Dentistry's Orphan

Photo courtesy of Aesthetic Porcelain Studios, Inc, Los Angeles, Calif.

Please consider a simple, desperately needed, highly profitable procedure that may be the most neglected dental technique from among the vast panoply of contemporary oral health wonders. As I’ll demonstrate, I suspect that, when ideal systems are employed, this appliance’s profit potential triples that of the often exulted crown. But its fabrication requires little of the intensity demanded by fine  crown and bridge, and suffers none of the crown’s significant downside peril, such as a painful abscess requiring post-seated endodontics, or risking fracture or caries, resulting in ultimate failure and tooth loss. The procedure is also a life-changing blessing for many suffering dental patients.

As a bonus, I have included a simple demonstration of a basic business concept that every dentist who desires financial freedom must comprehend and frequently implement in order to determine the approximate profitability of any given procedure.

PUT UP YOUR GUARD

The procedure I am referring to may be a by-product of living in this so-called “age of anxiety.” Prevention Magazine’s 1996 Prevention Index Survey reported 73% of adults said they feel great stress on a weekly basis. On the other hand, maybe I’m finally beginning to grasp what dentistry is all about. Over a career spanning three decades, I’ve never seen so many patients who critically need custom-fabricated hard mouth guards as I have over the last few years.

Some definitive indications for mouth guard use—situations where they can serve to protect teeth and eliminate discomfort—include:

(1) TMJ Syndrome (by whichever of the 30 current definitions you prefer). This is so common, I see about 10 sufferers a week. Here’s my secret screening technique: I watch patients when they open their mouths. If, instead of opening on a undeviated vertical path, the mandible moves side-to-side, or cants hard left or right, I inquire, “How much trouble are you having with headaches?” They respond, “How did you know!?”

There’s a bit more to TMJ than this elementary observation; enough to fill volumes. But detailing definitive diagnosis and treatment is beyond the scope of this article. I also have no interest in entering the dialogue regarding whether TMJ is bite-related.  After 30 years of seeing pain, often of years duration, disappear—sometimes almost instantly—after inserting a properly adjusted hard mouth guard, to me the debate is moot. I know that conservative, completely reversible treatment of this debilitating malady dramatically enhances the quality of many patients’ lives. I’m honored to provide such valuable succor.

Following is a quick test to see if a splint will relieve TMJ symptoms. This test impresses patients and keeps me out of trouble. Have the patient quickly open his or her mouth in a straight line. If they suffer TMJ dysfunction, this hurts and the TMJ pops. Insert two tongue blades between their teeth, approximating the thickness of a splint. If the disc is recaptured when they again open and close, all pain and clicking will be completely stopped, and the prognosis for a splint is excellent. If pain and/or clicking still occur—which happens very infrequently—you have a viable TMJ surgery candidate that I would refer for treatment. A vital component of dental success and sanity is learning what one can’t do.

(2) Painful Cervical Abrasion and Abfraction Lesions. It’s easy to tell if these common and painful lesions are bite-related. Check the occlusion. I believe dentists will usually find the hardest contact is on the teeth with the deepest cervical lesions. (Such an observation should be considered a clue!)

There are many palliative ways to treat cervical sensitivity. The myriad number of such solutions indicates none of them are effective. (When something is efficacious, there need be only one technique.) If you wish to create missionaries among your patients, correct occlusal problems, then treat symptoms, and make it possible for suffering patients to enjoy sweet and cold things again. If they enjoy ice cream as much as I do, you’ll have created devotees for life.

(3) Extreme Wear and Fracturing of Teeth. I live in a rough and tumble rural area, with many people involved in a variety of agricultural and construction-related fields among my patients. These folks ingest more than a healthy mouthful of microscopic “grit” on a daily basis. This causes occlusal wear so severe it sometimes requires multiple endodontic treatments. The wear seems worse in the anterior region, where tooth structure loss destroys aesthetics. These folks develop a highly unaesthetic inverted smile line. Before corrective crowns, veneers, or bonding are attempted, the cause of the oral breakdown must be eliminated (bruxism), or extensive treatment is doomed to failure.

(4) Protection of Sophisticated Restorations. As a continuation of my last point, any patient with parafunctional oral habits treated with veneers, bonded inlays, etc, should wear a hard mouth guard. It’s a lot easier to make a mouth guard than to perfectly match 5-year-old veneers when the one on the central incisor chips.

