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Post Removal & Discounts Post Removal with Ultrasonics & Why Discounts are Problematic
This episode opens with a news article discussion regarding strategies to use when interacting with special needs patients. Next, Ruddle presents techniques to remove posts utilizing ultrasonics. Then Ruddle and Lisette turn their focus to the business of dentistry and why giving discounts, although generous, can be problematic and detrimental to profitability. Finally, “after all is said and done, more is said than done”… That’s right, this show closes with some more Ruddle One-Liners, so stay tuned!
Show Content & Timecodes00:09 - INTRO: Special Needs Patients 06:32 - SEGMENT 1: Post Removal with Ultrasonics 32:53 - SEGMENT 2: Business of Dentistry - Discounts 46:38 - CLOSE: Ruddle One-Liners
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This transcript is made available by The Ruddle Show in an effort to share opinions and information, and as an added service. Since all show text has been transcribed by a third party, grammatical errors and/or misspellings may occur. As such, we encourage you to listen/watch the show whenever possible and use the transcript for your own general, personal information. Any reproduction of show content (visual, audio or written) is strictly forbidden.
INTRO: Special Needs Patients
Welcome to The Ruddle Show. I’m Lisette, and this is my dad, Cliff Ruddle. How are you doing today?
Did you have a good weekend?
Did you stay busy? [laughingly]
He’s always busy. What did you do?
Well, this weekend was really busy, all around the clock, because we’re getting ready to launch a Trifecta through Dentsply Sirona, and that means the files, the fabulous disinfection equipment and technology, and then, the filling side. So, all those are coming together. Each one’s like a project all by itself. But all together, yeah. It’s a really busy period, but it’s fun.
Okay. We’ll keep you updated on the ongoing projects throughout the season. But we wanted to start our show talking about an article that Dentistry Today News published about a month ago. And in it, they talk about strategies your office can take to improve the dental care for special-needs patients.
Now, maybe some of you already see special-needs patients and understand that they can pose their own set of challenges. But then, there’s other clinicians who might not fully understand that common cognitive disabilities, like autism and Down syndrome, can be detrimental to oral health. So, to start, what should clinicians be aware of regarding the oral health of special-needs patients?
I’ll probably get off script right now, but the first thing a healthcare professional should clearly analyze and evaluate is, “Am I – is my staff and our environment, are we able to see these people?” Because some countries like Australia and New Zealand actually give specialty training beyond dental school degrees, one-year programs, two-year programs, and even I found there’s a three-year program, just for special needs. So, it’s a whole thing, because it’s very complicated. Over in the United States, the best we can do is, we have the AEGD. That’s the Advanced Education for General Practitioners. There’s GPR programs. And there, you get to go into these environments, like they’re usually in hospitals. So, you see a lot of it. So, that’d be the first thing.
Do you even want to listen to what we’re saying and try to get trained up for it? Or maybe you’d be better off getting the patients where they’re used to getting maybe sedation, general anesthesia, things like that, to do the work. But if they are in your office, look for caries, look for periodontal disease. There’s a lot of grinding and clenching and chewing on things. And so, you can have mobility and fractured teeth. Dry mouth is normal in a lot of these conditions. And of course, it’s exacerbated by medications they’re frequently on. And these medications just pronounce xerostomia. So, be sure when you take them on, you realize there’s a medical component, besides the syndrome itself.
And I think I should say – everybody knows what “special needs” is, probably. But it’s really intellectual disabilities, and it’s further, medical problems, physical issues, and psychiatric issues. So, it's a whole thing you’re taking on. The dentistry is what you’re good at. So, mainly, we have to make a decision, do we really want to take these on?
Okay. Well, I think that maybe understanding some of the issues goes a long way to sort of making the experience better for everyone.
Teaching special-needs patients how to take care of their teeth maybe is a good place to start. And in the article, they suggest posting a chart in their bathroom, so that they can actually see the steps. Because visual learning is how they learn best. So, if they’re able to see the steps to follow, that’s helpful. Also, we have to remember that caregivers are usually very involved with their oral healthcare. So, the caregiver should also be well educated in good oral hygiene. But also --
-- the article pointed out that – and I thought this was very interesting, that teledentistry could be helpful, dealing with special-needs patients.
So, why don’t you explain that?
Well, we just found another use for teledentistry, didn’t we? We’ve talked about it several times on the shows over the seasons. Teledentistry is a chance for you to maybe, say, Zoom, if you will, and meet your potential client, your patient. And they might be accompanied on the other side with a caregiver that you talked about. But without your mask and your helmet and your garb and all your PPE stuff, it’s an opportunity to meet them in a much more casual manner, where it’s less threatening and intimidating. And then, try to make a connection, a human connection of any kind.
Find a little commonality, you know, in their world. And then, let’s talk about the stuff they love to talk about. They can even bring something in. They could bring in a stuffed animal, or maybe they love to play tennis. They could bring in a tennis ball. Tell them, “We’ll bounce the ball a couple times, when I see you. Be ready to bounce the ball!” So, they’re already looking forward to it. And then, back to your caregiver thing. I think the caregiver needs to be on the Zoom call, because they’re gonna make it work.
My connection’s very brief, very short, but they have hours or days to keep telling the patient, “All right, get to see Dr. Ruddle! We’re gonna go to the dentist! You’re gonna bounce the tennis ball!” [animatedly] They’re already getting into an atmosphere or a mood or maybe a place, mentally, where you can do your work.
