dry mouth

I am a dentist and also suffer from oral cancer.  I was diagnosed with osteosarcoma of the right mandible 4 years ago.  Initial treatment included removing my right mandible along with my right parotid glad.  After that I had many courses of radiation and chemotherapy.  Both of these took a toll on my ability to produce saliva.  As a result I have an extremely dry mouth every day.  As mentioned, I am a dentist and know many of the common treatments for dry mouth including hyper hydration, salivary substitutes, drugs to increase salivation, stimulation of saliva with various mints or by chewing.  Unfortunatly because my glands are so extensively damaged none of these treatments has been adequate.

From personal experience I can tell you that dry mouth is no fun.  It makes it hard to speak, harder to swallow, and is just generally uncomfortable.

If I use a salivary substitute, and I do, I find that it provides me a few minutes of relief but not very long.  So the other day I had this idea that popped in my head and I tried it.  The idea was this.  Instead of water or a salivary substitute, why don't you use a little bit of coconut oil?   I had some of this in my home and I gave it a try.  The results were very satisfying.  As mentioned salivary substitutes provided minuted of relief however coconut oil left my mouth feeling moist for hours after taking it.

It is so easy.  Coconut oil can be bought almost anywhere and is inexpensive  In addition it is a very healthy oil, it tastes good and it melts at body temperature.

Here is how I use it.  When my mouth is dry I simply take a spoon, gather up a piece of coconut oil about the size of a pea and put it in my mouth and move it around for about a minute before swallowing.  The results have been very nice.

I intend to write an article to be published because I think others would benefit from my discovery but in the meantime I will start with simply posting a blog on the topic here.  I hope that it is of benefit to you.

A paradigm shift

So, as you may know, I have had some serious health problems as I have fought oral cancer for these last four years.  During that time I have gone to countless doctors visits.  I believe that there are some valuable things we can learn from what our brothers and sister physicians are doing.  Let me tell you one that seems to be working out really well in my office.

Most of the time when I go to my physician for an appointment I am first greeted by the receptionist of course but the next person to greet me is a medical assistant.  This person carefully reviews my medical history, updates my medication list and gets my vitals.  I have become very attached to some of these medical assistants.  In many cases they are very kind and seem to really care about me as a person.  I can think of one case recently where I learned that my medical assistant was taking another position out of state and I literally wept when I heard the news.  I was at least at attached to her as I was to my physician.  I still miss her beautiful face and the kind way that she always treated me.

So, I began thinking about how this model might be applied in my own office.  I have a very busy practice and I ask a lot of my hygienists.  Some times they don't review the health history as well as I would like or update the list of current medications.  They are pretty good about blood pressure, though they forget sometimes.  They rarely do other vitals.  Most of my patients are very fond of my hygienists but I think that same fondness could be associated with another person.  I have chose in my office, to call this position the hygienist coordinator.

In my office her job duties are as follows.

• First and foremost, to great my patients promptly by name and with the greatest love and kindness that they can muster.   I tell them that I want my patients to weep if they hear that my hygiene coordinator is leaving for any reason.
• Second to do an EXCELLENT review of medications, health history and to capture vitals.  For us that includes, blood pressure, temperature, pulse oximetry.  With many of the changes that appear to be coming it may soon include blood sugar as well for people that we consider to be at risk,
• Then to take excellent digital radiographs and a full series of extra oral photographs and make sure that they are in the chart to be viewed.
• They are to keep my hygienist perfectly on time.  In other words, they will greet my patients out front exactly at the appointed time so that there is no waiting and at the same time inform the hygienist, "I am now going to get your 10:00 patient.  Please know that I will have them ready for you in 15 minutes.

I made some simple changes to my panorex room to convert it for the use of my hygienist coordinator.  We have pretty state of the art vital monitors and all of the other equipment that she needs to do her job.

In my office I usually have three hygienists at a time and several doctors..  This new position has allowed us to work much more efficiently, stay on time, get better records and not lose the personal touch that is so important in our office.  We have been doing it for about a year now and I have been so happy with the result so far.