MISSING OUT ON OPPORTUNITY

Dr. Gordon Christensen, who seems to know a lot about such matters, has been telling his massive and enthusiastic audiences for decades about the crucial need for mouth guards. No opinion is more respected than Dr. Christensen’s, so it is puzzling why so few dentists have acted upon his sagacious advice regarding this important subject. I can determine two primary reasons why this preeminent leader in our profession hasn’t gotten the response to his emphatic plea one might anticipate.

Reason 1. Many dentists don’t understand occlusion. I sadly believe this, as I’ve treated a lot of iatrogenic disease over the 30-year course of my career. Many patients suffer for years after a poorly done crown, restoration, or denture painfully retrudes their mandible upon closure. Within every crisis lies opportunity. The dentist who stops the almost daily pain is a hero.

It is not optional to understand occlusion. Dr. Peter Dawson, The Pankey Institute, the aforementioned Dr. Christensen, and others offer excellent courses on this foundational topic that most of us don’t comprehend when we leave dental school. Once occlusion is completely understood, consistently delivering superb dentistry of every ilk becomes a lot easier.

Reason 2. Dentists don’t know how to present this care, and don’t think it’s worth their time to fabricate mouth guards. Here, I reveal my system, and believe I can persuade the most obstinate dentist that this fine service can be performed quickly, simply, and (highly) profitably by one who understands occlusion.

SIMPLE, PROFITABLE SYSTEM FOR MOUTH GUARD FABRICATION

Diagnosis and treatment plan for a mouth guard are completed during the already scheduled recare or new patient examination. I demonstrate the specific indications for a mouth guard—showing patients such signs as wear facets, abfraction lesions, severe anterior wear causing cosmetic concerns, mobile or cracked teeth or fillings—on our intraoral camera. The need for treatment clearly established, and possible consequences of nontreatment explained, I display a sample mouth guard, and answer their questions. In our area, many insurance companies cover mouth guards.

The excellent study models and bites (centric and protrusive) needed to create a mouth guard are usually taken by my hygiene assistant that same day, should the patient wish. We charge a study model fee for this procedure. My in-house lab technician, Mr. Larry Robbins, who has been creating excellent removable dental appliances since 1963, fabricates the mouth guards.

Other than discussing the need and function of a mouth guard during already appointed exams, my total time involved in the entire process is 10 minutes, scheduled to refine the occlusion upon insertion. Because Larry is in our building, we schedule patients in our chair for 20 minutes with him before I see them. He does preliminary intraoral fit and occlusal adjustments. He’s so skilled at such modifications, I usually have about 5 minutes of my 10-minute appointment remaining for a quick cup of coffee. CAUTION: One must understand occlusion before he or she can fabricate an adequate mouth guard, or perform any other significant dental work.

My lab cost for this appliance is $65. The fee we charge (ADA code 9940) is $289. This means our office makes a net profit of $224. Since total doctor time involved is one sixth of an hour (10 minutes), hourly net is $1,344 (6 X $224). I know this rough calculation doesn’t include any overhead except the lab bill, and net will vary depending upon how efficiently one’s office is run and the level of skill one has obtained in mouth guard fabrication. However, for those not bothering to treat occlusal problems, these figures provide some real food for thought.

As a basis for comparison, let’s calculate similar rough net figures for a crown. For illustration purposes, assume a crown fee of $600 (I hear you guys on the coasts giggling) and a lab bill of $100. Crown net after lab is  $500. If 80 minutes of doctor time are required to prep and seat the restoration, the net per hour is $362 ($500/1.33 hours). The per-hour mouth guard net of $1,344 is 3.7 times greater or 370% of the per-hour crown net of $362. Please substitute your fee, lab bill, and scheduled time to personalize this comparison.

CONCLUSION

Do your practice, patients, and yourself a favor. Become a student of occlusion, as are all master dentists. When this knowledge has been achieved, you’ll begin to fabricate a minimum of two mouth quards a week. (The least behaviorly adept dentist can gain case acceptance for a simple, noninvasive technique that ends daily headaches for $289! These suffering folks spend that much a year on medications.)

Consider this: Helping patients with the previously delineated problems is our professional obligation! If a patient’s dentist won’t treat occlusal problems, who will?

Consider this: $289 X 2 per week X 50 weeks = $28,900 additional production/year, without increasing fixed overhead.

Consider this: Suffering patients are dramatically helped by this service, and the reputation of one’s practice and our profession is enhanced. Isn’t that nice?


Dr. Wilde is the author of over 100 published articles and five dental books, including Dentistry’s Future, A Prescription for Success, Wealth and Joy. To discuss issues with Dr. Wilde or to receive information about or place orders for books, call (217) 847-2816 or fax (217) 847-9922.