Marrying Clinical Techniques and Teamwork

Ross W. Nash, DDS, and Debra Engelhardt-Nash, AA, BFA
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Ross W. Nash, DDS, and Debra Engelhardt-Nash, AA, BFA

Our editor-in-chief, Dr. Damon Adams, interviews Ross W. Nash, DDS, and Debra Engelhardt-Nash, AA, BFA, about their collaboration of clinical dentistry and practice management.

Tell us a little about your beginnings. When and how did you become involved in dentistry?
Ross: I graduated from North Carolina State University in 1970 with a bachelor of science degree in textile technology and went to work for DuPont in a nylon yarn manufacturing plant as a process engineer. In this role, I was able to learn a lot about how polymers (plastics) work. In 1972, I accepted a job with Ciba Geigy Chemical Company in Charlotte, NC, as a dye chemist (colorist) in the textile fiber division. It was my job to develop dye formulations for the customer to achieve specific colors on textile fabrics. I learned a lot about color (hue value, chroma, etc) and believe that the knowledge gained in both of these jobs helped me later when I became a dentist.

During that time, I became acquainted with dentists and discovered we had similar traits. They were technical, like me, but they were also involved in a “helping” profession and were able to directly improve the lives of others through their work. This attracted me to the profession, so I applied and was accepted at the University of North Carolina, School of Dentistry. I graduated in 1978 at the age of 31 years old.

Debra: I received my bachelor of fine arts degree from the University of California, Long Beach, and my teaching certificate from the University of Washington in Seattle. I was working as a high school fine arts instructor in the early 1970s when all the school bond issues were voted down and fine arts programs like drama and music were eliminated from public school curriculum.

When I was bemoaning my fate to my dentist, he said, “You would be great in a dental office.” I questioned his opinion, since my understanding of dentistry (at the time) was that it was all science and technology. I was all about art and humanities. He explained that what dental offices needed, in addition to excellent clinical skills, were team members who were excellent communicators and possessed strong people skills. My dentist loaned me a textbook on dental assisting and asked me to take the Myers-Briggs personality test.

I was trained to be a dental assistant and eventually moved to the business office of his practice. When he sold his practice and moved away, I worked for a dentist who was part of a 4-man “solo-group” practice and eventually became the administrator for the group, until I was recruited to become a consultant for a large dental consulting firm in 1982.

Ross, your practice and your teaching at the Nash Institute emphasizes cosmetic, aesthetic, and full-mouth rehabilitation dentistry. When did you start focusing on this type of dentistry?
Ross: In just a few short years after graduation, I grew a busy practice in Charlotte. I was providing preventive services, placing amalgam restorations, performing crown and bridge procedures, delivering dentures, and providing many other services in a normal general practice. I was enjoying my career.

But something happened at that time in our profession that changed the future of dentistry and me, personally. Light-cured composite resins came on the scene. There were no light-cured composites when I was in dental school. We had a few chemically cured materials that could be used for a few procedures. Class III composites could be placed after etching the enamel margins with 50% liquid phosphoric acid for 60 seconds and rinsing and drying to achieve the frosty, micromechanically retentive surface that was readily bonded to with a resin bonding agent. Dentin bonding was not performed, so the enamel bond and mechanical undercuts were expected to hold the restorations in place. Class IV restorations such as corners of incisors could be restored if a pin was placed. The pin would often need an opaque applied to hide it, and then the enamel etching and resin bonding process and composite placement were performed as above. There were no posterior composites, and Class V restorations were difficult because they were nearly all dentin. Beyond this, aesthetic and cosmetic dentistry was performed with porcelain jacket crowns and PFM crowns and bridges.

