Dr. Greg from Dental Clinical Pearls. I hope everyone is doing well. I want to share with you some private practice efficiency tips, so you can produce more, with less effort.
Before I start, I want to discuss this. There is nothing wrong with producing. As long as your work is clean, you’ve tried your best, and the patient is well-served, your production is a direct measure of how many people you have helped in a day. And that’s the reason why we got into dentistry in the first place – to help people.
This post discusses team and personal private practice clinical efficiencies, so it’ll be helpful even if you’re not a GP.
There are 2 parts to this post. What I will do is this:
Part 1: go through highlights of my day + commentary about the clinical aspects. In this section, I will share how long I scheduled for each appointment. I want you to know $10,000 – $15,000 dentist production days as a GP are very real and very possible.
I have also put some clinical dental tips + links to cases throughout the post.
Part 2: the skills needed to replicate more consistent and comprehensive treatment and production.
Before I start, I should address a few common questions. I do not double book procedures. I see one patient at a time. The only double-booking is walk-in emergency exams, night guard impressions + deliveries (the assistant does those) and small things like a bite adjust or children’s checkup. I do NOT book procedures against procedures, so there are no matrix bands being placed on patient #1 while I give local anesthetic to patient #2. I do not double book.
So I want to show some of the younger dentists a few techniques on how to run things so you are efficient and using your time well.
Please remember, I am NOT fast. I am organized. Being an efficient clinician with an efficient team will get you there quicker than the fastest prepper in the world with a disorganized team. Nobody would say I am a fast clinician. I do accomplish a LOT in an hour though, and I will share the tips at the bottom of the post how to do this.
Part 1 – Breakdown + highlights of my 8.5h day
I had a few dental fillings here and there, but I’ll spare you those details. So here is my first patient of note of the day:
Patient #1: Stage II + open tray impression, 40 mins, zero charge for this (we bill at the implant insert)
Nothing overly special. Uncovered an implant, took the open-tray impression, assistant did lower arch impression + bite reg, and we moved on.
Pt #2: Implant crown delivery: 30 mins
I placed a 4.1x14mm bone level Straumann a while back. This is a flowable pickup impression to capture the soft tissue. Delivered his crown. My camera exaggerates yellow and reds, but it looks great in the natural light
Original PA day of placement. Straumann 4.1x14mm bone level RC implant. For those who want to learn more about anterior impressions, the full case is here.
My assistant struggles w/ canine PAs. It wasn’t overlapped. Only in this PA. Checked to make sure abutment was seated.
Anodized titanium abutment. Use a seating jig for your abutment. Erythemia will go down. used zinc phosphate to cement. Wasn’t able to go screw retained on this one, but a fairly nice overall result.
For those who want to read more, full case is here.
Next 2 patients are emegency patients and I have an unexpected 90 min opening right after
TIP: My front desk team knows to schedule emergency appointments at the START of an opening whenever possible. That way, if I can help the patient the same day, the schedule allows for it.
In a future email tip, I’ll give you some communication tips to that are highly effective at converting emergency patients to receive treatment the same day.
Emerg patient #1: 30 mins, 2nd column
Broken filling. I forgot to export the x-rays + I/O photos for this case. My assistant took PA and BW while I worked up my other Emerg patient #2. The filling was first placed by me 6 months ago (it happens to all of us). Local anesthetic, replaced lower 2nd molar DO at as a courtesy (no charge – but always say “courtesy”) for exam, x-rays, replacement filling. As sitting patient up, she complains of her upper tooth hurting her off and on for the last few weeks. I cold tested upper 1st molar, necrotic. I had already worked up another pt in my main column (my 2nd emergency patient) so scheduled endo for this emergency patient in a few days. Wrote down my cell # and gave it to pt just in case things started to hurt.
The point is, if this patient hadn’t come in and if I hadn’t taken care of her broken filling in a manner she felt was fair, she probably would have NEVER mentioned the upper root canal and gone somewhere else. I would have never heard about the endo. Patients will test you. I sincerely think that patient’s will test you to see how you will treat them. Treat patients how you would want to be treated and the numbers will take care of themselves.
Emerg pt #2: 30 mins, main column
Broken lateral tooth. Let pt know would require endo + post and new crown. Talked about implant option. Patient is 85 year’s old. He wasn’t interested in an implant or a bridge. Patient wanted me to save the tooth. I asked him if he wanted to do it now, and he agreed.
Same patient – RCT/Pin/Post/Crown Prep, 120 mins
(Remember I have a 90 min opening after, but the pt is scheduled for a 30 min emergency exam prior. At about minute 11 we’ve already talked options, pt elected to save the tooth and I’m giving him anesthetic – so I still have 109 minutes to do a single-canal + crown prep.)
Same pt as above. Sodium hypochlorite + time is important. I use minimum 10cc of sodium hypochlorite per case, plus an ultrasonic to agitate the irrigant.
