Communicating Shade to Labs

I used to just wrtie “A2″ in a box on a lab sheet and hope that the lab would figure it out.  That was pretty dumb.

Unfortunately (or fortunately) our teeth are not identical to the VITA shade guide tabs.  There is far more complexity that exists in our dentin and enamel, so if we are to hope to acheive a higer level of replication we must put in some more effort than just writing a letter and a number on a lab script.

The good news is that you don’t need a masters degree in the fine arts to be able to take a good shade.  Here are some simple steps I use:

(1) Buy a damn digital SLR camera with flash and macro lens

I promise you that getting a professional camera will bring you to another level of dentistry.  There are a number of reasons, which our friend, Dr. Albert Yoo, is writing about in this month’s issue of Dental Economics.  But for now let’s be concerned with the fact that shade communication is far better with a proper camera set up than with your smart phone.  Two popular palces to get the whole package are Lester Dine and PhotoMed.

(2) Pick a few shades that look good

Don’t just pick one shade for your photo; pick a few.  Chances are that there’s more than one shade tab that will offer insight into the teeth of interest.  Giving more than one tab will also give the lab technician some variety and the ability to compare elements of color between photographs.  Don’t forget to give the lab a stump shade (shade of the prepared tooth) if you are using all-ceramic restorations.

(3) Take a proper photograph with the shade tab

Make sure the tab identifier is visable (e.g. A2, C4, etc).  Make sure the tab is held at a similar orientation as the teeth of interest so that the light plays off of it similarly.  Take a few photographs under different lights and not just your treatment room.

The orientation of the shade tab is a bit off, thus giving us a reflection that is not present on the teeth of interest.  This photo isn't terrible, but we lose an opportunity communicate some information to the lab.

These photos are more accurate. We have good orientation of the tabs, we can see the tab identifiers, and the lab has two photos for comparison.

(4) There’s more than just shade to communicate

But of course we’re not ONLY interested in communicating shade, are we?  There is also characterization and texture; what are the nuances of how the shade is distributed on the surfaces and what tiny lumps and bumps are to be found?  For these bits I like to take an extreme close-up photo, which can really only be done with a camera with a proper macro lens.  This can be separate from your shade tab photos so you’ll have a free hand to use a cool toy like a contrastor.

The left lateral incisior will receive a veneer. Note all of the “personality” on the adjacent incisors. We have craze lines, small incisal chips, and other details that the lab technician can emulate. Bonus points for using a contrastor to black out the background and help show translucency.

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Here’s My Policy on Advertising on this Blog

Quite simply: I don’t allow advertising on The Curious Dentist.

I write this blog for fun, to keep in touch with people, to share content from my lectures, and to generate discussion with colleagues.  I do not write this blog to make money.  After some initial set up costs, this whole operation is fortunately not that expensive to keep running.  I sell an e-book (more on the way) that actually does pretty well but I only charge $9.99 for it.  That basically offsets the cost of keeping this ship afloat.

Viceroy-Dentist I am approached often by companies that want to put up an ad banner on this site.  I politely decline.  I’m not morally opposed to ads; I just want to keep this site visually clean.  If you look to the right hand side of the screen there are two banners.  One is for Dental Learning, which is an education company that I have written for in the past.  They also supply reciprocal links from their site back here, so that sounded reasonable to me.  The second banner is for Answers.com, where I an considered an “Expert Writer.”  I have written and number of articles there that are more geared towards patients than dentists.  There are many non-dentists that stumble upon this site so I figured I could show them over to Answers.com for information that is more appropriate for them.

I do occasionally mention product names here.  I have never been paid to do so nor will I in the future.  If I mention a product it’s because I dig it.  When I travel to conferences I will often post on our Facebook page and Twitter about products that I find interesting.  I am not paid to do that either.

I’m approached very, very often by companies that would like to write articles to promote their products and services.  No money would change hands, rather they supply content and get some exposure.  I politely refuse.  I’m not morally opposed to it; I've published a couple of these posts in the past and they just haven’t performed well.

There is new kid on the block called “native advertising.”  It’s like the situation I just described but money does change hands.  It’s a bit controversial because content and advertising should be kept separate if one hopes to maintain a shred of journalistic integrity.  I have been approached to do this as well and politely decline because I am morally opposed to it.  Here’s HBO TV show host John Oliver with his eloquent reasons for why you should also be concerned about native advertising:


I do think that there are ways to make this work but there has to be a more compelling reason to do it rather than just “A company approached me with a bag of money!”  For example, I am considering aligning with a student loan refinancing company who provides very low rates thanks to something called “peer lending.”  My initial investigations are promising.  If it all checks out, I would consider writing a few articles about student debt and refinancing with mentions to their service.  If you were to click on a link I provide in the article and then actually sign up for a refi, then I would get a flat finder’s fee.  I've thought long and hard about this.  It doesn't make my spidery insetting to get paid to help a company with a good idea get in touch with collages who may really need their services.

Is that advertising?  They aren't dictating content or frequency.  Each time I provide a link I would fully disclose that I am getting a finder’s fee.  It’s more like an affiliate agreement.  I feel okay about that but do you think it would taint our relationship?  Would it make you begin to doubt our blogger-reader trust?  Let me know what you think.