Figure 1. Bonding agent (ALL-BOND UNIVERSAL [BISCO Dental Products]) cured with LED curing light (bluephase 16i [Ivoclar Vivadent]). Figure 2. Lithium disilicate (IPS e.max [Ivoclar Vivadent]) veneers placed with a dual-cured luting composite (DUO-LINK UNIVERSAL [BISCO Dental Products]).
Figure 3. Finished lithium disilicate (IPS e.max) veneers. Figure 4. COMPONEER and SYNERGY Composite (Coltene).
Figure 5. COMPONEER placed with “Placer” instrument. Figure 6. COMPONEERS in place.

In these early days of my practice, the new light-cured composites changed everything. The materials could be hardened on command, rather than having to wait for the chemical cure. Manufacturers developed dentin, enamel, and incisal shades that would allow layering to mimic the look of natural teeth rather than just tooth-colored “fillings” as before. We eventually discovered that we could indeed bond to dentin as well as enamel. Posterior composites strong enough for occlusal function were produced. We found that we could use composite resin to cover the entire facial surface of the teeth, and direct composite resin veneers came into use.

My previous background in resins and colors helped me realize the huge potential with these materials. I wanted to learn all I could about them. The only way to do that at that time was to attend seminars provided mostly by manufacturers who wanted dentists to know about their new products. A few dental schools were providing courses on these innovative materials. I traveled wherever I could to attend seminars on these subjects. I studied and learned from many of the pioneers in this field of dentistry. It was my desire to know what materials I could use to provide our patients with the health and function we are responsible for as doctors and give the patients the aesthetics they were looking for.

We found that we could etch the internal surfaces of ceramic restorations and bond them to the teeth with composite resins, and our choices expanded further. Pressed and milled ceramic materials gave us enough strength for function. Aesthetic inlays, onlays, and crowns for posterior teeth entered into our routine treatment plans. Anterior aesthetics that challenge one to determine which teeth were natural or restored became commonplace. Thin veneers with no need for aggressive tooth reduction gave our patients options for elective cosmetic treatment. The introduction of lithium disilicate ceramic provided us with an even higher strength material that could be fabricated very thin for veneers and thicker for crowns and onlays (Figures 1 to 3).

Zirconia oxide, a ceramic whose strength is equivalent to many metals, gave us the opportunity to replace metal foundations for crowns and fixed bridges with a material that does not alter the aesthetic value of the layering porcelain. Requests from dentists to dental ceramists for porcelain- fused-to-zirconium oxide are commonplace today. Full-contour, monolithic zirconia oxide crowns with no layering porcelain can now be used on functional surfaces.

Figure 7. Excess facial sulcular depth. Figure 8. Diode laser (Picasso [AMD LASERS]).
Figure 9. Healed tissue after 2 weeks. Figure 10. Crowded anterior teeth.
Figure 11. Inman Aligner in place. Figure 12. Teeth aligned in just 6 weeks.

It seems each year brings us new and better materials and procedures that can enhance treatment outcomes. Assisted direct composite resin veneers (such as Coltene’s COMPONEERS) using premade facings have given us the ability to predictably create aesthetic direct veneers (Figures 4 to 6).

CAD/CAM technology is providing same-day services for many restorations. Diode lasers have become affordable for every dentist, and tissue treatments such as frenectomies, gingivectomies, and hemostasis can be performed predictably and easily (Figures 7 to 9). Minor tooth movement with removable appliances can be accomplished quickly to enhance aesthetic or cosmetic treatment and allow for more conservative tooth preparation (Figures 10 to 12). The list goes on and on.

Debra: Something also happened in practice management that dramatically changed the way dental offices operated and altered the manner in which dental teams performed their duties. Computerization created new practice dynamics. Dental software replaced manual scheduling, record keeping, and charting. Where there was once a clear distinction between front office and clinical duties for team members, there was now a blending of responsibilities and skills enhancing patient management. Cross-training was not optional—it was required. The auxiliary who could blend clinical experience with exceptional communication skills became the employee in demand.

Intraoral cameras were first introduced in the late 1980s and were met with great hesitation in the dental practice. Hygienists were using them as coat racks and not as they were intended—as patient education tools. Auxiliaries were resentful of the additional time required to give patients a “tour” of their mouth.