Got the rubber dam on. Troughed a good 3mm down with slowspeed #2. Had ultrasonic ready, but didn’t end up needing it.
Notice I’m using c-files for my 6, 8, 10 instead of regular k-files. They’re stiffer and hold up better in my hands than k-files.
I use niti hand files for 15 onwards. I rarely use hand-files on straight forward cases, but for calcified cases I like to hand-file to at least a 25.02 to depth. Another tip: With calcified cases I use a balanced force technique and go up to a 25 or 30 HF balanced force (doesn’t mean to apex) before going back w/ rotary.
Master cone PA.
Placed post + pin.
Buildup. Notice I APPROXIMATE the buildup. Does not need a perfect buildup, but the general shape, because I am going to prep the tooth in 5 minutes.
Once you get into private practice, you’ll do enough preps that it gets quick with good results.
Prep. Notice the ferrule for the tooth. It was always there.
Lingual. Again, I have fairly good ferrule.
Maybe an implant is better, but this pt is 85 year’s old. He wants his tooth fixed. IF it was my mouth, I would have done the endo
TIP: when doing ENDO + Crown Prep in the SAME VISIT, place the cord before taking an x-ray. TAKE your FINAL ENDO X-RAY WHILE THE CORD IS WORKING. Just saves you time, and is more efficient on 2 steps you have to be doing anyway.
Tip: For those interested in good tips on gingival cord + retraction for crown and bridge, here is a good post.
I go off and do 2 hygiene recall checks. I tell my assistant to take the PA and then do a wax buildup on the tooth and take an impression for a temporary.
This is important. Get your assistants to work with you.
I’ll help you with the timing of these things in future emails.
You can see the matrix for the temporary here that she made.
Final PA for the endo + post + pin:
Impression: small pull on lingual ABOVE the margin. Will be fine. My lab is excellent, and have worked with the same technician for 5 years. Crown will have minimal to zero adjustments and have great margins.
Bite reg. Get the prep + 1 tooth on either side. That’s all the lab needs. No more. Saves on material costs and pt doesn’t get confused biting down.
Temporary. Not great, but better than what he started w/. Pt is very happy. Comes back next week to cement it (my partner will cement it – I will be lecturing to you guys and in town visiting.
Started w/ this:
While assistant is cleaning up, reviewed w/ pt all the hard work we did. This is VERY important. In future emails exclusive to Helpful Dentist Insiders I will share with you the techniques that work best for me and the ones to avoid.
Total time for calcified endo, post, pin, prep, impression, temp: 2h
Lunch 30 mins for assistant #1
If working with 2 assistants in an office, STAGGER their LUNCHES so you can always absorb another emergency patient, should they come in.
Emergency Patient #3 – 30 mins
I do a hygiene check and see another emergency pt. 30 mins in 2nd column Broken premolar. Discuss large filling versus crown. Pt books crown for tomorrow w/ my partner since I didn’t have any openings.
Assistant #2 forgot to take the BW I want, and only took a PA. Have to have a talk with the assistant after the pt leaves. Two always:
(1) ALWAYS talk to the assistant or hygiene when ALONE and NOT in front of a patient
(2) Always BW + PA. Not only PA.
Next Pt: 6 anterior crown preps. Booked 2h:
Pt WAS going to do 6 crown preps, but he sat down and told me he changed his mind and decided to only do 4 crowns this year.
TIP: That’s fine. Agree with patients. If you don’t, they will find someone who will listen to them. If the procedure isn’t going to harm them, LISTEN to your patients, and help educate them to the ideal, but take their lead.
Talked to the pt about pros/cons. Let him know ideal is 6 but more importantly I let him know WHY. He wants to wait on the canines. In my mind I prepared these for the ideal guidance when we build the canines up. Fine, we do the 4. Big tip: Always keep the pt happy. Let him know not ideal (but can certainly make it work with a good lab.
We talk a little more and I find out his insurance re-sets in 1 month. We decide to prep 4 today and prep the 2 canines at the time of 4 crown insert + leave the canines in long-term temporaries (fast forward to the insert day: I cemented those canine temps w/ permanent cement) and I will re-fine the preps + impress the 2 canines in 1 month while having the new canine guidance protection for his new 4.
Do I typically do this? No. I can’t think of the last time I broke up an anterior case. But the timing works, he’s not aesthetically demanding, so I’m happy to work with him on a solution that works for both of us. Win-win.
Smoothed lower teeth w/ red diamond.
During the prep, one of the cracks in the tooth (important to have pre-op pictures + discussion w/ pt IN ADVANCE) had decay. Decay went to nerve in UL central. Took photo and showed pt. Had cracked tooth side by side pictures for him to see why.
Mid-prep. See the nerve?
