleep medicine, behavioral sciences, physical therapy, and interdisciplinary medicine from leaders in their respective fields to help professionals treat TMD and muscle pain patients most appropriately. But, Dr. Okeson, recognizing the abundance of perpetuating myths that fellow colleagues tell patients about TMDs when they simply do not understand, gave us a very interesting synopsis in “ways in which we learn.”

So, how do we learn?

Here are different ways in which we learn:

  1. Trial and error
  2. Sometimes we learn from our own personal experiences
  3. Sometimes we learn from others, but cannot remember why
  4. Sometimes we learn from others, and repeat the same mistakes
  5. Sometimes we learn from others, who then become our mentors

My experience is that many dental professionals make treatment decisions based off of a pre-conceived set of “beliefs” that are not supported by modern-day science (physiology, evidence-based research, methods of imaging, etc.). This is a major disappointment to me. Undoubtedly, I will have conversations with other dental professionals who tell me they are treating “Mrs. Jones for TMJ.” I simply cannot imagine a fellow orthopedic surgeon telling his or her colleague that they are treating “Mrs. Jones for knee.”

However, we have allowed this in our profession. If we speak this way, how can we expect our patients to understand their conditions? We have taken our sophisticated masticatory system that is controlled by our joint (and muscles) and over-simplified it because we do not want to take the time to understand (I will explain why I believe this is the case in a future entry).

So, what do I think causes the confusion?

Let’s draw a quick picture:

Surprisingly, many United States dental schools teach very little about the jaw-joint (TMJ) in their formal pre-doctoral programs. Therefore, it is left to those to explore and learn on their own journey after they have begun the clinical practice of dentistry.

In dental school, we learn diagnosis and treatment planning on a limited basis. We learn how to identify a cavity, remove it, and place an appropriate restoration. Most dentists are accomplished at this task to some degree of clinical acceptability. We learn how patients present with a conventional toothache, and form diagnostic boxes based upon this formal training. Ask any dentist about someone who has extreme throbbing in a tooth with prolonged thermal (cold) sensitivity keeping them awake at night, and I guarantee they respond that this patient "needs a root canal" (yes, they might need root canal therapy). By the way, the "toothache" is the 7th most common complaint of pain in the United States.

However, in dental programs, we also learn anatomy and physiology of other systems of the body in the medical sciences. We learn all of this information in order to be able to assist our physician colleagues in treating our patients comprehensively, and address any potential systemic issues that may exist. All of this information results in an incomplete and hazy picture of our complex head and neck systems.

So, we leave dental school, and things are simple. We “fill cavities” and treat periodontal disease. Patients come in with toothaches, and we treat them. We become narrow in our thinking, because things are "working." We are practicing dentistry of the past. Let’s face it, at this stage, we are unaware of sophisticated dentistry. Some people remain in this stage for their entire years of practice. It is a safe, easy place to practice (far left on the graph above). Patients are (unfortunately) accustomed to this, like giving your identification and credit card to the check-in staff in a hotel lobby.

But, if you are like me, you strive for more. You begin to know yourself and understand how you want to treat your patients. You need to learn more if you aspire to treat people appropriately. And you need to learn from the best. And it comes at a cost when you’re learning from the best, but it does not matter, because the strive for excellence trumps any other form of motivation.

We learn something new on an entirely different level than the majority of our colleagues understand it. We begin to isolate ourselves from the way the majority of our colleagues think. We view things as complex, and look at an entirely different set of risk factors and methods of treatment based upon sound science.

Patients (even some practitioners) may view us as “different,” even though we are incorporating data based upon the literature in our diagnosis and treatment planning decisions. Unfortunately, however, patients have been given misinformation for so long (many times from purported “experts”), that we become the practitioners who are almost hard to believe.

"Nothing so needs reforming as other people's habits." -Mark Twain

We are healthcare professionals. It is not appropriate to learn from trial and error. It is not appropriate to simply tell patients what they desire to hear, because they have been told for years by those who have not done their due diligence to read the literature and convey scientific evidence to them in fear of rejection. How can we fail to recognize, utilize, and incorporate the incredible advances we have made to treat people in maximum comfort and aesthetics using scientific principles?