"Help, I'm behind"

No matter how well I plan it seems that sometimes I just can't stay on schedule.  If I had to list the number one stress in my professional life it would be this, getting behind on my schedule.

So, what should happen when I'm behind.

First, hopefully my front desk people are paying attention and can begin to run interference for me.  This might include calling the next patients and warning them about my schedule.  They are given the option of coming later or rescheduling, whichever works best for them.

Second, I hope that my back staff don't add to the pressure.  Imagine I am behind and doing the best I can and a staff member comes in and says "I have a patient who has been waiting 30 minutes for an exam" or even "Do you have any idea how much longer you are going to be?"  I already I know I'm behind and don't need the fact rubbed in my face.  Furthermore, how do you think that the patient I am working on will feel if they here those sorts of comments.  Probably they are thinking, "I guess I am going to get a rush job here since he is so far behind"  Better to just leave me a note with the time written on it stating what you need from me.

Far better would be for my staff to start working on ways to help me get back on schedule.  Maybe a hygienist can do my anesthetic on the next patient.  Maybe an assistant can take the hygienist's next patient and get them started so that they aren't waiting as well.  Maybe we can reduce the amount of treatment we are doing on another patient.  Perhaps you can explain in a kind way to other patients why they are having to wait.  I find that the next patient is much more willing to be forgiving when they hear something like "Sorry for the wait.  We had someone show up with their front tooth knocked out and we are doing our best to take care of them and still take care of you."  When patients realize that I am helping someone else and doing my best they tend to be less annoyed.

Third, and this is important, the most person in my whole world is the one that I am working on at that moment.  There is a temptation when you are behind to cut corners to try and catch up.  You just can't fall into that trap.  We had a mission statement in our office.  It is posted in every single room.  It states,

"We believe in providing our patients with the same quality of care 

that we would like to receive ourselves."

When I am behind I often look at that statement or at least think about it.  The problems with my schedule will soon be behind me but the work that I do and the way that I treat people will remain.

Doctor means educator.

One of the primary roles of a dentist, dental hygienist or dental assistant is to educate patients about the conditions in their mouth and what can be done about them.  Some people feel that they have to "Sell dentistry".  I just don't buy that philosophy.  Years ago I worked as a door to door salesman selling water softeners and to be honest I stunk.  I'm just not a good salesman.  What I am good at is education, and I enjoy it.  This is one of the reasons that I love dentistry because I don't have to sell things, I just need to educate.  If I do a good job of education then patients will most often choose what is best for them and their budget.

This is the way that I like to educate my patients.  I like to really do a good job at the start listening to them describe what is going on in their mouth both now and historically.  The patient lives with their mouth day in and day out and they know more about it than I ever will.  I talk with them upright, at eye level and really listen to what they have to say.  I ask questions that give them a chance to talk.  Good questions start with phrases like "Tell me about…." or "Could you explain to me…." etc.  This invites answers that give you great information.  Yes No questions are of limited value.

The next step is to get great records.  I need to have data available to make intelligent decisions.  Great radiographs, photographs, perio probings, gum recession measurements, a record of all existing work, models if needed and maybe even bite registrations or transfers to mount the models on an articulator.  Whatever I see is necessary to really look at the whole person.  I also like to know about their dental history and what their goals are in my practice.  When we have all that information we are really ready to start.

I love co-diagnosis.  I start by telling the patient that we are going to review all their records together and that I am just going to talk out loud about what I am observing.  I invite them to stop me at any point if they have questions and I will do my best to answer them.  Then I begin looking with them.  I explain what I am looking for and I point out the things that I observe, both the good and the bad.  If they have had great work done in the past I point that out.   If I see something that isn't right I tell them that too.  I might start out saying "I notice that….."  "May I tell you about how that could be improved?"  Most of the time people are happy to hear about their options.  For example, I might say, "I noticed that your front teeth are crowded.  May I tell you about some of your options for improving that?"  I am always surprised at how often people will tell me that they have been going to the dentist for years and that the dentist never mentioned that they could do something about it.  Somewhere in this discussion I like to bring up what will likely happen if they don't do anything and what they might expect if we were to treat the condition.  This should be an honest appraisal not a sales pitch.

