Wednesday, September 7, 2022

Using CBCT to Diagnose the Depth of a Cracked Tooth

 One of the many uses of CBCT is to help us determine the depth of a crack - seen on the occlusal surface of a tooth, but uncertain as to how deep it goes down the root.  Obviously the deeper the crack goes below the CEJ, the poorer the long term prognosis.

This patient was mostly asymptomatic until he recently bit into something and has had pain ever since.

Periapical film

2 Cracks seen on the MMR - with staining

CBCT shows a narrow, bony defect identifying a crack in the axial (Z) view.  The sagittal (Y) view shows the depth of the crack.  A new crown would have to go past this depth to cover the crack up.  This view helps us make a determination of the restorability of the tooth.

In this case, the crack would never be completed removed or covered up by the crown making the long term prognosis poor.  CBCT allows us to make this evaluation without having to remove the amalgam filling and chase the crack - saving the patient (and us) time and money.

Friday, March 4, 2022

Innovations in the Dental Insurance World


Medical insurance has been using tiered systems to provide care to patients for some time. A tiered system categorizes physicians by quality and cost efficiency standards. While the patient chooses their provider, the patient's copay may vary based upon the provider tier that is chosen. Insurance companies can reimburse different tiers on different fee schedules potentially allowing network providers with better outcomes higher reimbursements. An example of medical insurance tiered system:

Providers meet excellent quality and/or cost efficiency standards
Members pay the lowest copayment
Providers meet good quality and/or cost efficiency standards
Members pay the mid-level copayment
Providers who are outside the insurance network
Members pay the highest copayment

As you know, trends in dentistry typically follow trends in medicine. While the tiered provider system is not yet here for dentistry, the concept of evaluating the quality of dental care has been on the horizon for some time, and will shortly be utilized by major dental insurers. How will this work?

A leader in this type of data analytics is P&R Dental Strategies. They have developed a unique, objective, quality measurement program for dentists. Their methodology, called DentaQual, leverages a nationwide, multi-payer dental claims database (DentaBase) to measure quality by analyzing cross-payer claims and dentist utilization data. Quality is measured based on metrics scored in each of 5 categories.
The DentaQual score for a dentist is based upon an individual dentist's "standard deviation from the norm", the norm being the average practice behavior of a dentist's peers in a geographic area. It is not based upon predetermined or subjective benchmarks such as user reviews.

As the largest dental insurer in Arizona, Delta Dental of AZ, will soon make these quality scores available to patients to help them in selection of their dentist. Other insurers such as United Healthcare and other Delta Dentals have already incorporated this platform and it's probable that other insurers will follow suit.

In order to better understand the purpose behind these metrics and how insurance companies will be using them, we have invited Mr. Mike Jones, President and CEO of Delta Dental of Arizona to participate in our upcoming seminar. Mr. Jones will provide us with an update of current and future initiatives and explain how Delta Dental will be leveraging these new metrics.

We have also invited Mr. Michael Urbach, President of New Markets for P&R Dental Strategies to come and explain how DentaQual works and what affect they expect to have on the dental insurance marketplace.

We look forward to their presentation on Tues, March 22, 2022 at 6:00pm at Superstition Springs Endodontics.


Monday, November 1, 2021

Survival in the Dental Office: Brain Based Leadership Concepts to Help your Practice

During the 2020 spring shutdown, due to the COVID-19 pandemic, I found myself at home with my family looking for ways to entertain ourselves. We planned daily "quarantainment activities" like playing indoor games, outdoor games,
 cooking competitions, bike rides, ping pong tournaments, movies etc. At some point, we began to watch back seasons of the CBS reality show "Survivor". In this show, a group of very different people get stranded on an island, with just the clothes on their backs. They compete individually and in teams but ultimately have to vote each other off the island until there is one remaining survivor. We did some major binge watching, but it was fun. Watching the drama of such different people put in a stressful environment, competing for food & small comforts, making pacts with each other and ultimately doing anything to survive in the game - including the all too famous "blindside" was just too entertaining to look away!

At the same time, we all found ourselves in a business survival mode. How do we handle our emergency patients? Do we layoff employees? Can we get a PPP loan? Can we get it forgiven? What happens if someone on staff gets sick? How do we pay for sick time? If a staff member gets sick, do we have to shut down the office? What if my family gets sick, can I come to work? How do I handle the hygienist's concerns? How do we manage our team's anxiety about the whole situation? How long will this go on? etc. etc. The threats to our businesses and livelihood were real and we all felt a little "blindsided" by COVID-19.