For example, it may seem out of sorts for a dentist to inquire to you about potential cervical spine issues when you show up in his or her chair with a toothache. But, what if science has proven that certain cervical spine issues refer pain to the chewing muscles that can present almost identically to a toothache? How often does a dentist inquire about Vitamin B12 levels when a patient presents with an unexplained burning feeling in their mouth? Are we helping our patients to the best of what modern day science offers? No longer does “no cavities” equate to “comprehensive” or a “healthy” oral cavity.

Eventually, we implement systems and acquire enough education and knowledge to make our decision making processes simpler, but at a highly proficient level. We strive to be at the furthest point to the right on the graph above. We become truly competent providers (so competent that we are again unaware of treating people any other way). And things are simple again.

Very few practices achieve this level of competence. Patients invited by others to a practice like this understand the systems well, and come to expect the level of thoroughness and intellectual integrity that is distinctly different from the “usual” routine.

Healthcare Marketing.

I am currently in the process of creating a website for my practice. This has been a few years in the making, and I realized I had to do it when one of my patients said to me: “You know, you really ought to at least be in the phone book.” Point well taken.

Honestly, I just cannot stand external “marketing” for healthcare. It pains me to see what much of our profession, which has the potential to be so extraordinary, puts on the internet for patients to read.

So, during this process, it physically saddens me when I browse different dentists websites explaining their practice and their “philosophy.” This is your page, and the public can view it at anytime! A 24/7 reflection of you, your values, and your philosophy.

  • “$50 cleaning! $100 whitening! $1,000 crown!”
  • “Free exam and x-rays!”

Really? How did we get here? ($100 whitening and we don’t even know each other yet…)

  • What about care, skill, and judgment?
  • What about maintaining our mouth in comfort, beauty, and aesthetics?
  • What about building relationships based on mutual trust and respect?

I went to this course with an exceptional restorative dentist, Dr. Ryan Mizumoto, who practices on the other side of town. He is a great colleague and friend, and sometimes the learning outside of the classroom proves to be more valuable than in the course itself (we literally listened to the 2014 American Equilibration Society’s annual meeting on the drive home). For more information, feel free to visit the AES here.

"To eat is human... to digest, divine." -Mark Twain

While in Lexington, we decided we needed a change in the normal cuisine we were having. We also decided that we needed a break from tasting authentic Kentucky bourbon, so we searched for a unique restaurant in Lexington. Finally, somebody told us about Yamaguchi’s. Yamaguchi’s has recently become my most respected restaurant for two reasons:

  1. Yamaguchi’s is in a strip-mall with no signage (see picture). You cannot find this place unless you know about Yamaguchi’s. It looks like a total dive.
  2. I need to quote the menu: “Our phone number is not listedand the phone is turned offall the time to provide a hideaway experience for our guests.”

Yamaguchi’s is not about advertising the quality of their food. Yamaguchi’s understands that the people who appreciate their quality will find their way to their restaurant and bring other like-minded folks with them. And, it works. It works really, really well.

The second you walk into Yamaguchi’s, you forget you are in a dingy, old, almost abandoned strip-mall. You surely forget you are in Lexington, Kentucky. We were not let down with the experience. The fish was delivered overnight, never frozen, and hand selected. Every single tapa dish was exceptional. The owner works diligently, solely concerned about the quality of his food and experience of his guests... not the volume of his customers. He knows that people will find his restaurant, somehow, someway, because of the excellent cuisine and ambience (enhanced by the fact that you never hear a phone ring while dining). Nobody accidentally leaves their cell phone ringer "on" in Yamaguchi’s.

Can you imagine telling a restaurant owner that it is a decent idea to never turn your business phone on? Sounds like a ridiculous idea, I know. But, Mr. Yamaguchi knows that his level of commitment provides cuisine so far superior to anyone else that people will come. And, people will know what to expect. They can expect an education in properly crafted tapas. His commitment to exceptional tapas and service is enough to drive success, despite what appears to be a difficult location for a high-end restaurant.

I want to try and (succinctly) bring all of this together.

Conclusion.

"Always do right. This will gratify some people and astonish the rest." -Mark Twain

"The man with a new idea is a crank until the idea succeeds." -Mark Twain

Wrapping up, we covered two important issues. We discussed ways in which we learn, and that we must be careful to use sound principles of science as healthcare practitioners in our decisions while treating patients with complex problems. We also observed how certain types of marketing may be a distraction from the sophisticated services we are able to provide for our patients. We conclude that if we stay committed based solely on altruistic motives, people will find us.