As this technology improved and became sleek, innovative, and more user-friendly, intraoral cameras became an expected diagnostic aid in modern dental offices.

Digital radiographs and paperless and chartless patient management are today’s standard of care. Patient education software such as CAESY (Patterson Dental) and Guru (Henry Schein) are commonly integrated into the patient experience. CAD/CAM technology, digitized impressions, and new anesthetic delivery systems all change the way the dental team performs today. And the clinical innovations in cosmetic, aesthetic, and conventional dentistry change the way all team members function. As techniques, materials, and technologies continue to expand and improve, dental personnel must continually increase their knowledge and clinical acumen.

It’s one thing to have the clinical aptitude and the latest in dental technology. It’s another skill set to communicate effectively with the patients so they understand and appreciate the quality of care your office can provide. The dental team (including the doctor) must have effective communication skills to help the patient choose the care that is being offered.

As treatment options expand and patient demand for cosmetic and aesthetic treatment increases, patients will be investing more in their dental care. The practice must be skilled in discussing financial arrangements and payment options, and understand the regulations in truth in lending guidelines. Working with outside financial resources such as CareCredit has become commonplace in today’s dental world. Many offices have a direct link on their website so prospective patients can explore financing options prior to their first visit. This option eases the conversation about payment plans. All team members must be trained to be comfortable in having treatment investment conversations.

In our courses and in-office team training, I discuss the 80/20 rule. Eighty percent of the reason why patients choose their care is based on the relationships they establish with the team and the doctor. Twenty percent is based on other factors such as facility, location, and insurance. We teach communication skills at all levels—from the moment the patient calls the office to the new patient consultation and exam and recare visits. Communication skills are more critical than ever before—at every level in the office. It was always an important component of my training, but now it is even more essential.

What are the benefits of working together in the practice as well as teaching together in the Institute?
Ross: I met Debra when I was attending an ADA annual meeting in Seattle. She was one of the presenters and was a host for another speaker. Debra was a dental practice business consultant and owned her own consulting company since 1985.

We fell in love and were married in 1995. After she moved from Seattle to Charlotte, I asked Debra to manage my practice. In the first year, she helped me computerize my practice, improved my systems and my team, and doubled my net income.
In the second year, we built a new office with 6 operatories and a lecture hall for seminars. Together, we created the Nash Institute for Dental Learning. We provide seminars for dentists and team members. I focus on clinical courses for direct, indirect, and full-mouth aesthetic and cosmetic dentistry. Debra teaches the practice management and team involvement aspects of this type of dentistry.

Figure 13. Debra lecturing at the Chicago Midwinter Meeting in 2015, where she received the Gordon Christensen Outstanding Lecturer Award.
Figure 14. Ross enjoying his work, teaching hands-on courses at the Nash Institute.
Figure 15. Patient relationship management system (Solutionreach [Solutionreach]).

The Nash Institute expanded in 2005. We moved to a larger facility with more teaching space and began offering courses for a larger number of participants. In 2007, we opened a general practice in Huntersville, NC, a suburb of Charlotte. In 2010, we closed the larger facility and relocated the Nash Institute next to our office in Huntersville. Today we have a beautiful lecture and teaching center along with 6 operatories for the dental practice and hands-on courses.

Even though she has other consulting clients, having Debra as my practice coordinator allows me to concentrate on treating our patients with the latest state-of-the-art care. She has taught our team to always go the extra mile in providing exceptional care for our patients. We maintain a full-time general practice focused on aesthetic and cosmetic dentistry, so we truly practice what we preach!

Debra: There are a number of factors that make working together successful. First, we understand the difference between being the leader and being the boss.

What do you mean by the difference between leader and boss?
Debra: The doctor should always be the leader. That means that he or she is the passionate, subjective thinker for the practice. The leader has a vision of his or her preferred future and will share that with employees. The leader inspires the team to act.

