This section is to provide helpful information and commentary for dental students. The goal is to help students get a more complete education IN dental school, and to provide some awareness as to what life may be like AFTER dental school.
Your Biggest Fear
You are at THE pivotal point in your dental career – as you build toward graduation you must think about how confident you’ll be AT graduation. Your confidence will be based not on wishful thinking or on doing what you are asked to do in the program, but on how many procedures you have done ON patients, how much attention you pay to EVERY detail of what you do on patients, AND on knowing the fundamental principles that differentiate between good dentistry and dentistry that is DOOMED to fail.
Ultimately, your success as a dentist is determined by how much you CARE!
By “success” above, I DON’T mean financial success. I mean whether or not the procedures you do SUCCESSFULLY solve the patient’s problems, and meet their needs long term. That is, after all, our job.
Our “job” is NOT to establish a practice where we have lots of patients and our staff gets well paid and we take home a nice profit at the end of every month. It’s fine if we do these things, but it is a secondary concern.
True, we can’t help our patients if we don’t have a working and profitable practice from which to do so, but that is the MEANS, not the END.
As students you are trained to pay attention to the details, because it is the small details that determine clinical sucess or failure. Even a .1 mm mistake can cause premature failure of our work for the patient.
If you truly UNDERSTAND how small errors can compromise life expectancy of our work, AND you care to do your best for each patient, the potential is there to do good dentistry, and to do it for the rest of your career.
If you do NOT have a profound understanding of failing errors, even if you care, you may be able to do good work by rote once you’re in private practice – but you can expect the quality of your work to degrade over the years.
I once worked with a practicing dentist who was running a “successful” office for 25 years. But he was not HAPPY in his practice. It turned out it was because he didn’t KNOW if he was doing good work for his patients. He simply had no ability to judge – no landmarks or standards to use to evaluate his work – but since he CARED, he felt bad, in a way that he didn’t fully understand. As we worked together and he started to SEE more because he knew what to look for, and his skills improved, he became far happier and started enjoying his practice again, AND started teaching part-time at a dental school!
The last paragraph is a cautionary tale – we shall see if we can keep this from happening to you!
If you are afraid of ending up like the guy I described above, unhappy in your practice, there are TWO things you can do to avoid that:
- Really internalize a profound sense of how dentistry works, or
- Don’t care about your patients.
Are you shocked?! I sincerely hope so!
Last month I spent some time at three different dental laboratories video recording the cases that had been submitted from local dentists. I recorded impressions, stone models, and articulated sectioned and trimmed dies. I studied the work of about 50 practicing dentists. What I saw made it very clear that the skills of all of these dentists had degraded since graduation from school.
I can put this in perspective for you. I have been making videos to use in a program I’m designing to calibrate dental school faculty. I had made two videos already showing REJECTED clinical crown impressions taken by dental students where I was on the faculty. NONE of the impressions taken by the dentists practicing for 10-30 years were at the level of quality of the student work. Notably, the lab technician told me that few of their client dentists use impression cord when taking impressions! And they suspected that often the assistant takes the impressions, which is generally illegal.
Safety in your professional career comes from knowledge and caring.
What can you do?
As dental students you must realize first that your primary teachers are your patients. Faculty will help you with fundamentals and guide you, but it is the experience you can only get from doing complex procedures on PEOPLE that makes you who you are.
Most schools provide adequate access to the clinic so you can do many procedures on many patients, but you may have to supplement the patients available through the school with those you bring in from outside the school.
So, go out and get patients!
There are online sites, like Craigslist, where you can advertise free dental screenings done at the school Sunday afternoons. Arrange with the dean to have a junior faculty member assigned to cover the screening clinic. Make the deal that you have first choice to work on any patient that responds to your ad, and that the graduate prosthodontics department has second choice.
Find COMPLEX cases – like you will find in your practice. You can learn SO much more from a patient needing 6 crowns than one needing just one. If the school wants to assign you a patient who needs one filling, find a patient that needs 15!