It is our duty, as professionals, to approach our careers as a journey that lies along an infinite continuum of learning, growth, and personal development.

I believe that true commitment to being the very best one can be is enough to harbor trust, growth, and respect amongst colleagues, peers, and patients. I would advise anyone in any profession to simply immerse themselves in the highest level of professional growth they can, before their habits overtake their hunger for learning.

Be a life-long learner.

Learn from the masters.

And, aspire to surpass them.

Invictus

One of my favorite quotes is from the famous William Ernest Henley poem "Invictus." Invictus is a Victorian poem that was published in 1875, but what many people don't know about Henley is that he actually had one of his legs amputated just below his knee at the age of 17. Henley contracted tuberculosis of the bone at age 12, and when it progressed to his foot, physicians felt the only way to save his life was through amputation. Surprisingly, Henley remained active until the age of 53. I won't copy the entire poem here, but the quote that I'd like to elaborate upon (especially based on Henley's life circumstances) is:

"I am the master of my fate

I am the captain of my soul."

Let's put this in perspective. William Henley suffered a serious "life-event" that would normally result in complete immobility, compromised lifestyle, and self-pity. We must remember that, especially in this time period, we did not have efficient ways to mobilize and restore function to people that suffered amputation. However, Henley remained positive and took ownership of his problems. He knew that he was the only one who could choose his life direction, and did not blame others for his ailment.

So, what's your point?

In dentistry, as with many other professions and businesses, we as practitioners choose how we want to practice, and develop our own philosophies to create a practice that represents our true values. When I first graduated from dental school, I imagined that I would enter into the "real world" and be equipped to solve the most complex of issues that my patients faced. What I didn't expect to find over the first two years was a great lack of personal fulfillment when I would see (way) too many patients each day and try to solve all of their issues myself. I began to think that it was just my patients that weren't owning their own problems, and that if only they would change, then I would be happier. I couldn't be any further from the truth.

Like Henley, I had my first "ah-ha" moment of my professional life. I was failing as these patients dentist. I needed to change. That is not an easy thing to realize and admit, especially coming from someone who has always strived to do and be the very best. I wasn't failing because I was doing anything technically incorrect, but because I was not spending enough time with my patients. I was too busy, and I couldn't get to know them---the most fundamentally important thing that I should have been doing.

Enter: The Pankey Institute (http://www.pankey.org).

The Pankey Institute for Advanced Dental Education in Key Biscayne, Florida has provided a place for dentists to explore the meaning of excellence and renew their commitment to the kind of dentistry they want to be doing. L.D. Pankey's basic tenet to successful practice was: "Know yourself. Know your patient. Know your work. Apply the knowledge."

With the constantly changing healthcare system, many dentists tend to forget that we are the masters of our fate: not an insurance company or government mandate. It is our job to create an environment that harbors our own personal values. So, I felt it necessary to make a change.

I started to take more time---a lot more time---with each individual patient. I couldn't believe how much I got to know about so many interesting people. More importantly, I couldn't believe how much easier I could assist these patients in achieving their goals after thoroughly understanding their values, beliefs, and perspectives. I committed myself to an extraordinary amount of high level continuing education, and surrounded myself with some amazing practitioners in various study groups. I started to practice interdisciplinary dentistry utilizing extremely talented and knowledgeable specialists to help coordinate optimal patient care. But does all that really matter? No, of course not. We all know that people don't care about how much you know until they know how much you care.

Other dentists (often seasoned dentists who want to mentor "the kid") will often ask me why I spend so much time with each patient. They tend to mention that "time is money" and that my time would be better spent seeing more patients and therefore doing more "work."

I will hear comments such as:

  • "What do you do for an hour with a new patient?"
  • "Aren't people too busy to come and see you?"

I like to remind them that we are not treating a set of teeth, but people. We must address our expectations, goals, and desires. We must understand each others paradigms. Our goals for a patient may not be the same goals that the patient has for himself or herself. Arguably, an hour is often insufficient time for us to accomplish these tasks together. It is, however, a way to begin building a mutually beneficial relationship with each other based on trust and respect. Would you give up an hour of your time if it meant preventing losing teeth in the future? Taking a comprehensive approach also provides the baseline information that we need to do our work in the most predictable and optimal manner---with specific goals in mind. This, in my opinion, is the only way to create true value in the services we, as professionals, provide.