In our office we have a monitor directly in front of every chair.  This is where we view most of our images.  We use an intramural camera for part of this.  I love to freeze an image and talk to them about what I am observing and answer their questions.  By the way, I have owned a lot of intra oral cameras over the years.  The first one I bought cost me nearly $20,000 with the monitors and printer.  The intra oral camera I have now cost me about $120 on eBay, straight from China.  At that price I put one in every room.  Frankly, I like it as well as any camera I have owned.

By the time we are done most patients feel that they know more about their mouth than they have ever known in their lives.  I sit them up and give them a synopsis of what we talked about and what treatment options are available to them.  We answer questions and begin to form a treatment plan based on what they need and want to do.  Larger treatment plans we may invite them back at a later time so that I have time to formulate an overall treatment plan and prepare needed visual aids.  Simpler plans we will compile that same day.

Education is easy, enjoyable and allows you to provide your patients comprehensive care.  The word doctor literally means educator.  Perhaps we should do more to live up to that title.

Ideal recall visits

Ideal Recall visits

I am going to begin this blog talking about the most repeated service provided in a dental office, a recall prophy and exam visit.  

We believe in providing templates in our office to insure the quality of our services.  We use the template idea in a number of settings including our hygiene visits.  The idea of a template is that we outline how a certain procedure should take place if everything went perfectly and then we strive constantly to make events follow that template.

Here is how the template for a recall visit works.

1.     The hygienists meet their patient at the front desk promptly at the appointed time.  Exceeding patient expectations is a key to success in a dental practice.  How often have you gone to a doctor’s visit and had zero wait time before being seated?  Right, it doesn’t happen very often.  Being exactly on time is a great way to exceed expectations.

2.     We have the multiple doctors in our office.  As the patient is being escorted back to the treatment room the hygienist asks the patient, “Do you have a preference which doctor does your exam today?”  We don’t ask, “Which doctor to you want to see today?”  Think about it, that is a very different question.

3.     The patient is seated and their medical history is reviewed and updated on the computer.  Any significant changes are noted for the doctor to see when he comes in.  We have toyed with doing this on a iPad and having the patient make the updates themselves.  This is cool and kind of high tech but we met a fair amount of patient resistance, especially among our older patients.  It is also less personal and that isn’t what we are about.

4.     The patient’s blood pressure is taken and recorded for the doctor to view when they comes in.  If the numbers are not ideal, the hygienist talks to the patient briefly about what that might mean.

5.     The hygienists determine the appropriate radiographs to be taken.   The standard in our office is four posterior bitewing radiographs and four anterior peri-apical images, three on the upper and one on the lower.  We are currently using digital radiographs.  We also take vertical bitewings in the posterior because they show the bone so much better.  Panoramic radiographs are taken once every four years starting at age eight.  Having said that, there are reasons to alter this protocol.  Radiographs should be determined individually.  If we recommend radiographs and the patient refuses, we ask the patient to sign a radiograph waiver.

6.     Hygienist sits the patient up and reviews the radiographs with the patient.  Point out to them any areas of concern.  Teach the patient what you are looking for and you will find them looking for problems with you rather than being at your mercy.  In our office we call this co-diagnosis.

7.     Six photographs are taken and added to the patient’s permanent record.  I find that these pictures are invaluable in keeping track of patient conditions and initiating discussion about cosmetic concerns.  These six photos include:

a.     Smile, lips at rest

b.     Full smile

c.     Retracted, teeth slightly apart

d.     Retracted, teeth together

e.     Maxillary mirror view

f.      Mandibular mirror view

8.     Full mouth perio probing is done on every adult patient.  If this is a non-perio patient then we simply record any number that exceeds the norm, (deeper than 3mm in any pocket, bleeding, mobility, furcations etc.).  We note in the chart that a full perio exam was completed with abnormalities noted.  At this time we also record all recession levels so that we can track total clinical attachment loss.  If a patient’s probing show evidence of periodontal problems then the doctor is informed promptly to come in and confirm the periodontal diagnosis.  While waiting for the doctor to come in the hygienist can discuss with the patient what the numbers mean and what you discovered.  We need to explain in clear, easy to understand terms what is going on and then to focus on solutions.  Help them understand the problem but focus on the solutions.  This should be a hopeful discussion.  It is often helpful to use an intraoral camera during this discussion.  The goal should be to help the patient understand and own their condition.  Without ownership we will never win this battle.