Okay. Some great information. And we’ll gonna talk in our show, later, when we talk about actually a whole different topic -- we’re gonna talk about concierge dentistry. And maybe we’ll also see, when we talk about that, how that could also maybe be good for special-needs patients. So, stay tuned, and let’s get on with the show.
SEGMENT 1: Post Removal with Ultrasonics
Today, the assignment is post removal. And when I first started to build the lecture, my family crushed me down like a ton of bricks, because it was going to be like about a two-hour presentation. So, this is gonna be about 20 minutes. It’ll move fast, and it’s gonna talk about the ultrasonic option. Because there’s other ways to get posts out, when ultrasonics fails. And from experience, I can tell you that ultrasonics does not eliminate all posts from all teeth at all times. So, we need to have always a few more ideas in our bag of tricks to better serve our patients. So, let’s look at the ultrasonic option.
Well, first of all, let’s talk a little bit about the concepts of what we’re going to be doing. Usually, teeth that have posts, we can imagine there’s a core. The core could be amalgam, it could be cements, it could be adhesion dentistry composites. We have luting agents. And of course, as the generations have unfolded, the luting agents have become quite retentive. That means, for the guy that – and gal that’s doing retreatment, we as dentists, then, we’re gonna have a bigger assignment with the fourth, fifth, and sixth generation. Some of it’s like Geristore stuff. It’s gonna really hold those posts inside the teeth.
Another thing I really want to stress on your x-rays is, I want you to see the length of the post. I want you to see the diameter of the post. And I want you to see the direction, because the direction can be very deceiving. If a post is starting to deviate from the long axis of the actual canal that it was placed in, then sometimes, if it’s in the primary beam or away, it can look centered, but in another angle, it can be badly off axis. And that means a weaker root, already. So, these are the things I really want you to start thinking about. Anticipate maybe crown removal, anticipate core removal. And then, let’s fully expose the post.
And then, let’s further understand the luting agents. We’ll have another – they’re another factor that will determine quick and successful and easy removal. Well, we have the classic post I just showed you. Cast gold post is done quite a bit in the Santa Barbara area, by prosthodontists. It’s a superb post when properly done. It takes the shape of the canal. I like that. We don’t have an optimally prepared canal, and then put a post drill in an optimally prepared canal and make the canal bigger. That weakens the root, and it delivers stresses at the base of that post, oftentimes. So, cast gold.
Well, the other one is the very retentive and threaded active post. And what you need to understand about the active post, it is the most retentive of all posts, but probably – this is a joke, now! It probably got its name from the service it delivered to the patient, the screw post. All right. So, again, these need to back out. They’re threaded. With ultrasonics, you can vibrate some of them loose. And in other shows I’ll tell you how to take out a lot of active threaded posts where the threads are deep in the dentin and ultrasonics isn’t working.
So, if you look at the tools, I already said, when you look at an x-ray, if you can imagine, in this x-ray, we might have seen a post. I’m just making this up. Well, I better start over, because it kept moving, didn’t it? So, if we have a post in here, and you imagine a Christmas tree head, look for what? The length of the post, the width of the post, and the direction of the post. And of course, by getting three angles – and if you have CBCT, there’s some artifacting with the metal.
But you’ll start – certainly see that view that you can’t see from conventional films. Magnification always helps. You – many years ago, we had the binocular tube for the assistant, and we had the oculars for the doctor. So, both people were operating under magnification and lighting. For some procedures that are grosser and bigger, like removing a post, sometimes we don’t need that. But the operator needs to see really well. So, put on your glasses, because I’ll show you where it really comes in handy. So, vision, x-rays, at least three films, get three angles, so you can see length, diameter, and direction.
And then, of course, some of the tools that are Hero Tools are the big ball. That’s the Endo One. These are ProUltra tips. They’re from Dentsply Sirona, internationally. And these tips – this is the Hero tooth – or this is a tip for the post. This – it’s got the ball. The ball’s gonna pound like a punching bag on the post. And you’re gonna work it high power, power boost. We’re gonna be over here. I’ll show that in a minute. After, though, you get through the crown, or you’ve taken the crown off, and the cores, you’re probably gonna use a chamber tip. It’s a stout tip. It’s pretty short, so it fits interocclusal, and it’s for blowing out cements, fragments of amalgam and alloy, and your restoratives, to free up the head of that post, so you can totally visualize it.
We’re not gonna be using these tips. They’re for other purposes. You’ve seen the shows, probably, so you can see other times we’ve used those for, like, broken instrument removal. So, your heroes are the one and the two. And you need a good generator. This is Satelec, private label for Dentsply Sirona. It’s probably one of the best generators in the world, and it has a – we could talk a lot about generators. But it has a lot of power, and it’s well known and respected internationally. So, you need a good generator.
And finally, the Stropko. You take your quick disconnect. Eliminate it. Take it out of your syringe, your triplex syringe, and this is the Stropko, this part right in here. This goes up in your handpiece, and it snaps in, quick-connect. And then, it has Luer lock threads, so you can put different cannula – different gauge cannula on the end, so when you push down the air, it doesn’t fly off like a bullet and put somebody’s eye out. So, these Luer lock threads retain the cannula, and you can blow air into these pulp chambers – the assistant does. As you’re working with [makes burring noise] ultrasonics, and the byproduct is gonna be dust and debris, she can blow that up into her hose. One hand’s got the Stropko, one hand’s got the high-speed suction, and we have vision that way. We have continuous vision.
