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By John J. Stropko, DDS

More than six decades ago my incredible journey toward the pursuit of excellence in the dental profession began. Over the years I lived in five different locations and successfully started two restorative and three endodontic practices. Looking back now, I realize that success was achieved by constantly spending much time, money and effort on practice management, continuing education seminars and upgrading the office and staff.

But there were some “little things” we normally did without any extra effort and that possibly made a huge difference in the patient’s perspective of treatment received.

During my travels, I was fortunate to study under some of the great practitioners in the world. I spent time in their practices, and we often become close friends. One of my first mentors was L.D. Pankey. Dr. Pankey made presentations before numerous local, state, national and international dental groups, and he was best known for his seminars on “A Philosophy of the Practice of Dentistry.” One of Dr. Pankey’s most memorable quotes was, “Strive to be the best, because there are so few up there. But strive to be the best for the right reason, and that is to serve patients to the best of your ability.” The Pankey Institute was founded and opened doors to its first class in Miami in 1972 to teach a philosophy of dentistry that focused on saving teeth for a lifetime, as well as creating a patient-centered level of care. After several continuums at the Pankey Institute, what I learned about treating patients served as my guide for the remaining years of my career, both as a restorative practitioner and an endodontist.

Every patient was greeted by the staff and treated as though they were the only patient in the entire practice. The reception room décor was fresh and was furnished with the patient’s comfort in mind. On occasion, when no one else was around, I would go sit in the reception room and pretend to be a patient. I wanted to be sure no upgrades needed to be made, that there was no dust in the corners, and the area was kept as clean by my janitorial service as if it were my own home. The patient was given a tour of the office and made as comfortable as possible while necessary records were completed in preparation for the doctor to spend adequate time with them on their first visit.

One of the most important tasks for the entire office staff (doctor included) is to schedule enough time for the procedure to be completed and maintain a stress-free environment. Especially when practicing at the highest level possible, the doctor has to be realistic on what amount of time is normally necessary to accomplish the specific procedure. Of course, not every procedure goes as expected and complications do happen, but the office team should have allowances made to accommodate this when it does so no one is stressed as a result.

The consultation visit was scheduled so there would be adequate time to educate the patient and answer any questions about their treatment, including possible post-op experience, the expected prognosis, and the fee. I felt comfortable presenting the fee, and the staff would then discuss financial arrangements, insurance coverage, etc. The patient was then scheduled for treatment.

On the day of treatment, the patient was seated in the treatment room and made as comfortable as possible. One of the things we did to assure their comfort was to use different types of small Tempur pillows beneath the patient’s neck, small of their back or under the knees. Personally, I have never been comfortable in any dental chair without a neck pillow. One of the things that always got a very positive comment was the placement of a pillow beneath the knees of the patient, especially the elderly patients. Tempur pillows of all varieties are available online and should not be too firm or too soft. When a time-consuming surgical procedure was done that required the patient to keep their head turned in one direction, we would have the patient turn onto their side and prop them with pillows so they would remain comfortable for the entire procedure. By the way, this was an incredible “practice-builder”!

One of patient’s biggest concerns was the injection of anesthetics. While doing the injections the chairside assistant would usually place a hand on the patient’s shoulder as a sympathetic gesture to comfort the patient during the procedure and assure them that someone was there if needed.

There were a few ways we tried to eliminate the causes of the discomfort.

First, to eliminate the “thermal shock” experienced whenever injecting a cold solution, both the anesthetic carpule and the syringe were prewarmed on a standard heating pad with a sterile cover and set at a low temperature. Some doctors use carpule warmers, but when the warm carpule is placed into a cold syringe, the anesthetic becomes quickly cooled and the patient feels the unpleasant “thermal shock.” So, it is important to warm both the syringe and the carpule.

Second, the actual piercing of the needle can be greatly reduced in all maxillary injections by using pressure anesthesia at the injection site. The lip is retracted with the thumb and forefinger and pressure placed at the point of injection. The syringe is placed so the bevel of the needle is toward the bone, and the lip is quickly pulled down over the needle and anesthetic slowly injected. In the case of the incisal and greater palatine injections, the pressure can be placed using a blunt or rounded end of an instrument like the handle of a mirror.

Third was pre-injection of the injection site when using some anesthetics that have a chemical “burn” when used. For example, bupivacaine vs. lidocaine: the bupivacaine anesthetic solution is more readily felt than lidocaine, so a small amount of lidocaine is normally used prior to the injection of bupivacaine.

All mandibular treatment cases were anesthetized using the standard IAN injection plus an additional injection at the foramen coli to anesthetize the ascending branch of the mylohyoid nerve. It has been shown the ascending branch of the mylohyoid nerve may be a source of innervation to the mandibular teeth [Mendel Nevin, DDS, and P.G. Puterbaugh, MD, DDS, text, “Conduction Infiltration and General Anesthesia in Dentistry,” revised 5th edition 1956. p.45]. The foramen coli is located lingual to the apex of the mandibular second molar. Not all patients have this innervation present, but this may sometimes account for the pain during an operation following an apparently successful mandibular injection. As a result, a “missed” mandibular nerve block was very rarely experienced.

When interviewing dental patients over the years regarding uncomfortable feelings they have about their dental treatment, some are invariably going to mention dental fees. Maintaining a practice committed to delivering the highest level of excellence to patients requires many things: the latest technology, up-to-date instruments and equipment, an adequate facility in a good location, and many hours of training for both the office team and the doctor. With every new technology, a new and very significant commitment of time and money is involved. Unless the fees are sufficient it is not possible to continue delivering the highest and most predictable quality of care to the patient.

The only way a doctor can control their practice is by the fees charged for services. In general, if a practice is too busy and the doctor can’t spend the necessary time to perform procedures to the desired level, the fees are too low. When the fees are increased, some patients will not perceive the value and will leave the practice, allowing more time to be spent with patients who value the doctor’s time. The fee must be fair for both the doctor and the patient. The value received by the patient must be justified as well as the reward for the doctor. Keeping all in balance is an ongoing challenge that must be met for the good of both the doctor, the staff and the patient.

To summarize, in order for success in the patient-centered practice, the following concepts need be adhered to:

Follow these steps to enhance your patients’ experience.

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