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Getting Paid On Time: Managing Accounts Receivable

My jaw hit the floor.

Last night I spoke with a friend who works as an associate in another practice.  She told me her office’s policy is to send patients to collections after 150 days.  One, hundred, and, fifty, days.

If you have a lazy collections protocol then two things will happen: (1) more money will slip through and ultimately not get collected, and (2) you’ll lose money by having to pay your team to chase down the delinquent payments.  All of this can be avoided by having a solid system in place for your team to collect money.  Here’s my flow chart:

Treatment Date: Your front desk asks for the fee or copayment, which has already been presented to the patient so that there is no surprise.  If the patient “forgot their checkbook,” then they are handed a stamped envelope containing the billing statement and asked to send it in when they get home.

14 Days: A friendly phone call to remind the patient that they were supposed to send in their check.  We remind them that we can also take a credit card payment.

30 Days: A friendly letter.  I’ve already written about how I’ve revamped my billing statement letter.  Make sure there aren’t any “aging columns” that suggest the patient can wait to pay the bill.

45 Days: A slightly more stern phone call.  At this point there really isn’t a reason for you to not have been paid for services rendered.  If the patient is experiencing financial hardships we can sign them up for Care Credit or work out some other arrangement.  If they’re not returning phone calls, start to get worried.

60 Days: It’s been two months since you provided care and you haven’t been paid.  A stern letter that hints at further action is mailed.

75 Days: A final phone call.  If the patient hasn’t been reached this entire time then you should be concerned that they are trying to dodge payment.

90 Days: A final letter that describes the collections process.

100 Days: Notify the collections agency of the delinquent account.

Each month I get a report from my office manager about our accounts receivable.  I want to know that she’s on top of it and to review any arrangements she’s made with patients.  What happens when I have to take a patient to court for collections?  Well I’m in the middle of that for the first time.  I’ll let you know how it goes…

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Depression and Dentistry

No doubt you've heard that dentists have the highest suicide rate of any profession.  Is that true?

Well before I address that, let’s talk briefly about depression.  Everyone gets a little down now and then; it’s a part of life.  The next level of depressive reaction is reached when that down feeling lingers for a few days to weeks to even a few months.  It’s temporary but the symptoms can be severe, including sleeplessness, irritability, and lack of enjoyment of normal activities.  Major depression is a longer lasting and more severe condition that can lead to suicidal idealization.  These depressive episodes are often triggered by a specific negative event (or series of events) or they can occur spontaneously.  Then there are the spectrum of depressive disorders (e.g. Bipolar Disorder) that affect fewer of us but can be devastating.

depressive experienced depressive reactions a couple of times in my life.  The first time was in my third year of dental school when I was falling behind in my clinical requirements.  Not only was I under significant pressure to catch up, I was wondering if I was cut out for this whole dentistry thing.  I was slow, disorganized, and afraid of hurting my patients.  I snapped out of it after a couple of months thanks to the support of my friends and family.  Since then I can only recall one other time a couple of years ago that I felt that same crushing bleakness.  It just feels like 100 pounds of sadness is sitting on your chest all day.  Fortunately my symptoms were not severe.  I was able to identify what was happening right away and I kept positive knowing that it would soon pass.  And it did.

But it doesn't pass for some of us.  So are dentists the profession most likely to take their own lives?  The research is a bit unclear, as this study points out.  Do a quick Google search on professions most likely to commit suicide and dentistry will appear usually in the top 3.  I believe it… we’re under a tremendous amount of stress.  Our work is physically demanding, patients can be unpleasant, and running a small business is scary at times.

I’ve personally known two dentists who have taken their own lives.  Both had apparently suffered from chronic depression that required medication, but no one knew about that until after they had left us.  I miss them.

If you even remotely suspect that a colleague may be battling depression, please reach out to them.  Take them aside as a friend and ask how they’re doing.  If it seems like they’re unable to handle it themselves then get them the help they need.  Your local dental society may also be able to help.  Dentists do suffer from depression more frequently than the general population, so let’s not let each other suffer alone.

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I Took a Patient to Court for Collections

A few months ago my office manager knocked on my door.  “Our collections attorney set a court date for the Johnsons.  He wants to know if you still want to pursue it.”

“Who the heck are the Johnsons?” I replied.

She told me I treated them back in 2012 and they never paid their bill.  After numerous ignored billing statements and voice mails, our  attorney was able to get a hold of them but they still refused to pay.  The only remaining tactic was to take them to small claims court.

“How much do they owe us?’ I asked as I read through the patient charts.

“About $280,” my office manager shrugged.

I raised an eyebrow.  Would it be worth it to close my office for a morning and show up in court for $280?  Surely that would a dumb business move.  I held my breath for a moment.  “Screw it… yes, I’ll be there.”