So, those are your Hero tools. Oftentimes, when you’re doing retreatment – and 90 – over 90 percent of my practice was doing non-surgical and surgical retreatment. That means, out of every 1,000 patients I would see in any given period of time, 900 arrive already having endodontics performed. So, one thing you start to notice as a clinician that does a lot of retreatment is, usually there’s poor access. So, one thing to get a post out is to have great access. The old expression, “If you can see it, you can probably do it.”
So, let’s realize they didn’t even completely deroof. Now, maybe everything old is new again. When the people weren’t deroofing [laughs] in the ‘50s, ‘60s, ‘70s, and ‘80s, they were probably thinking, “Minimally invasive endodontics”! [animatedly] But when you’re doing retreatment, you really need access. So, let’s go in here and get good access. You’re gonna come in from the top, through the crown. You’ll go through the crown. If it’s aesthetically pleasing, biologically acceptable, ferrule effect, free gingival margin, everything’s healthy, and it fits well, you’ll go through the crown probably.
But always tell your patients, pretreatment, “The caveat is, you might need more access, and the crown might have to be sacrificed.” Plant those words pretreatment and pave your way for treatment plans for no surprises. All right. So, you’re going to tunnel in. And you’ll see, I will straighten up those line angles. I want you to completely free up the head of the post. And you’ll come in here at a high power. This is power boost. That is way [with great emphasis] too much power for almost everything Ruddle ever teaches! But the power boost is for post removal.
So, as you go up and down the exposed post and go circumferentially up and down, and what you’re gonna notice is, heat! The byproduct of ultrasonic energy is heat, and heat is transferred into the post, and it can transfer trans-dentally, out to thermocouples. And thermocouples have been placed on the outside of the root, and we can absolutely see that. So, the heat build-up can be -- in less than 10 seconds, you can get to temperatures that are starting to flirt with osteonecrosis. So, you gotta wick off the heat. That’s the whole point here. You gotta wick off the heat.
So, here we go. We’ll take a shot at it again. So, go around that post. Free it up. Make sure all the cement’s out of the line angles, that little crevicular area between the post and the axial wall. Understand heat’s gonna build up, so every now and on, nod to your assistant. She’ll come over with her high-speed suction. She’s got a triplex syringe, and ch, ch, ch, blow some water on it, cool it down. We wrote an article about thermal injury. And that thermal injury is because Al Gluskin sees a lot of lawsuits in North America, because people have got too much heat transfer, and the patient’s tooth has fallen out, because of osteonecrosis.
You might think that’s an exaggeration. Call Al Gluskin. There’s a lot of cases that get thermal injuries. Go to a lower power! You’re using a small tip. You don’t want it to break. And it’s axiomatic that apical to the post will be cement, and it could be brick hard. So, blow that out, and that is basically how we do it.
Now, I have a 10-minute rule, and I just made that up, but if I can’t get a post out in 10 minutes, I’m off to option 2. Okay? So – I just made it up. It might be 9 minutes, it might be 11, but I’m not doing this for 15 or 20. I’m not saying let’s provisionalize, dismiss, and then we’ll have him back for another two-hour visit of vibration! Feel the good vibes! No, it's not the music that we’re listening to when they come back. It’s the procedure we wanna finish when they come back. We don’t wanna be saddled with beating on the post endlessly. So, have a timeline. If the post is making progress, you see a little wiggle, you see a little bit of back-and-forth movement, and you’re at 9 or 10 minutes, stay the course.
But I’m just saying, if nothing’s moved in 10 minutes, do something different. Change your approach. The reason we hate stock posts, like ParaPosts -- they’re one of the most popular placed posts in the world -- is because you take a perfectly prepared, shaped canal that’s appropriate for the root that holds it, and then, you take a special post drill, and you take a perfect hole and make it bigger. And we get these shelves, right in here. And these shelves distribute loads that break and fracture roots. So, if you’re gonna use a stock post, chairside – I used to do this for decades, take a diamond – a big, coarse diamond, and just rough it in. Taper that post so it fits perfectly into your shaped canal and touches gutta-percha, confirm it with a radiograph, and cement it. All right.
So, low power for the small endo tips like the two, three, four, and on out, but on the big ball, the big one, we can operate over on power boost. So, let’s look at a case we’ve seen previously. I might’ve shown this about 35 weeks ago, actually, in terms of “Ruddle Show” chronological order. And I sold this off as a missed canal. This is an example of coronal disassembly. This could be an example of removal of core and post. This is an example of out with the gutta-percha – we could talk about gutta-percha removal. This is a case we could talk about the apical block, okay?
So, we have a lot [with emphasis] of different things, and that brings me to the thought, in retreatment, it’s never just one issue. You know, you’re always thinking chairside, “If I just get the post out, I’m home free!” But you gotta remember, apical to the post, there’s another material, gutta-percha, silver points, carriers, or paste fillers. Apical to that, if it’s short, anticipate a blocked canal. We talked about that on the last show. So, now you know how to do more of this stuff. We’ve talked about gutta-percha removal. We’re talking about post removal. We’ve talked about how to manage blocks. May your reach exceed your grasp. May you grow into a new range of cases to better serve your patients. How about that!
So, we’ll go through this quick. I can give a lecture, and I will, on this show, about coronal disassembly. Coronal disassembly isn’t sacrificing the restorative and throwing it in the wastebasket. Restorative disassembly means the idea is to remove the dentistry intact, with the concept that we’re going to replace it, at least for provisional basis, like six months, a year, maybe the rest of their life, but we’re gonna take the dentistry off. So, this bridge is coming off, because I have access. When you look at this tooth, it doesn’t look like any molar I’ve seen. It’s not just an average-looking molar.