9.     A brief discussion about Perio.

a.     This is how we approach perio in our office.  There are a number of triggers that can move a person into a periodontal program. 

                                               i.     Unresolved gingivitis.  If the patient has gingivitis and the record shows that this is ongoing, in other words it has been talked about before, but the problem continues, then we move them into a perio program.  If this is the first time the gingivitis is noted then we would inform them and tell them that if the problem continues to be present at the next visit we will need to move them into a perio program.  We have a lot of patients in ortho who enter the perio program while in braces.  We don’t call it a perio program.  We call it “Treatment for gum disease”

                                             ii.     If a patient has isolated 4 mm pockets without bleeding, we would inform them about the situation and warn them about the problem that were observed.  It is helpful to be aware of smokers.  These people often have disease without bleeding.  Don’t be tricked by smokers.

                                            iii.     If a patient has isolated 4 mm pockets with bleeding we move them into a perio program.

                                            iv.     If a patient has any pockets 5 mm or greater, with or without bleeding, they enter a perio program.  Patients need to understand that 4 mm pockets or bleeding are a real wake up call.  5 mm is a dangerous situation.  6 mm or more represent major, maybe irreversible, disease.  Every mm makes a big difference in the prognosis.  Make sure that you talk to patients in words that they understand.  If you are probing, tell the before you start, what the numbers mean, and then tell them to listen for any numbers greater than 3 mm.  Don’t use words like perio, probing, pockets etc.  Use words like gum disease, infection, etc.  Use words that they understand.

                                             v.     If a patient has a spouse or partner with active gum disease we want to determine this as well.  The infected partner will need to be treated at the same time so that they don’t re-infect one another.

                                            vi.     When the doctor comes in the doctor will expect to have the hygienist explain the situation and give their recommendations for treatment.  Treatment recommendations might include:

1.     Shortened recall, usually three months, maybe more often

2.     Improved home care

3.     Oral hygiene aids, including Sonicare, Waterpick, floss holders, Perioguard, gum tonic, oral probiotics etc.

4.     Scaling and root planning.  The number of quadrants will be dependent on the needs of the patient.

5.     Chemical agents, such as Arrestin or other agents.

6.     With non responsive patients we may recommend testing to determine the dominant type of bacteria and the best antibiotic’s to approach the problem.

10.  If the patient is not a perio patient then the hygienist simply passes a note to the doctor or doctors letting them know that they are ready for an exam at any time.  It is much more efficient to have the doctor come in and interrupt the hygienist to perform the exam than to have the doctor come at the end.  If you don’t inform the doctor until you are done then you will waste time waiting for them at the end.

11.  Proceed with the prophy.

12.  “Passing the baton”.  When the doctor arrives in the room, immediately sit the patient upright so that the doctor can talk to them at eye level.  Introduce the patient to the doctor.  If the doctor already knows the patient then start the conversation with a personal note.  “Doctor, John just got married…” or something to that effect.  “They are first a person and then a patient”.  Next tell the doctor anything that you have noticed that the doctor should be aware of.  These might be medical changes, blood pressure problems, things that you noticed on the radiographs etc....  It’s good to mention positive things that you may have noticed as well.  Don’t get into the habit of only reporting on negative items.

13.  In our office the doctor provides both the dental exam and the soft tissue exam/cancer screening.  In some offices the soft tissue exam is delegated to the hygienist.  I prefer to do it myself.  If the hygienist has images or radiographs of a problem area it is helpful to have these up on the screen when the doctor enters to begin the discussion.