Survival is what the brain is designed to do. The brain identifies threats and keeps us alert and aware of them at all times. Unfortunately, sometimes this state of arousal can create challenges and problems when it comes to communicating, collaborating, solving problems, setting goals, and leading a team in your office. Modern neuroscience is teaching us many new things about the brain and cutting edge leadership is taking advantage of that new knowledge.

Our upcoming Inner Space Seminar, will discuss how brain based leadership focuses on understanding how the brain works and using that information to our advantage. David Rock, of the Neuroleadership Institute, has described five social domains that the brain treats as primary rewards or threats. Since your office is social system, understanding these concepts can change the way you communicate, lead your team and interact with your patients more effectively.

Our upcoming Inner Space Seminar will be presented by Jason Hales DDS, MS on Thursday, Nov. 11th, 2021, will review these leadership concepts and help you survive as a leader in your practice.

To register please contact Annette at or 480-807-8022. Seating is limited.

Monday, April 26, 2021

Dealing with Cracked and Fractured Teeth - An Inner Space Seminar


At a recent Inner Space Seminar, Dr. Jason J. Hales discussed dealing with cracked and fractured teeth.

Monday, March 8, 2021

Partner for Success - What Does A Real Partnership Look Like?

At Superstition Springs Endodontics, one of our five core values is "Partner for Success". To us this means, that we are successful when our partners are successful. As we have focused on this value, we have come to more clearly understand who our partners are, and how we can help each other be successful.

At SSE, our partnerships are primarily with our referring dentists, but also include other important providers of supplies, IT services, legal services, accounting services and even janitorial services. While insurance companies are often viewed as an adversary, we should look to build partnerships with them, when possible.

A 2009 study by the L.C. Williams & Associates Research Group details a group of dentists who refer less than 10% of their root canals to endodontists. This group of dentists have a very different perspective about working with endodontists. They tend to believe that they perform the same quality of endodontic treatment as specialists at a lower cost. They are less likely to admit that certain difficult cases should have been referred to an endodontist than their peers who refer more than 10% of their endodontic cases. These dentists are also less likely to describe an endodontist as their partner in delivering quality dental care. As you can imagine, these are not the dentists that we are interested in working with.

efining this value of partnership has given us the freedom to realize that while most of our patients come from general dentists, there are times when we are forced to choose which dentists are given access and priority of our time, schedule and expertise. As you can imagine, those dentists with whom we have a partnership will get that priority.  W
hile working with this previously described group of dentists typically brings frustration, working in sync with partner dentists, and the relationship with them, is a rewarding and fulfilling part of our work.

A partnership is a relationship that benefits both parties. At SSE, this is what partnership looks like to us:

Our partners know:
  1. We will take care of their patients when in pain.
  2. We will stand behind the work we do for their patients.
  3. We will treat their patients the same way that they do.
  4. We will support their treatment plan.
  5. They can contact our doctors directly at anytime with any question or concern.
  6. Their patients will return more confident in their dentist and appreciative of their referral to SSE.
  7. We will do everything possible to help them be successful.

We know our partners:
  1. Respect our team and their efforts to serve their patients
  2. Respect our time and are patient and flexible in getting their patients in
  3. They know our treatment is worth the cost. They encourage patients to see the value in coming to our practice regardless of insurance benefits or distance traveled.
  4. See us as a valuable part of their dental team - not just an emergency service or someone to call to bail them out when they get in over their head.
  5. See value in the work that we do for their patients. They recognize the expertise that comes with endodontic specialization.
  6. Are comfortable calling our doctors directly to help them deal with any especially difficult case or situation.

We understand that referral patterns in dentistry can change for many reasons. The previous study found that the longer a dentist was in practice, the more positively they perceived their endodontist colleagues. Younger doctors were more likely to say that economics of treatment and their availability are more important factors when deciding whether to perform or refer to an endodontist. As doctors become more experienced, better acquainted, as professional relationships grow stronger through improved communication and experience together and as teams get to know each other and work together partnership improves. Sometimes doctors are discouraged from referring to endodontists because of their employment status as an associate dentist. Sometimes an owner doctor gets busy enough to choose procedures that are more profitable for them (crown & bridge) or they just get tired of searching for the MB#2 and look to build a partnership with an endodontist.