Discussed options w/ pt. Used word like “Existing damage” “wear on teeth” “Crack in the tooth” and how the decay led to the nerve. Offered to do RCT on the spot. Pt said ok
Tip: pt’s HATE having to come back. Don’t push yourself to where the work suffers, but if you can help the patient the same day for unforeseen circumstances patients will remember that.
Placed RD. Did the RCT.
Post verification after burnoff.
Looks good! Sealed the post in
just kidding. Looked terrible. Would you want that in your mouth? I do a lot of endo, but something happened, and the GP got caught up in the burnoff. Unacceptable. I took the post out, removed the burnoff GP w/ my 35.04, and put a new GP down and re-did the obturation.
TIP: I do NOT care how busy or how behind you are. Always do quality work, and give pt’s your best effort.
Even if you lose money on that case, you will be fine.
Quality work never goes out of style.
So round two on the endo that is putting me behind schedule. Not ideal, or intended.
Doesn’t matter. My assistant is bringing back the next pt (single unit crown prep) and will get everything setup for me.
Tip: I let the endo patient know, “to squeeze you in and avoid having to come back I am going to go next door to anesthetize my next patient” – he is understanding and appreciates that.
PA looks better. After this master cone PA I trim off 0.5mm with a 15 blade of the GP (after this PA).
Final burnoff w/ post.
Placed cord. Used size 1 in this case.
For those interested, here are two great step-by-step guides on how to place posts:
Tip: when everything has gone well, consider taking the final endo PA AFTER the cord is placed when doing endo + crown prep at the same time. This lets the cord have more time to work for a better impression. Try to always have 1 thing working for you passively while you do another step.
Took Impression of 4 crowns. Custom tray for no compromise.
I tell the endo pt, we are squeezing you in with the root canal so you don’t have to come back. I am going to freeze my next patient and will be right back to finish your temporaries.
I go next door, freeze my next pt (also a crown prep) and come back and temporize.
I like to separate my temporaries in 2’s and really open the embrasures. That’s how I do it. The shrink wrap isn’t consistent w/ the periodontal management in my hands. It works well for others, not me.
Temporaries. I smoothed a bit more after this. Once cemented, I use some flowable to close the diastema and keep it one unit.
I section the temps and take off 1 by 1 on delivery day.
Tip: I tell the pt is to start using CHX 4 days before insert. The CHX rinse we sell does not stain teeth, thankfully.
If you want to see the final crowns for this case, the full details are here.
Total time booked for 6 preps 2h, actual time to finish talking to pt about treatment changes + 4 preps + 1 RCT w/ some complication management, 2h25min
NEXT PT: Crown prep lower left pre-molar, 60 mins
I’m running behind schedule now, but the assistants know their jobs, so the next pt was brought back on time, they took the matrix for the temporary, and scanned the upper jaw (used the Itero for this case to take the impressions). Basically the Assistant sets up the procedure to the point so I can WALK IN, GIVE LOCAL, come back and START DRILLING
See the large filling? That picture is up when the pt walks in the room.
Not my endo.
We take out the old core, place a post (IMPORTANT) and new buildup. Prep the tooth, place cord. Take the impression w/ the Itero (different case pictured here)
I don’t have any pictures from this case because a single-unit crown prep isn’t really a big deal. You get used to these and they don’t phase you.
Anyway, I take the impression w/ the Itero, then the assistant #2 tempories the pt and I do not come back in the room. I call this patient in the evening to check in on her and she’s doing great
NEXT PT: single unit implant placement #36, scheduled 90 mins
I did an upper left sinus lift on the pt 3-4 months ago, so I ask the assitant to take a PA of Q2 while he is freezing up to monitor healing. Looks great.
CBCT taken for his Q3 also included his Q2 implants, so checked that out earlier in the day. Bone is still maturing, but shows good healing.
Used the MD guide I’ve shown you guys in the past.
I’m a bit buccal here, so corrected that with the versah drills
Placed a 4.8x12mm WN straumann SLActive.
Pans sometimes make things look funny, so I like to also get a PA.
Previously I placed the other restored implants last year. Same thing. Pans make them look funny.
Straumann 4.8×10 RN (tissue level):
Straumann 4.1x14mm tissue level:
Getting back to the LL implant I’m placing, 4-0 PTFE sutures. Here is the clinical spacing. Will see pt in 1 week for wound check 20 mins in 2nd column and 2 week for suture removal 20 mins min column.
Did 2 hygiene checkups while assistnat was taking x-rays. Go over postop. assistant finishes that. Done case in about 45-50 mins.
For those who are interested, the full case including the sinus lift is here: https://www.facebook.com/groups/107090419924668/permalink/115917492375294/
Last pt: tx plan consult. 30 mins.