14.  At the conclusion of the appointment, make sure that the patient understands any work that needs to be done.  If the patient has significant treatment needs, 3 or more crowns or treatment costing more than $3000, then schedule them to come back with the doctor for a consultation before beginning treatment.  We introduce this by simply saying “You have some significant challenges with your teeth.  The doctor would like to take some time to carefully consider how to best take care of you and then have you back to talk about your options”.  We almost never have anyone unwilling to come back when it is presented in this way.  If they have a spouse or significant other we invite them to bring them to the consult as well.  This will allow them to get their questions answered as well and help to avoid conflict at home regarding the cost of treatment.  If the patient has less complicated treatment then you can proceed to treatment plan the case in the computer.  Feel free to ask the doctor what they would like to do first and how much time they will need.  These patients should leave with a print out of their proposed treatment and the associated costs.  The hygienist can also set up their appointments or this can be deferred to the front desk if time is short.

15.  Set up the next recall visit with the patient.  We never let a patient leave without their next visit scheduled.  If a patient says “well, I don’t know my schedule that far out” we simply say “Well, I know one appointment that you have now” or if we want to be more serious then we say “This will reserve a time for you.  If there is a conflict when it gets closer we will give you plenty of notice to change your appointment for a more convenient time.”

16.  “Passing the baton” Escort the patient to front desk, let the front know what is needed next.  If they have more than $300 of work to be done, the front desk person will set up financial arrangements with the patient and make sure they know what to expect at the next appointment.

First blog and introduction

Hello, my name is Eric Vogel.  I am a practicing dentist in Provo Utah and have been in practice for about 26 years now (Since 1988).  During those 26 years I have always taught pre-dental students at the local university and that has been a source of great joy for me.  During those 26 years I have done thousands of hours of continuing education and tried to put into practice many of the things that I have learned.

In this blog I hope to share practical things that I have learned or invented that have helped me in my practice and have helped me to improve the quality of care that I provide.  Teaching has always brought me great joy because I feel like I am helping others.  At this point in my life I find that helping others is a lot of what life is about.

In the upcoming posts some of the topics I will cover topics will include:

• Having an amazing new patient exam
• Building your practice from within
• Ideal day planning
• Managing you online presence
• Things that you can do to avoid embezzlement in your practice
• Effective morning huddles
• Ideal oral health care visits with your dental hygienists
• Taking great alginate impressions
• Pouring up bubble free models
• Taking consistent quality radiographs
• Enhancing your practice with photography
• Making beautiful, durable temporary crowns
• Choosing a material for your crowns
• Taking perfect final crown and bridge impressions
• Taking complex final impressions for full rehab cases
• Making the most versatile bite splint: the anterior flat plane appliance
• A simply way to determine centric relation
• When and why to use an articulator and how to use it
• Predictable, tight contacts on class II resin restorations
• Making your posterior resins fit better and have less sensitivity
• Two cord technique for crown and bridge
• Determining where to place the margin for final restorations
• Smile analysis for smile makeovers
• How to use your digital SLR camera
• Simple sinus elevation for anterior implants
• Protocol for removing wisdom teeth that speeds up the procedure and decreases pain and swelling
• How to do great shade selection
• Using composite to close anterior diastemas
• Using wax ups to treatment plan complex cases
• Minor orthodontic movements using clear retainers
• Preventing bone loss around implants
• etc.

Some of these topics will be of value to your assistants, others will be of greater value to the dentist.   I hope to include photos, short video clips and descriptions.  

I have always tried to provide the best care to my patients that I was capable of.  When I have combined this with some financial wisdom I have found that dentistry has provided me a comfortable income.  Putting patients first has always been my goal.  I hope that my blog posts reflect that philosophy.

As you read I will welcome your comments and thoughts about the topics presented because, together we are smarter than any one of us is alone.  If you have suggestions on topics that you would like to have me address I welcome those suggestions as well.  I hope that the content of this blog helps you to provide great care to your patients and improves your overall job satisfaction.