Our mature partners (and by mature I do not mean age) express to us that they feel that relieved sending their patients to SSE because they know the experience their patients will have and how it will move them forward in their treatment plan. While many of these partners may still perform some endodontic treatment, they become experts at diagnosis and case selection. They recognize the cases that will save them time and money by referring rather than treating. If you could ask them, they would explain that they are more successful and profitable by the working partnership they have with SSE.

Because of our value "Partner for Success", our partners are given the highest priority in our schedule. While we try to accommodate everyone who needs to be seen, our partners are given priority over self-referred patients, online referred patients or patients from offices that we don't have an established and working partnership.

We appreciate working with the best dental practices around and are always excited to make new partners. If you are looking for the kind of partnership described above, please let us know so that we can take the steps to build a stronger relationship with you and your team.

Monday, February 8, 2021

How to Manage Your Debt So It Doesn't Manage You

At our last Inner Space Seminar, Dr. Danny Masters and attorney Amber Masters discuss financial principles to managing debt so it doesn't manage you.


Tuesday, September 15, 2020

Aerosol Anxiety and COVID-19 Critical Thinking with Dr. Hessam Nowzari


A big thanks to Dr. Hessam Nowzari, and his presentation, "Aerosol Anxiety and COVID-19 Critical Thinking" presented as an Inner Space Seminar. Hosted by Dr. Jason Hales and Superstition Springs Endodontics.

  • After 8 or 9 months, those who claim we don't have enough data for proper decision making are misguided or naive.
  • Majority of current complications and deaths are based on decisions made upon flawed mathematical models.  
  • COVID-19 is not a novel virus.  COVID-19 shares 90% of its genome with other coronaviruses - which we have been exposed to historically.  We already have some amount of cellular immunity to COVID-19 because of our prior exposure to other coronaviruses.  COVID-19 is an RNA virus which, by probability, gets weaker as it is replicated.
  • The strength of the COVID-19 virus is the speed of contamination - not mortality rate.
  • The US has ignored many of our scientific colleagues in Taiwan, Japan, Sweden etc. and the information and warnings they gave us early on and the success that they are currently having.
  • We should expect to see increasing case positives and mortality rate as we move into October due to the regular flu season.
  • We know that our young people are safe.
  • We have to protect our elderly population and people with co-morbidities.
  • COVID-19 is very sensitive to soap & water. Wash your hands with soap and don't touch your face or eyes.  You don't need alcohol or expensive chemicals that destroy your natural biome.
  • Every person has over 100,000 viral elements in their DNA.  Viruses are part of who we are.

Friday, April 3, 2020

Your Brain and the COVID-19 Pandemic

The COVID-19 pandemic which has spread from China, through Europe and is now increasing in the United States, in addition to the reaction by the World Heath Organization, Centers for Disease Control, state governments, state dental boards and the non-stop media coverage, is causing tremendous anxiety and uncertainty among the dental community.  Congress has enacted legislation (HB6201) to expand sick leave and the dramatically expand the Family Medical Leave Act (FMLA) which will now apply to business under 50 employees, causing dentists to scramble to decide how these changes could affect their business.  The 2 trillion dollar stimulus package, S3548 Care Act, contains loans for small businesses to keep people employed provides some hope for dentists hoping to keep their teams in tact, but comes with the stress of trying to get approval before the money runs out.  This environment has created tremendous anxiety and stress for dentists.  Your practice needs leadership now more than ever!  As leadership coach, Joel Small says, "Your leadership legacy is being forged right now!"

Modern neuroscience has come a long way with the devlopment of the fMRI (functional Magnetic Resonance Imaging).   This technology allows researchers to see the brain in action by visualizing the neural activity in real time.

David Rock, of the Neuroleadership Institute, coined the term neuroleadership to describe the application of the findings of modern neuroscience to leadership. This article will help you understand how your brain works and provide some tips to help you to better manage your own anxieties and negative emotions and better communicate, teach, train and mentor your team.

A Quick Summary:

The brain can be divided into the limbic system and the cortex.

The limbic brain is considered the primitive part of our brain because it is focused on survival.  It is constantly scanning our world for threats and rewards.  It the the emotional center of our brain and closely tied to memory.  It has the ability to work at tremendous speeds and has inconceivable capacity.  The limbic brain is the strongest part of our brain and will typically overpower/override our cortex.  This part of your brain is causing you, and your team, to feel great anxiety in the current situation.