The boss is responsible for the objective thinking and the day-to-day operations of the practice. The boss is responsible for training and guiding the team (the resources) to move the practice toward the leader’s preferred future.

I have a workshop entitled, “For Better or for Work—A Spouse’s Survival Guide” to help spouses work together more effectively in the practice. Seventy percent of spouses work in the practice and another 12% have worked in the practice at one time. There is potential for a great partnership and also potential for professional and personal disaster. Doctor and spouse need to establish certain parameters or agreements before they choose to work together.

What other factors contribute to your working together effectively in the practice and in the teaching center?
Debra: We have an amazing team who understands our professional objectives and embraces our practice purpose. We do have an office manual (Bent Ericksen’s Practice Personnel Systems), but more importantly, we lead by example; we have 3 credos:

1. We hire grown-ups. We expect them to behave accordingly and self-manage their behavior on a daily basis.

2. We expect everyone to be flexible and “keep your knees bent.” We will try new products, new materials, new treatment modalities, and new systems. Resistance to change doesn’t work in our office.

3. You will get what you give. We ask a lot of our team. We ask them to be 110% focused on patient care while they are at work. But we understand they have lives outside of work and are sensitive to that. For example, we don’t want any of our team members to resent being at the office when his or her child is in a play at school or a sporting event. So we let them have that time away from the office. If there is a special event, or a family or personal need, we are sensitive to that.

And giving our team that type of flexibility generates more loyalty and a stronger work ethic.

Our team also attends our programs at the Nash Institute so they have a tremendous understanding of Ross’ clinical abilities and they are trained in the practice management style that we prefer. By training our own team, we know our patients will receive the quality of care to which we strive.

Third, I respect the executive privilege of the doctor. Ross’ strength of conviction in clinical excellence and patient care drives the practice as well as directs what we teach at the Nash Institute.

Ross: And we love what we do. I think that shows in all we do with our patients, our team, and our attendees at the Nash Institute.

How did you get where you are now with teaching, consulting, and lecturing?
Ross: I attended so many programs early in my career to learn new materials and techniques that a manufacturer’s representative noticed me and asked me to write an article for that company’s product. I learned very early the importance of taking photographs of all of my patients and creating step-by-step technique series (which were slides at the time). I have more than a million clinical slides and more than 10 million digital images in my library. Dental materials manufacturers and dental companies began asking to use my images in their instructional pamphlets and their advertising. The requests to present my work came after that.

One of the things instrumental in my profession was earning accredited Fellowship status in the American Academy of Cosmetic Dentistry. My affiliation with that organization has been an important part of my dental career. It helped me improve as a dentist and propelled my practice focus into cosmetic and aesthetic dentistry.

Debra: I had been consulting for about 2 years when one of my clients asked that I write an article for the Oregon Dental Society newsletter. A few doctors who read that article invited me to present programs for their study clubs. I wrote a few more articles that were published in major dental journals, and I began receiving invitations to speak at larger meetings. My first invitation to speak at the ADA meeting was in 1991, and I was over the moon! I have been very fortunate to travel throughout the United States and Europe presenting programs for dentists and their teams, while still consulting and working with Ross in the practice and the Nash Institute. To this day, when I am invited to speak for an organization or study club, I consider it a great honor and have a responsibility to merit their confidence (Figure 13).

I am a member of Speaking Consulting Network and a founding member of the National Academy of Dental Management Consultants, of which I am currently the vice president/president-elect. These are tremendous resources for me as a dental professional.

The Institute began in 1997 and is still in operation. Who attends your programs?
Ross: Our courses are said to be some of the most comprehensive and affordable courses in the world on aesthetic and cosmetic dentistry, practice management techniques, and team development. The participants are those dentists and team members who want to increase their treatment offerings to their patients in the areas of cosmetic and aesthetic services. This can be for the purpose of increasing their net income, improving their skills, or enhancing their professional rewards.