I don’t know if you can see it, but I’m kinda seeing something right here. Well, this defies the rules of symmetry. The distance to the Cavosurface is not equal between the systems. So, I’m thinking probably even a missed canal. Let’s erase. So, you move it over, and with the bridge off, I’m isolated. Things are going pretty well now. You’ve got about 10, 15 minutes in, the bridge is off, it’s intact, nothing broke. The patient’s gonna be thrilled, because I already sold them that they might need a new bridge! And here’s our core. Well, if you really see the three posts, and you really see that there’s three posts, and you see on the x-ray that there’s three posts, then you’re wondering, what is all this? And it takes pulp to elaborate dentin.
So, if you think about pulpal development, if you think about tooth formation, usually, then, there might be something in here we should go chase. But first, let’s get this thing disassembled. The first section is buccal to lingual, okay? Right down to tooth structure, right down to tooth structure. Then, it’s central mesial. Run it out! And now, you got three areas to focus on. You’re simplifying. Always simplify. Now make your next cut. You know the cut. You’re gonna make it buccal to lingual. You’re gonna make it central to mesial.
And now, we’re gonna go till we find a different color! And if it’s the same color, all the way down, blue composite build-up, start brushing carefully as you get deeper, because anticipate there’s a pulpal floor! Pulpal floor. And just use your two. I said you could use the ProUltra number two, and you can go [makes burring sounds], get out on the leading edge. Don’t get up next to the post and start breaking up. You’ll break a lot of tips. In fact, the secret is, get out on these leading edges and blow it off, blow it off, blow it off. Work your way from the central area towards the post, towards the post. And thinner tips sometimes to go around this area, to completely expose the head of the post.
This is what I keep saying. Expose the post. Expose the post. Now that you got the post exposed, you could even go to an Endo three or four, and you can start getting down in here and undermining a little bit more cement, and you could run out the inner connector between the MB and the ML post. And that’s gonna just undermine cement retention and facilitate removal. How about that! You look here, and it looks a little funny right here on the wall, little bit of cement in there. So, let’s chase that out. But first, let’s get another look at how this works.
So, you’ll send a sinusoidal wave down through that metal tip, and you’ll get a lot of movement. And that movement is up against that post, and it’s just boom, boom, boom, boom, boom! If you’re a boxer, think of Muhammad Ali, and you’re throwing a series – a burst of punches, uppers. Okay. So, there was a canal. And that day, you can see we used unidirectional stops. I know you can’t see red on red, so we’ll just forget that. But anyway, we got the post out. These have been cleaned and shaped, and now we got this – this is your MB. This is your ML. And I’m gonna call this for fun, Ruddle language, ML2. Like an MB2 in a maxillary molar, that might be an ML2, okay? So, whatever.
But it’s a canal! It’s a system. And we can cut immediately right to the post-op. And it’s pretty fun. You know, you’re starting to have a pretty good day. I mean, this thing started about 8:00, the way I remember it, maybe about 7:30. And it was like, bingo, let’s get in on this, and let’s get that crown and bridge off, and let’s get that core out, and let’s get that core resected, and let’s free up those posts, and let’s knock those posts out. Now we got the gutta-percha out. And then, we used vertical condensation with the warm gutta-percha. In all the systems, use a little bit of solvent. I like to send my cases back to the general dentist really cleaned up and spiffy.
So, you can use a little solvent, like Xylol on a cotton pellet, and you can just wipe it across the floor. The gutta-percha will even shine a little bit. And then, I can provisionalize this, I can do a core build-up. It depends on who I’m working with. We had a show the other week where Lisette and I talked about, “Whose job is it [laughs]?” So, is it the restorative dentist? Is it Cliff Ruddle? Well, let’s just be on the same page, and then, it doesn’t matter who does it, to me, as long as it gets done. And we want to protect the endodontic seal as soon as possible.
And we’ll cut into the post-op, and you can see, you know, all that effort, because of concepts, because of old ideas, because of principles, because of working short, because of leaving pulpal stumps behind. And a lot of dentists go, “But it was a vital case. Those old pulp stumps, they should stay vital for the life of the patient!” Listen! As soon as you become God, and you can practice chairside, let me know. I’d like to come train with you. But I don’t know which pulp stumps are gonna break down. I don’t know which ones will stay there, resident to the tooth, and be nonreactive biologically over the life of the patient.
So, why don’t we just take everything out. Why don’t we quit fighting about this. Why don’t we just eliminate the root canal system, like the extraction. This cost hundreds and thousands of dollars, for the patient. Now fortunately, we’re saving their bridge. That went back on, provisionally. I’ll let the general dentist decide if they wanna make a new bridge or not, but I think it’s as – fitting as good as it did when they came in. So, probably with this result – and actually, this is a recall. You can see the lesion is completely healed in. So, isn’t that cool? So, millimeters do make a difference. About a millimeter too short, about a millimeter – about two millimeters short here, merging systems – merging systems, to about right in there. And then, on around the curve, this is the ML2! This is your ML2! It had its own apical, separate portal of exit.
For you surgeons, were you really going to come in from the buccal, lay a flap, tunnel through miles of bone? You would have beveled the root and seen the ML, the MB, and the distal, and you would’ve said, “My work is done.” You would’ve retro prep, retro filled, put the flap back in place, sutured, and been surprised it didn’t succeed. How many of you watching would’ve gone all the way on a second molar, clear over towards the lingual cortical plate, to get across that root end and get it beveled, and then, even then, you would’ve been corking an empty canal, hoping that you could incarcerate Avogadro’s number of microorganisms over the life of the patient. Not so predictable, is it?