The cortex, and especially the prefrontal cortex (PFC) is the younger, conscious part of our brain.  It is the center of conscious thought, reasoning, decision making, memorizing, inhibiting, recalling and moderating social behavior. The PFC is slower, limited in capacity and easily fatigued.  While our cortex can easily be overpowered by the limbic brain, modern neuroscience shows that intentional or mindful use of our PFC can change the electrical activity of our brain.  By consciously activating this part of your brain, you can inhibit some of the negative emotions and threats you and your team are currently feeling.

Your Brain During the COVID-19 Pandemic:

Right now, in the midst of the COVID-19 pandemic, your limbic brain is highly aroused and likely overpowering you prefrontal cortex, making it harder to make decisions and keeping you focused on the negative emotions and threats you are feeling.  These threats include how to keep our teams employed, how to make rent, how to manage debt and cash flow, how to manage patient and employee concerns, how to interpret the laws that have been passed and applying and qualifying for loans with the CARE Act, just to name a few.  Add to the fact that many employment lawyers and accountants are recommending layoffs or furlough for that team that you have worked with side by side for years.  The 24 hour, non-stop media plays a huge role in activating a threat response in our brains to the current situation.  Constant coronavirus headlines, drastic modeling predicting dire consequences make it worse day by day.  Everything around you is stimulating the "fight or flight" reaction of the limbic brain.  It's no wonder that we are all feeling threatened!

Overarousal of the limbic system overpowers and reduces the resources to the prefrontal cortex.  This inhibits understanding, critical thinking, decision making, memorizing and inhibition, all of which you need to be the leader your practice. When the prefrontal cortex is overpowered, the we tend to do more "automatic" thinking and tend to respond more negatively to situations.  We say things that we don't mean and that may trigger threats to the people around us.  Because the limbic system is more affected by threats than rewards, you will find that threats to the limbic system come on faster, last longer and are harder to change.  It becomes difficult to see the positive and we become more risk averse.  We can only see the glass half full.

Neuroscience has shown that intentional use of the prefrontal cortex can change the electrical activity of the brain.  The following techniques can be used to "put the brakes" on the negative emotions/anxieties that your limbic brain is currently focused on.  These techniques can be helpful in every aspect of your life and help you as a leader.
  1. Symbolic Labeling:  The act of consciously putting words to the emotions that you are feeling, expressed to yourself or others, actually stimulates the right ventrolateral prefrontal cortex (RVLPFC) which is the center of inhibition for your brain.  This will help inhibit the negative emotions/anxiety that you are feeling due the powerful limbic response of your brain.
  2. Reappraisal: Reappraisal is another conscious activity of the prefrontal cortex which has been scientifically shown to inhibit the limbic response of the brain.  Reappraisal is the conscious activity of looking at your situation from different perspectives.  This requires more focus and energy, but has been shown to be more powerful than symbolic labeling at changing your brain's activity.  Reappraisal can be done in the following ways:
    1. Reinterpreting: Consciously choose to reinterpret your current situation.  Look for the positives and find opportunities in your situation.  For example, "I have time to re-evaluation our systems" or "I have time to get more CE done" etc.
    2. Normalizing: Take a few minutes to focus upon what is normal about your situation.  For example, "I am in the same boat as all the other dentists around me. We are all working through this together. etc."
    3. Reordering: Consider reordering what your values are in the situation. "My team or family's health is the most important thing right now." "I have to make this tough to decision to protect our practice so our team can have a job in the future."
  3. Healthy Brain Habits:  Re-evaluate these habits in your life and prioritize them for better brain function.
    1. Sleep - get enough
    2. Nutrition - find balance
    3. Exercise - make time
    4. Breaks - time correctly
    5. Mindfulness Training - practice
Understanding how our brain works will not only help us in times of great anxiety and concern, but will also help us as leaders in our practices.  Stay tuned for more brain hacks that will help you as a leader in your practice.


Wednesday, April 1, 2020

Perspectives on the Pandemic - Interview of Dr. John Ioannidis of Stanford University

This is a follow up interview to his recently published article.  I think you will find this a fair, balanced, rational and "science-first" approach to data surrounding the COVID-19 pandemic.