So, I remembered Henley, and that only I was the master of my fate. Do I take a chance and begin reflecting my values and philosophies into my work and my practice, or do I remain a technician of the mouth? If a patient called me on a holiday after breaking their front tooth, would I know who they were? Would I know what they expected of me as their dentist? In the beginning, probably not. However, now I have chosen to practice how I would like to be treated, and after a few years in, I can tell you that I am much happier both professionally and personally. I truly know my patients, and I don't need to scribble notes about their children, jobs, and hobbies on the front of their chart to remind me who I am treating. That in itself is personal fulfillment. I can now truly help my patients simply by understanding them as individual people living busy lives and dealing with unique and complex problems.

I fully recognize that we are living in the era of digital downloads, text messaging, fast food, and quick service, but there are many times when we need to rely on old-fashioned human relationships. It is important for us to get to know each other. It is important for the future of our journey together.

Embark upon your journey the same way, and remember, only you are the master of your fate.

Let's begin our journey together

Welcome to my blog, and let me be the first to say "thanks" for visiting. I have been debating for quite some time whether or not I want to expose my thoughts and ideas to the vast world wide web out there, but I've recently been inspired to do just that. So, before we go on this journey together, let me tell you what you can expect (or not expect) from this blog, and a bit about myself:

  1. I am a restorative dentist who practices in Lyndhurst, Ohio, and have committed myself to extensive post-graduate training. I practice relationship-based, comprehensive dentistry (much more on this later). What does this mean, for you, the reader? It means that I can't help but tell you that there will be many dental topics and philosophy to be discussed. I promise that I'll try to keep it interesting.
  2. Total health & well-being is of great importance to me. My life changed after reading Weston A. Price's Nutrition and Physical Degeneration: A Comparison of Primitive and Modern Diets and Their Effects. For anyone interested, I cannot recommend this book enough. Dr. Price was a Cleveland dentist known primarily for his theories on the relationship between nutrition, dental health, and physical health. This book was published in 1939, and the research is applicable to this very day. We will explore various aspects of Dr. Price's research in posts to come, but if you're interested, I would ask that you visit the Weston A. Price Foundation (http://www.westonaprice.org) for great resources on total wholeness and well-being. I should disclose that I receive absolutely no benefits for recommending this Foundation and/or book.
  3. I enjoy staying active. Outside of my practice and family, one of my greatest passions is CrossFit (http://www.crossfit.com). CrossFit is a strength & conditioning program that builds around community, nutrition, and mental strength and toughness. I am proud to say that I have been able to immerse myself in a great community of incredible people at CrossFit Distinction (http://www.crossfitdistinction.com) over the past two and a half years. It has been an incredible ride being surrounded by a community that knows exactly how to get the very best out of you at any given moment.
  4. I'm a Clevelander. Born and raised in Cleveland, Ohio, I enjoy all that this city has to offer. Despite our sports history, I am a passionate fan of the Browns, Indians, and Cavaliers. I have found this city a great place to stay and live. Cleveland (really) has it all.
  5. I went to college in Ann Arbor (yes, Michigan). Despite my loyalty to Ohio, when it comes to collegiate sports, my allegiance goes to my Michigan Wolverines. I attended the University of Michigan with a concentration in Cellular, Molecular, and Developmental Biology before attending the Case Western Reserve University School of Dental Medicine for professional school. Go Blue!
  6. I'm married to an (awesome) lawyer. You would think that wouldn't be easy, but surprisingly when you are the dentist in the relationship you learn to stop arguing with the attorney very quickly and succumb to defeat. I've thought about keeping a miniature white flag in my pocket at all times, but I don't think that is going to happen. Laura and I live happily with our favorite dog, Dylan, who also lives an all-natural lifestyle.

I know as we move forward you will get to know more about me, and what goes on inside my head. If you don't find this interesting, then please accept my apologies in advance. But, if you want to stick around for the ride, I'm glad to have you on board.

Thanks again for visiting.

Matt Kogan, DMD