So, it’s a call to do good work. It’s a call to be definitive. It’s a call to look at another post. So, let’s look at our last case, and then we’ll be done. I’m going to talk about the screw post, the active post, the fiber post – because we have to remove fiber posts. We won’t do that today, but those will be shows that are coming up. So, right now, look at this case. Again, appreciate everything. It’s provisionalized. The dentist cut the crown down and is waiting for the crown to come back from the laboratory, and the patient blew up. And they blew up, and it looks like this, when they come in.
So, they were waiting for a crown prep. They thought everything was [laughs] going fine. They went in, had some caries removal, had a build-up, got a provisional placed on, bye-bye. And when they went and left the office, they blew up. They exacerbated, and they are thrilled to be swollen. Come on! They’re not thrilled to be swollen. They’re very frustrated! Now they’ve been referred to me, and they’re going, ‘”What’s goin’ on around here!?” I said, “We’re gonna dance. I just learned how to – snap those fingers! Come on! Ruddle! Snap those fingers!” All right.
So, we have an asymmetrical lesion. We have a post, a pin. When we have an asymmetrical lesion, let’s appreciate the lesion’s form, adjacent to the portals of exit, POEs. LEOS, lesions of endodontic origin. There’s a relationship and an interconnection between the two. Also, there’s probably a missed canal, isn’t there? Because the distance from here to here and here to here is not equal, so – we had a show on the rules of symmetry. We had a show on the 14 ideas to find previously missed canals, calcified canals that are mineralized, stuff like that.
So, let’s get going. So, I took the post out. You can see that little point right in there, where it’s right in there! Bullseye! Okay? So, that’s the post out. But look at the distance from here to here and look at the distance from here – and I’m off the screen. It’s not even. So, take your bur in and start adjusting your access, tunneling carefully towards the lingual, to preserve maximum tooth structure. I made this tooth yellow, so we would feel really and joyful today, you know, yellows and reds and whites and pinks. It’s quite a beautiful day here in Santa Barbara. And if you tunnel on over, like I said, boom, you just fall into a big, putrescent canal.
Can you believe this? We’re gonna put a new crown on this tooth, and the dentist thinks it’s fine. You know, maybe the patient blew up – I’ll grant that. Maybe the patient blew up from the time of the provisional to the time, a few days after the visit. But do you think that all happened in that period of time? Come on! We’re not being good diagnosticians! Let’s really treat people! This should’ve been sent off for retreatment, and then do the crown! And look how happy the patient would be, if we lay it all out and treatment plan for no surprises.
So, if you come in here and get it done – I was just talking to my other daughter, that you rarely see, her name is Lori. That’s Lisette’s sister. And I said, “You know, I had to retreat” – so you’ll know, I did retreat this one. It comes in as an ugly one, because it’s like a classic box prep from the past, where this is the canal, and then here’s your root, like this. And they make a box – we talked about, you know, you hate the ledge up in the curve. Well, that’s a big shelf, or that’s a ledge. So, yeah. I did take out that gutta-percha and retreat it, because I don’t trust it.
And it’s got an asymmetrical lesion. Is the portal of exit coming off the lingual or the buccal? So, this is the lingual canal. This is lingual. I’m looking for a buccal. And I did find a buccal. And I shaped that. It has its own apical portal of – look carefully. What Lori and I talked about is right there! You can see a thin, white line – shoom! And the puff is at the end of that lateral canal. So, in fact, the POE – there’s two POEs. There’s two portals of exit on the buccal system. It’s not a buccal canal. It’s a buccal system! And does it matter? Of course, it matters!
When you look out at 15 years, notice how the bone’s filled in. Notice the apical repair. Notice that endodontics is a regenerative procedure. Okay. That’s a little lesson on posts. Obviously, we’ve talked about quite a few ideas in about 25 minutes. And listen carefully. You can apply these ultrasonic concepts to a myriad of clinical situations. So, I hope your post removal days have just begun. And for those of you who are a little intimidated, if you have good vision, you have some ultrasonic instruments, you have a generator, you can expand the level of care you provide your patients.
So, just in case you need more help, just in case you need a little bit more help, don’t be a stranger! Tens of thousands of people visit my website. That’s not “The Ruddle Show”. That’s the bank. The bank of where you have the PDFs, the articles, the videos, the tapes, and all that stuff. Well, this is old-fashioned. So, this is online. You can look at this and acquire this online. It’s “Ruddle on Retreatment”. It was reviewed by Craig Baumgartner, one of the big giants in the field of endodontics, some years ago, and it was called absolutely worthy of dentists to look at. This was in the Journal of Endodontics. This was in our professional specialty journal.
So, you have me still present. Even in my absence, you can continue to keep learning. And of course, on these DVDs, we spend about an hour, hour and a half, on post removal, ultrasonic options. So, there’s more there. So, best wishes, and good luck!
SEGMENT 2: Business of Dentistry - Discounts
Today, we wanted to return our discussion back to the business of dentistry, this time, focusing on giving discounts. So, for example, say you want to give a discount to your friends, and you’re thinking that 10 percent sounds relatively harmless and would be a nice gesture. Or in some cultures, negotiating fees is routine, and it’s expected that the actual cost is going to be less than the quoted fee.
So, what if we told you, though, that by giving a 10-percent discount, you’d be giving up half your profits? Maybe then, that discount is not seeming so attractive. So, why don’t you explain?