Your School Patient Base
I was graduated from dental school in 1992. Of my class of 100 students, there were NONE that didn’t feel confident that they could practice independently right out the door! Nobody went to get more clinical experience in a GPR or AEGD program. 30 years later most graduates feel they need more. But this is not necessarily the case – if YOU take control of your patient base.
I have thought occasionally about publishing my patient treatment record from when I was a student. It provided me a great foundation from which to practice on my own, and the lessons I learned from my patients were lifetime lessons. Some of my student cases are shown in this site – see the DI case in Dentistry for Kids, the case illustrated in the chapter on Full Mouth Rehabilitation, and illustrations in the Chapter on Gold Onlays.
You can do interesting and complex cases in dental school as I did, but you need to exert yourself and GET the cases to do. It’s a once-in-a-lifetime opportunity – take advantage of it!
This Site Can Help You
There are myriad patient situations discussed and illustrated that are far more personally presented than for a text book. This is more of a memoir than a textbook – but written for the general public primarily.
What the general public understands about dentistry you need to understand too.
If patients realize that not all dentists care to do adequate work, you need to realize that as well.
As the ideal or optimal approachs are discussed in this site, you need to know that many dentists will deliberately deviate from these for their own benefit.
I simply want you to NOT walk out of dental school and be blind-sided by your naivete, as I was.
Yes – I was.
I hasten to point out that I have known many incredible dentists in practice – many that I admire greatly. But you must know that not all are admirable.
I worked 9 months for a dentist who had just bought his first practice, while I was building my own office. He knew I was on the faculty of the school from which he was graduated. And yet, he allowed me to see his strategy for working with patients to maximize his own personal profit.
For example, he showed me how to place a Class V composite so it would fall out! He said you should tell the patient how difficult it is to restore these areas (for example small abfraction lesions) well, and if it does fall out he’ll try again at his cost – but if it fell out again he’d have to do a crown!
One day, on my day running the practice, he had a 25 year old guy come in for crowns on 12 and 13. I couldn’t see ANYTHING significantly wrong with the teeth! I asked the patient and he said it was because the composite kept falling out. Yep, from really small Class V’s. I did the Class V’s that are probably still there today and sent him home.
That night I got an irate call from the ower, but I was ready to be fired if he wanted. He didn’t, but I quit.
Just today I was teaching a student that shared one of his experiences shadowing a dentist in his practice. He observed that the dentist looked up the amount of money that was left on each patient’s insurance coverage for the year and tailored the treatment plan to match this amount!
Again – I do not mean to imply that dentists, taken as a whole, are less ethical than any other profession. But I am always saddened that I so often hear about dentists who seem to care more about themselves than their patients. There should be NO dentists like this in practice – ONE is too many!
Many of you will go to work for “Corporate Dentistry” – in fact this may be the most likely way to get a job with adequate and consistent pay to manage your student loans.
NOW – it might be a good idea for you to read now the chapter on The Business of Dentistry! It will provide some more perspective for what you are about to read.
Perhaps you have some sense of what dental practice IS or MAY BE about in the real world – maybe your father or your mother runs a practice. But they do not have $300,000 plus of student loans to pay back, and never did. You probably do.
In that chapter I outline what private practice entails, from a small sole practitioner office to multi dentist offices and multioffice practices. AND – there is the possibility of Corporate dentistry, either corporation owned group practices or offices managed by Dental Support Organizations …. I elaborate the possibilities in this arena carefully in that chapter – available to the public – because patients need to know something of the burden you work under too.
Corporate Dentistry, especially in DSO practices, will seem to make sense – you can earn $175,000 per year right out the door and there’s no other way to do that. Sound attractive? Well, the problem is that the contract you sign is about 200 pages. This is serious business and a contractual responsibility you must not take lightly – and I know of no 26 year old that has the experience to evaluate such a contract well. I talked with an attorney that helps dentists evaluate these contracts and he charges about $5000 for the service!