I did endo and tooth is still hurting a lot to biting. Suspect fracture. Endo looks great, and simple case. Referred pt to endodontist where I pay the consult for them to take a look. Do I do this often? No. Maybe 2x a year. Would I want the dentist to do that for me? Absolutely. I let the pt know “I care more about your long term health than what the insurance will cover, so let’s get a second opinion on this and I will take care of the consultation bill, so we can get to the bottom of this faster” – pt came in upset, but leaves knowing I care. Consult is $170, but better to get to the bottom of this fast. Scheduled 30 mins, done in 15. Going home a little early.
1 stage II surgery + implant impression
1 implant-crown insert
2 endos, single canal
7 crown preps (on 2 patients)
1 replacement filling as a courtesy
2 single-unit crown inserts
5-6 hygiene checks
1 NG insert (by assistant in 2nd column)
1 NG impression (different patient, by assistant)
3-4 random fillings
3 emergency exams (booked: 1 endo today, 1 endo next week, 1 crown tomorrow)
1 implant placement
a few other minor random visits + management of the staff, team, etc
Part 2 – How can you do this?
These probably aren’t the tips that were taught in dental school, but they work well for me, and I want you to have them too. Over the next few months I am going to touch on tips from all of these 6 points:
1) The team is well trained
They KNOW THEIR ROLES. Why? Because I am consistent w/ treatment so they know what their jobs are, even if I’m not there (ie. emergency exam is always a PA + BW on any posterior teeth). I know when to leave to do my hygiene checkups that the assistant is taking the x-ray for the endo. The assistants know what to do for a crown prep if i am running behind (take temporary matrix, place numbing jelly, etc). Remember, the bottom line is a well-trained team will outproduce a fast dentist any day of the week. Focus on training your team and everything else will come.
2) I use a LOT of photography
Patients understand what they can see. We spend less time talking, and they’re more informed. But the WAY YOU SPEAK and HOW YOU SAY THINGS MATTERS. A lot. I’ve put together tips that works best for me when communicating to patients about digital photography of their teeth.
3) I spend a LOT of time educating patients
You can’t walk into a $15,000 day. It takes time. At least 2 years of solid, consistent education to patients. But the good news is you have to go to work anyway, so why not spend time educating patients. The more a patient understands how they benefit from dentistry the more comprehensive your treatment will become. In the next few months, I am going to discuss in the email list how I educate my patients (click here to become a Helpful Dentist Insider to get all the tips that aren’t shared in the facebook group). I promise you, it’s a way more fun day to come to work when patients UNDERSTAND dentistry and WANT to be HEALTHY. I will show you the communication techniques, share the way I say things in videos, and go over the tools to help patients want comprehensive treatment instead of drill and fill.
4) I do a lot of single-unit crown preps
People think one can produce by doing 14-unit crown prep visits. Wrong! For a GP those patients come around very rarely. The patients that need 1-3 crowns is extremely common. I find my most productive days are actually when I have 5-6 crown inserts. Over the next few months, I am going to show you the tips to increase case acceptance for single and double-unit crowns prep visits.
5) I am reasonably proficient at molar endo
Every molar endo you do is an automatic crown. If you’ve able to take in emergency patients, get them out of pain, they become loyal patients. Both the facebook page + this list will focus on endo tips
6) The office + team is organized
Clinically everything is very organized. These cupboards are 3 steps from the main 2 dental operatories. The team knows where to get things, but more importantly (back to point #1), the team is WELL-TRAINED and the TEAM IS ORGANIZED.
7) This isn’t my first year
This comes with time. You get more experienced and will start to know clinically what you want to do before you begin treatment. Focus on quality and consistency FIRST. Your speed will come.
8) I focus on communication and relationship building
This is true for both the patients and the team. The better communicator you are, the more your patients and your team will trust you. Never violate this trust. Do what is best for the patient and be a good person.
Think of it this way. When your communication skills are high, and you have high case acceptance, you will become a BETTER CLINICAL DENTIST because you are taking on more cases, practicing more, and seeing more
I’m putting together a series of practice management tips, where I focus on communication, training a team, and the other aspects of dentistry that are not clinical, but will help dentists produce (help more people). These tips are separate to the facebook group and will only be shared with Helpful Dentist Insiders.
I buried a LOT of clinical tips throughout this email. Just so you know, future emails will be shorter and focus on 1 specific tip at a time. But I wanted to give you a taste of my world.
I hope this helps and shows you a day in my world. Please let me know what you liked and didn’t like, and most importantly, please sent me an email + let me know what topics in dentistry can I help you with.
Thanks for your time,
P.s. can you do me one favour? I’m having trouble spreading the words on alumni dental school class facebook groups. Adding dentists motivated to learn is the best way to improve the group’s quality for yourself. Could you please post a link to Pearls on your alumni dental school class FB group? Here is the URL to share: https://www.facebook.com/groups/DentalClinicalPearls/