Well, many years ago, I was taking a class. Ruddle does take classes and works on his game. I was taking a class, and they offered this thing called the “Kodak Study”. And it was done by Eastman Kodak, I believe in the ‘50s or ‘60s, but we’re not going to look it up.
We’re not going to look it up. But it’s a very old one. And as you know, Eastman Kodak’s not even in business anymore. Maybe it had something to do with what we’re talking about. Anyway, they did a study, and they basically said, and you can see it here. So, you don’t – if you don’t follow me perfectly, you can at least capture the board with your eyes. But they said that businesses that they studied in the U.S., small businesses, they usually operate at about 80 percent, 20 – 80, 20. 80 percent is the overhead, and the big 3 are staff, your mortgage or rent payment, and supplies, and then, the other 20 percent would be profitability.
Now, when I say “profitability,” the dentist still has to take that home, pay taxes, and there’s a whole bunch of other costs. But that’s what’s left for the doctor. So, it’s about 80, 20. You can massage the numbers behind me to make it fit your model precisely. Maybe you’re 60, 40. Maybe you’re an endodontist, might have a little lower overhead. But for dentistry, you have that big lab bill. So, it’s going to maybe be close to 80, 20. So, if it’s 80, 20, and you give a 10-percent discount that you talked about, then, guess what? $800 comes over to pay the big 3, $200 comes over for you to take home, and guess what?
Your expenses are still there. You’re still paying the ladies that run the office. You’re still paying the lab bills. You’re paying the mortgage, your rent payments, and you still buy supplies. It’s just locked in. So, that’s going to come out of your margin. And if you take 10 percent, 10 percent of 1,000 bucks is 100. And if you take 100 off of 200, whoa! Now you’re only making 100. So, really, you lost 50 percent by doing something as little as 10 percent. So, think about those discounts, because they have far-reaching and huge ramifications. I just did 10 percent. We could’ve done 15, that’s 150 bucks.
And then, I think you said, ‘Well, what if we did 20 percent?’ I mean, some dentists do 20 percent. Well, you’re basically paying the patient to come in and work on them!
And that’s okay. Because maybe you’re benevolent, and you’re kind, and you’re a philanthropist! So, you can do that. But if you’re gonna keep your doors open, then you gotta charge enough money to keep things going, so you can be there in the future, when they need you and arrive.
Well, definitely, I think we can all see a little bit clearer what a 10-percent discount actually represents. And from a patient’s perspective, 10 percent is not really that exciting a discount.
And, you know, it’s not very motivating.
And then, from a clinician’s perspective, if they’re giving up a large portion of their profits, that can’t be inspiring. So, obviously, we can’t be promiscuously handing out discounts. But in your opinion, are there situations in which discounts are warranted?
Absolutely. Discounts are warranted – this is all subjective. This is just Ruddle. I’ve been teaching for decades. So, sometimes I’m doing a teaching case, and I may say, “You know, we can just do this one on the house.” Because I’m gonna get – I mean, it’s gotta be an interesting case that’s no ho-hum. It’s gotta be something that’s really maybe challenging, it’ll push the staff, it’ll push Ruddle. And if we can pull it off, I mean, wow, I’ve learned something, and I’ve gotten better for the next patient. I might wanna do it with certain referrals.
I always divide referrals to A referrals, B referrals, C referrals, and D referrals. And I won’t define all these, but the A’s don’t even own files in their office. So, everything that they refer – they refer every endo case that they see. They don’t even do endo. So, if they’re sending me a lot of income per year – you can look at this as in a business model, you’re gonna treat certainly that dentist probably for free. And then, if they’re really a good office, they might be sending you an $80,000, $100,000 account a year, you might even treat some of their number-1 people that end up needing endodontics. So, I’ll do it for that. We didn’t get to family, but yeah. We throw family in there.
We throw staff in there. They get all the stuff for free. So, family, staff, and your best referrals, teaching cases. And then, sometimes we would do live demos. So, oftentimes, we put the word out around town, “Hey, we’re gonna do a live demo. We’re gonna get some dentists in from around the world, and they’re gonna come watch something. Do you have anything that needs to have endodontics, and they can’t afford it?” So, we might be doing a live demo on somebody who can’t afford it, and they get to have the endodontics, save their tooth. And then, we get to have a patient that’s more cooperative, because we’ll – we’ll be – we won’t be as efficient, because we’re taking pictures and talking to the dentists that are around, watching the procedure.
Okay. So, what can you say to a patient who’s asked for a discount or maybe a patient who keeps pressing for a discount, after you’ve already said “No, a discount can’t be offered at this time”?
Well, I think what we should do is be honest, and if we’re talking about this era as an example, it would be very easy to say, “You know, thanks for asking. I’ve been [laughs] trying to get discounts myself.”
But don’t make them wrong, and don’t make it a joke on them. But you might just say, “You’ve probably noticed, there’s a huge emphasis in medical and dental to be safe and be able to offer safe treatment. And so, because of that, we’re wearing a lot of stuff that we didn’t used to wear. And so, you have all your PPE expenses. There’s more time to turn a room over. We might not overlap patients in this era. We might have to see them more – we see fewer patients, less income.”