Depending on the corporation, you homework in this regard could save you a lot of heartache. You should know, however, that there are DSOs that really do have the best interests of the patients AND their providers at heart. And – the mandate of the DSO CAN allow for the provision of quality dentistry to those that would otherwise not be able to afford good care.
Still you may well spend 5 to 7 years doing corporate dentistry. I’ll just point out one thing here that you should know, of a practical nature.
Corporate or DSO dentistry is PRODUCTION based. In these larger practices there is more flexibility for learning on-the-job (some organizations have significant education programs), but your daily production is crucial to your success.
Now – how does one achieve high production?
- Efficient office layout, instrument management and dental assisting.
- Working multiple chairs
- Adequate anesthesia
- Patient comfort
- Communicate fully with patient ahead of appointment.
- . Excellent isolation
- Insightful scheduling
- Clear picture of strategies for preparation and restoration
- Taking TIME to evaluate every step of work and modifying if necessary so subsequent steps go more quickly
- Doing things again if necessary so that you don’t build more complexities in subsequent procedures
- Don’t cut corners!
- Appropriate impressions with clear margins and meaningful bite registrations where necessary.
Isn’t it interesting that sometimes you get things done faster by taking your time! Good judgment allows high production AND patient satisfaction both short and long-term.
How does one LEARN to “work fast”? Certainly NOT by cutting faster and with less awareness. It’s all about strategy, having a good sequence of steps to complete a procedure, AND knowing what it takes to get each step done well before proceeding to the next. An ideal Class II preparation can be done in less than 2 minutes using the same sequence of steps as a less experienced person would require a half hour. It’s a matter of COMPLETING each step before proceeding to the next.
Can you learn to work more efficiently and quickly in dental school? Yes – with determination and a good patient base. Then you can potentially thrive in DSO dentistry because you will NOT have to compromise your standards, or develop “standards” that are fictitious. You may even go to a school where they have a program where you can learn by working with an experienced DA. Make good use! And – why not cooperate with a fellow student that has no patient so you can practice working with an assistant?
Another thing you can do to increase your speed is practice preparations on a typodont. Once you get the strategy and flow, and finish each step completely with good judgment – your work should speed up many fold.
Clinical Questions to Ponder
- If you have trouble getting a good impression with VPS materials, will you get a better one digitally? The lab I was at last week hoped that they’d get better impressions when more dentists go digital/optical. I think this is a hope destined for disappointment. Another lab I visited receives many digital impressions from dentists online – and their experience is that most dentists don’t get a usable one for the first year!
The problem careless dentists have with impressions is their margins. If the margins are not clear of the tissue and DRY, an accurate or even meaningful impressions is impossible, no matter how done.
For a digital/optical impression the need for dryness is even greater because of the powder (IF a powder method is used) that is sprayed onto the preparation to increase reflectivity MUST be dry, all the way to the margin. Any crevicular fluid that is allowed to cross the margin will ruin the impression accuracy in that area.
2. When should you be sure NOT to use any ceramic on the entire occlusal surface of a crown? Consider a 17 year-old girl patient that grinds her teeth and needs a crown on #19. What would you do?
3. When I say “ceramic” what do you think I am talking about? Feldspathic porcelain? Lithium Disilicate? Zirconia? Yttria doped Zirconia? Did you know that the preparations for these may not be as similar as you were thinking? Did you know that many dentists just assume that no matter how thin the ceramic is even at the facial margin the technician can make a crown that looks good without compromising the periodontium? Do you think that is true? Is it more true for some ceramics than others?
4. What determines the abrasivity of the ceramic on the opposing tooth? Are there any ceramics that are significantly less abrasive than others? Have you seen research studies where measurements were done with small statistical errors and significant differences due to excellent experimental design?
5. Do you know how to adhesively bond a ceramic to tooth structure? Considering that many preparations in clinical practice are converging occlusally at 40 – 60 degrees, and many are SHORT – adhesive technology must be used at its best. And not all ceramics can be adhesively bonded the same way!
There are many more questions that I will ask you as time goes by, but for now let’s leave it here. If you write to me by email and have questions I may well address your generally helpful issues here so others can benefit.