Court Date #1

I arrived at the small claims court with a neat folder of patient records and copies of insurance claims.  After rereading the Johnsons’ charts the day before, I was angry when the details of the case came to light.  I did a few composite fillings for Mr. Johnson and my partner did a post and core for Mrs. Johnson.  Then they disappeared without paying their copayments.  They never returned our calls or answered our letters for months and months.  What gives?

The judge announces our case and my attorney steps forward.  I hadn’t met him before but he’s done a great job handling the few collections accounts we’ve had over the years.  The Johnsons had both showed up and that was pretty darn awkward to see them in the flesh again.  We step out of the courtroom with them (they didn’t bring an attorney) to see if we can resolve the matter before being sworn in.  I then learned why they didn’t think they should pay the $280 that they were contractually obligated to pay my office.  This is fascinating:

Lame Reason #1: “No one explained to us what the $280 was for.”

Really?  Hmm… well maybe if you had bothered to return any of our phone calls or respond to our numerous letters, we would have been happy to explain what the bills were for.  And my front desk always gives patients a heads up on what their next visits will cost them and how their insurance benefits will work.

Lame Reason #2: “One of the teeth you filled needed a root canal and crown.”

At this point I produced my patient record, which clearly documented the story of the tooth in question.  # 3 had gross decay and I had excavated and placed IRM.  I had done this procedure a second time (at no charge) as the patient was feeling better but not 100%.  The next week I had called him at home to see if he was doing better and he stated he was.  On the third and final visit he agreed to have a final composite filling placed.  ON ALL THREE VISITS I had documented that “pt informed tooth may require further treatment in the future including but not limited to RCT and a crown.”  Booyah.

Lame Reason #3: “I didn’t think my copayment would be so much.”

This one was from his wife.  She said that my office manager had told her that she had great insurance and that the post and core (done by my partner) would not be a large out-of-pocket expense.  Then she got the bill for $60 (part of the total $280 that was owed) and she was upset.  Apparently she thought it wasn't going to be that much and therefore she didn't have to pay it, or something.  We tell patients ahead of time what their co-payments will be but every now and then a patient wants work done before the Estimation of Benefits comes back.  That’s fine, but they then lose the right to complain to us about how much they have to pay.  We estimate their co-payments to the best of our ability in those cases.  And here she was complaining that $60 was more than she thought it should be.  When I buy groceries and the total comes out to more than I thought it would be, I’m not allowed to pay what I feel like and walk out with the groceries.  That would be theft.

Lame Reason #4: “Another filling you did had to be redone by my new dentist.”

At this point Mr. Johnson produced a copy of his radiographs from his new dentist.  My attorney stepped in and said those aren't admissible in court.  The only person qualified  to read radio-graphs is a dentist and I was the only one there.  My attorney stated that they could request an adjournment to a future date so that they could produce an expert witness (dentist) to back up this claim.  So they decided to do that.

Court Date #2

We reconvene a couple of months later and I have to take another morning out of my office.  The Johnsons showed up but (surprise!) they couldn't get their new dentist to come in and testify on their behalf.  So we get sworn in by the judge and start the party.

My attorney asks me a series of questions that help me tell my side of the story.  Thanks to good record keeping, I’m able to explain the series of appointments and show the list of copayments that justify the $280.  Then the Johnsons present their case.  They run through the lame reasons I listed above and I shoot each one down.  The judge nods as I defend myself and it’s looking good for our side.

Then we get to the best part.  Apparently the Johnsons were counter-suing me for $4000 in grief and lost wages for tooth # 3 that needed an RCT.  Really?  REALLY?  Well I showed the judge the patient record which clearly explained that he was told that might happen and that I was trying to be conservative.  That was the last nail in that coffin for the judge.  She dismissed us and later sent notice that she had ruled in my favor.

Lessons Learned 

(1) The value of writing good notes in the patient record was reinforced BIG TIME after this adventure.  I don’t write long narratives but I do include those important details about treatment alternatives, patients understanding potential complications, patient refusals, and so on.

(2) In New York State, the defendant can be held accountable for collections agency/attorney’s fees as long as it was part of an office financial policy that the defendant has previously signed.  I have a clause in my Consent for Services that reads: “Patient is responsible for all fees accumulated if account is sent to collections.”  That means the Johnsons don’t just have to pay the $280 that they owe my practice, they also have to pay the $150 or so for my attorney’s fees.  Hooray for New York!

(3) Would I take another patient to court?  Maybe.  If I had a solid patient record and it was clear that the person was skipping out on the bill, then yes.  If there was some genuine misunderstanding, my notes weren’t great, and/or the disputed amount wasn’t very much, then I guess I wouldn’t.  I love my patients and the vast majority are sweet, honest people.  It would take a special kind of person for me to want to chase them down for money.  And it’s not really about the money, it’s about the principle.  Which leads me to…

(4) There were four other cases being heard that second court date that involved dentists sending their former patients to collections.  This is not an isolated incident.  And the dentists couldn’t show so the case got dismissed in the patient’s favor.  It bothers me that some people think they can skip out on paying the bill for services rendered.  And it bothers me that we just let it go.  I don’t have a good answer on how we can change the public’s perception of paying for dental services.  But in the mean time, maybe you’ll consider taking patients to court when appropriate.

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