So, I think you – you don’t cry and whine about that, but you just mentioned it’s a big factor, and it’s a big hidden cost that, right now, insurances aren’t absorbing it. Patients don’t want to absorb it. And doctors don’t want to absorb it, but we are absorbing it. So, I would say – harp on that. Then, how about the technology? Turn around, and you can say, “You know, we invest a lot of money out of the margin”– this isn’t out of the 800 – it’s coming out of the doctor’s profit. We plow it back into maybe a microscope, X-Nav, CBCT, digital radiography” --
GentleWave, maybe. [laughs]
-- maybe. So, in other words, we’re trying to deliver optimal care, and to deliver it, then it requires best technologies that are relevant. And finally, “You know, Mary, I just sent my assistant and my front desk to a course, so that they can be training and continuing to learn.” So, we do a lot of – this is on CE. I go, I have to leave the office to not only give CE but to take CE. So, you want the patient to know that between the PPE environment internationally, between the technology, and then the training that’s incessant, and it’s annual, and it’s ongoing, and it never stops, that really you wanna deliver a high level of service, and discounts really don’t allow you to offer the service you would like to deliver.
Okay. Well, then, what else can you maybe offer them, that might be financially beneficial to them in some way, without giving them a discount? And this kinda makes me think of the concierge dentistry, which is interesting and is becoming more popular.
Maybe that – patients could find a way in that to save money.
You know, I really like this concierge model. In fact, your mother, Phyllis, is actually actively looking into this for her and I. And we belong to a tremendous medical – I don’t know, it’s called Sansum Clinic. People – they invented insulin, decades ago. So, people pilgrim in from all over the world, literally, to come here to get insulin and diabetic conditions treated. So, I’ve called there a couple times and either talked to a machine, or I was told the doctor would call back, and they didn’t – and I’m off on a tangent. But the point is, to me, I want immediate interaction. I want to be able to talk to a live voice. And I want to be able to maybe even get to the doctor through either Zoom or a phone call.
So, I think, for a concierge service could just be the availability for those patients who have questions and concerns, and they want a high level of care. So, it would be a membership. It would be something that a dental office would decide on, based on their overhead and everything, what they could offer. It would be an annual fee the patient would pay, and it would go towards the service they’re looking for.
And I guess that once they pay the annual fee, and then they’re coming in for their teeth cleanings and their check-ups, you wouldn’t even have to discuss the finances at that point, because it’s already handled.
So, that actually – then you wouldn’t even have to be talking about discounts. So, that would be helpful.
Well, you have quite a list of what some dentists are doing in their concierge packages. I was kind of shocked. But maybe – I think the audience could benefit.
Yeah. I did go online, and I looked up some various concierge dentistry plans that different offices were offering. And for the most part, they were similar. There was some differences. Some I noticed were way more mobile and would actually come to your home more.
And they – they had some kind of mobile set-up, which I don’t fully understand. But anyway, here’s --
Just think of cleaning out your Suburban and turnin’ it into an operatory. [laughs]
-- [laughs] so – but a typical concierge plan might include the following: a comprehensive exam for new patients, 2 professional cleanings and 2 periodic exams per year, an emergency exam if needed, a full-mouth series of x-rays every 5 years, 1 set of bitewing x-rays per year, 2 fluoride treatments per year if needed, and then, this was interesting, 15 percent off any other dental treatment they have done within that year, with no limit on how much dentistry can be received. So, I guess if you have cavities, maybe, then, you get a discount on that. Like, it – I mean, obviously, this type of thing seems more tailored to general dentists.
I don’t really see how an endodontist could have a concierge plan [laughs]. But --
Well, to me, I remember a dear friend of mine in Oklahoma, and he had a heart problem. And we’d be traveling like through Latin America or Russia or China, and a few times, he actually texted his physician. And then, they arranged phone time within, like, moments, and he personally talked to his doctor about what was maybe going on or what he could be doing. And then, the other thing is, this doctor, because he’s a physician, can facilitate maybe meds that might be needed in another country. So, sometimes this service really helps you get the service immediately. And then, there’s the reassurances that they’re as close as the phone.
I think this could be financially beneficial for everyone involved. I mean, from the dentist’s perspective, you know, there might be people that don’t use all of their – the things they can do, during the year. So, they might end up actually making extra money. Patients, maybe, that tend to have a lot of dental problems, they actually might be saving money with a plan like this. Like, for me, it seems like I always get a cavity, and I don’t know why, because I – I really try hard to take care of my teeth. But the 15 percent off any other dental stuff, that would probably apply to me. So, that could be good.
Well, for me, as endodontist, I’m more interested in offering a premium service, a high level of personalized care, than the discount part. So, for me, maybe I could offer, if I was gonna entertain this, availability and be there immediately to answer concerns and questions and reassure, and then, to make scheduling as possible, but not so much as the discount side, but have an annual fee, if they just wanna be tied into Ruddle.
I think the goal might be to have your office be so nice and such great technology and such great service that the people actually say they wanna pay more [laughs].
Sometimes they do [laughs].
So, I think you have a quote to share with us by Karen Salmansohn, who’s an author and a self-help coach. But what – what is that quote?
Well, she said, “If you realized what you were worth – so, if you realized what you were really worth, you wouldn’t be giving discounts.” [laughs]
[laughs] All right. Well, thank you for all the useful information. And that’s the end of the segment.
CLOSE: Ruddle One-Liners
Okay. So, we’re going to close the show with a few more Ruddle One-Liners. And we did a segment – this segment last season, and if you remember, it’s things my dad says, not necessarily that he’s invented in his head, but maybe he’s heard them or read them. And they had an impact on him, and he tends to say them a lot. So, I’m going start. I’m going say what they are, and then, you’re gonna maybe comment on it a little bit.
So, here’s the first one. “After all is said and done, more is said than done.”