We offer a hands-on program series on each of the following topics: direct aesthetics, indirect aesthetics, and full-mouth aesthetic rehabilitation (Figure 14). Each course can be taken independent of the others, but together they form a complete study in aesthetic and cosmetic dentistry. The participants vary from the inexperienced to experienced clinicians who want to improve their clinical skills or develop more effective team skills.

Debra: The good news about dentistry is that it is an ever-changing profession. New techniques, technologies, and modalities will require the dental professional to constantly grow and learn in all phases of the dental practice.

Training will always be a requirement for the dentist and the dental team. There is a familiar saying, “If you’re not growing, you’re dying.” Learning is never over. Online learning through webinars and pre-taped training sessions has some merit, but we have found our participants appreciate the hands-on approach, the one-on-one attention they receive, and they learn from each other while they are attending the sessions together.

What do you think about the future of dentistry? What is making a difference in your practice?
Debra: I think dentistry has a bright future as well. I also think there will be trends that will require scrutiny and strategies, such as more corporate owned facilities and large group practices with multiple specialties. These aren’t bad or good—but the solo practitioner needs to stay abreast of what keeps him or her in a preferred niche position.

External marketing will become more important. It will be important for the doctor to become adept in social media and learn how it can help expose the practice to the community and the population it wants to reach. Services that keep the practice connected to patients such as Solutionreach (Solutionreach) (Figure 15), Demand Force, Lighthouse, and other patient contact systems will simplify the process.

Patients are learning about healthcare via the Internet and educating themselves on what they do and do not want. Their senses are highly acute when they come into the dental office. Most patients have done their homework.

Patients will expect the utilization of new technologies and treatment modalities. They will request one-visit crowns and digitized impressions. They will expect to be able to communicate with the practice via text and pay their bill online and have personal access to their treatment records. They will expect accurate and real-time information regarding insurance allowances.

It will be up to the dental team and the doctor to provide these features to the patient. And the importance of incomparable customer service skills at all levels will be at an all-time high.

Ross: It’s an exciting time to be a dentist! What the future of dentistry presents to us will help us be more effective for our patients. There is so much to offer. We can help increase people’s self-esteem by offering them improvements in their dental health and appearance. Aesthetic and cosmetic dentistry continues to be in demand. Materials and techniques are constantly improving and patient delivery systems are becoming computerized, making us more efficient. I think the future is bright for our profession.


Dr. Nash maintains a private practice in Huntersville, NC, where he focuses on aesthetic and cosmetic dental treatment. He is an accredited Fellow in the American Academy of Cosmetic Dentistry and a Diplomate for the American Board of Dental Aesthetics. He lectures internationally on subjects in aesthetic dentistry and has authored chapters in 2 dental textbooks. He is co-founder of the Nash Institute for Dental Learning in Huntersville and is a consultant for numerous dental products manufacturers. He can be reached at (704) 895-7660, via email at rosswnashdds@aol.com, or at the website thenashinstitute.com.

Disclosure: Dr. Nash reports no disclosures.

Ms. Engelhardt-Nash has been in dentistry and healthcare-related fields more than 30 years. She is a founding member and served 2 terms as president of the National Academy of Dental Management Consultants. An active member of the American Dental Assistants Association (ADAA), she also serves on the board of the ADAA Foundation. She is also a member of the American Academy of Dental Practice Administration and a Fellow in the International Academy of Dental Facial Esthetics. She also serves on the Practice Management Advisory Board for the ADA. She has been listed in Dentistry Today as a Leader in Continuing Education and Dental Consulting since 2001. In 2008, she received the Kay Moser Distinguished Service Award given by the ADAA—it is their highest honor. In 2014, she was named one of the Top 25 Women in Dentistry by Dental Products Report and was also the recipient of the Gordon Christensen Speaking Award in 2015. She can be reached at (704) 895-7660, via debraengelhardtnash.com, or via email at debra@debraengelhardtnash.com.

Disclosure: Ms. Engelhardt-Nash reports no disclosures.