Eric Vogel DDS

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Resume for Eric Vogel

Eric G. Vogel, DDS

·              Objective	Introduction
·            Experience
	Professional Doctor of Dental Science (DDS) from Creighton University, Omaha Nebraska, USA, 1988. Bachelor’s degree in Zoology from Brigham Young University. (BYU) Provo, Utah, 1984.  I completed my four-year degree in two years. Practicing dentist 1988 to present. Provo Utah, USA. Member of American Dental Association, Utah Dental Association, and Provo District dental Society Fellow of the Academy of General Dentistry.  This organization focuses on the highest standards of continuing education. Part time professor in the Department of biology at BYU 1992 till present. Adjunct professor at BYU in the Department of Biology from 1988 to 1992. Member of the Academy of Dentistry International. Membership is open to dentists who have demonstrated excellence in their careers. 2006  Delegate to the Utah Dental Association since 1995.  This is a policy- making body for the state dental association. Clinical Research Associates (CRA) evaluator.  A group of 400 dentists worldwide who research and review new dental products for efficacy. 2000-present Co-developer and member of the board of directors of the Aribex dental x-ray system.  This is the world’s first portable x-ray source developed for use on humans  Author of textbook for young dentists preparing for dental school currently in use at BYU and universities around the country. FAGD Academy of General Dentistry, 2011,  Continuing education award given less than 1% of dentists for commitment to continuing education President of Provo District Dental society, 2011-2012  Nominated to International college of dentists 2012:  Honor reserved for highest achieving dentists  Nominated to Pierre-Fauchard dental society 2012;  Another society recognizing highest achieving dentists Faculty club member Spear dental education., a group that educates about 2000 of the top clinicians in the world Member of the American Academy of Cosmetic Dentistry Peer review editor for AGD journal “General Dentistry” Humanitarian  Founder and President of “Share a Smile” foundation.  This organization is dedicated to providing education and dental care among the less fortunate. Leader of humanitarian dental expeditions to Bolivia, Mexico, Malaysia, Russia, China , Belarus and Morocco and Navajo nation. Since 2001, I and others have organized local dentists and gone with them providing comprehensive dental care every month among the poor here in our community. In 2008 My organization built a full service dental; charity clinic in association with the Food and Care Coalition.  Dentists from throughout the area now come there to provide care for the poor. Currently building a second charity clinic in American Fork, Utah, to be completed in May in partnership with Henry Schein international. Full time Volunteer work 1980-1982       Bolivia Santa Cruz
	Scholarships Four-year Regional Dental Education Program scholarship to Creighton University Dental School 1984-1988. Full tuition leadership scholarship to Brigham Young University.
	Awards Scouting Second Miler award 1999.   Given for outstanding service by the Boy Scouts of America. State Points of Light Service award 2003:  given by Governor Leavitt of Utah. National Points of Light service award 2004: given by President George W. Bush.  Honored Alumni Brigham Young University 2004.  Given for recognition of excellence by the Department of Biology once annually Presidential Bronze and Silver service awards 2005.  Presented by President George W. Bush and Governor Mike Leavitt for service given Brigham award 2006. Given by Brigham Young University for outstanding service among faculty members.  One of six awards given annually at BYU  LDS Academy of Dentists Humanitarian Award 2007.  Recognizes outstanding service among academy dentists, one or two awards annually Utah Dental Association Life Time Service Award 2007.  Highest award given by the dental association Named Best Dentist of the Year 2008: Utah County, Daily Herald polls Dentist of the Year, Academy of General Dentistry, Utah chapter 2009  FAGD Academy of General Dentistry 2011:  Award given to less than 1% of dentists recognizing achievements in continuing education Nominated to International College of Dentists 2012: Society that recognizes highest achieving dentists Nominated to Pierre Fauchard Academy 2012:  Society recognizing highest achieving dentists Named Best Dentist of the Year: 2012:  Utah County, Daily Herald polls
Interests	Spending time with my wife and eight children Running: Successful completion of twelve marathons (including Boston) plus and ultra marathon of 56 miles Languages:  English (Native), Spanish (fluent), Russian, French and Mandarin Chinese (intermediate) Scouting, camping, outdoor activities, Gardening I am an cancer survivor, 2 1/2 year now.  Osteogenic osteosarcoma of the right mandible.  It has been a difficult and interesting journey.

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