Well, that’s probably one of my favorites. I’m in R&D. And I’ve been inventing for many, many decades. And I just think of so many meetings that are international meetings, where you’ll have five engineers, three salespeople, a CEO, somebody else, and you’re brainstorming. You might have that Zoom meeting for one month, and it might just keep going repeat, repeat, and you’re talking, and all of a sudden, I’ll look at another clinician, and we’ll go, “We’ve been over this, like 10 times.”
So, I want us to just get that first step, like, let’s go! [laughs] Let’s quit talking about it, and let’s do it!
Time for some action? [laughs]
Okay. This one I really like. That’s why I’m jumping down on the list a little bit, because I love this one. And this is something you used to always tell me when I was a kid, when I would be complaining about how much I had to do. And just to understand this, it’s also helpful to know that we also spent almost every weekend gardening, all weekend, with you [laughingly] and using a wheelbarrow [laughs].
So, here is this one. “You loaded your wheelbarrow. Now you have to push it.” [laughs]
Well, I learned that one – that’s my own quote. I used to work on construction, as you know, in the Bay Area, Berkeley. And I worked for a big construction company, and our leader was affectionately called “The Old Man.” And he was watching me carry mud – mud is concrete – in a wheelbarrow, because you could pipe it in, chute it in through a flexible big tube. You could – sometimes, you had to wheelbarrow it in. And so, I tended to want to to take less trips. So, I had my wheelbarrow pretty full of concrete that’s really heavy. And I learned that maybe a little less is better, because you don’t want to lose a load. I lost a couple loads --
-- and I got laughed at so much. So, I learned in life, you know, maybe an extra trip or two and not having a spill is better than fewer trips and a couple spills.
Yeah. I can’t say this one to my kids, because I don’t even know if they know what a wheelbarrow is. I don’t think I’ve personally [with emphasis] seen a wheelbarrow in maybe a couple decades. Okay [laughs].
Maybe you should get one on the show!
[laughs] Okay. Here’s the next one. “People like people like themselves.”
Well, when I was growing up, it was called “Birds of a feather flock together”, right? But it’s probably a more modern expression, “People like people like themselves.” So, I always try to make that human connection real quick. We do this perfectly as dentists. Oh, they do this wonderful! But like, I’ll see a patient, a big, strapping guy, and I go, “God, did you ever play ball? You look like you might’ve been a ball player.” And then, we get to was it football or basketball, connection. Maybe a woman, “Oh, gosh, you’re an English teacher. I have a – I – my daughter was very good in English.”
Anyway, make all these little – went skiing, you play ball, you go to church, you – anyway, all those little connections really help. And so --
Yeah. We actually kind of brought this up, developing the connection, in our special-needs segment that we did for the opener. I think that when you talk to somebody, almost anybody, you can always find something that you both --
-- have some commonality in.
No, stop. That was perfect. That’s critical when you’re a doctor treating a patient. You gotta find – you gotta find something [with emphasis], out of all the stuff that’s going on, quick question, get right to it, funnel glass right in, find something, and then people start to relax.
Mm-hmm. Okay. And this will probably be the last one. “Any request can be honored, negotiated, or denied.”
Well, when I was younger, “Ruddle, would you do that?” “Yeah!” “Ruddle, can you do that?” “No problem! Would you like it in five minutes or an hour?” You know, the Marines said, “We do the difficult immediately. The impossible takes a little longer.” So, I used to come from you wanna help people. I was kinda raised, you always help. You wanna give to people. So, now, as I’ve gotten older, you can’t do everything. So, you can either – you might say, “Can you do it by Friday?” “I can’t do it by Friday, Lisa.” I’m negotiating. I’m negotiating. “How about Monday? Would Monday work for you?”
So, there’s an example where you needed it Friday but yeah. You’ve talked, you thought it over, can go Monday. So, honor, deny, or negotiate, or maybe you want this, and I want that, but maybe we can get something in the middle. Both of us are happy. So, try to work with people by realizing that little expression, “Honor, deny, or negotiate” and you’ll find common ground.
I guess this can get a little problematic if you’re the one asking the question, and you know it’s a question you probably shouldn’t ask. But you’re just thinking, “Well, what’s the worst that can happen? My request will be denied?” Well, maybe some – there are some things that maybe shouldn’t even be requested [laughs].
Well – well, okay. So, I’ll – here’s another one, right off – we never even talked about this. My mentor, Alvin Arlen Krakow, he’s passed away, I loved him like a second father, but he used to say, “Shame on you for asking.” No, “Shame on me for not answering, but double shame on you for asking.”
So, in other words, don’t – maybe the person shouldn’t even be asking somebody an awkward question that’s going to precipitate maybe a harsh answer.
[laughs] Okay. All right. Well, that’s our show for today. Hope you enjoyed it and see you next time on The Ruddle Show.
The content presented in this show is made available in an effort to share opinions and information. Note the opinions expressed by Dr. Cliff Ruddle are his opinions only and are based on over 40 years of endodontic practice and product development, direct personal observation, fellow colleague reports, and/or information gathered from online sources. Any opinions expressed by the hosts and/or guests reflect their opinions and are not necessarily the views of The Ruddle Show. While we have taken every precaution to ensure that the content of this material is both current and accurate, errors can occur. The Ruddle Show, Advanced Endodontics, and its hosts/guests assume no responsibility or liability for any errors or omissions. Any reproduction of show content is strictly forbidden.
DISCLOSURE: Please note that Dr. Ruddle has received royalties on and/or continues to receive royalties on those products he has designed and developed. A complete listing of those products may be found at www.endoruddle.com/inventions.
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