Nurture Faith over Fear

Feb 01, 2010 No Comments by

I had moved my family. I had built a new office and hung out a shingle. It was a time of great change.

I had also been learning about the Dr. Dick Barnes philosophy, and I liked a lot of what I heard. I was starting to see things differently. But in trying to implement, I was finding out how much commitment it takes to become a better doctor. These weren’t just surface changes.

Then Tom walked through my door. He was looking for a dentist, the right dentist. So I looked him in the eye and focused on making a friend. He was charismatic and confident. He told me he was hurting. He had always had bad teeth, and he had let them go while his wife was dying of cancer. Now she was gone, and Tom had to start again. He really didn’t want to lose his teeth.

I was a good dentist. I had done some cosmetics, including a few cases with Arrowhead, and I had handled a few larger cases. I was also in learning mode.  I wanted to be a better dentist.  I had recently attended the “Over-the-Shoulder Full Arch” course by Dr. Jim Downs, and it had opened my eyes.

I had decided that I didn’t want to practice “hope dentistry” anymore. I wanted to know what I was doing, especially with patients with large-scale problems, difficult bites, and major cosmetic needs. I wanted to help these people with confidence. I just needed more hands-on experience.

And now Tom was standing in front of me, just the type of person I had wanted to help. At once my heart jumped in excitement and tensed in fear. Looking in his mouth, I found it a bigger commitment than I had taken on before.

Tom had a deep, tight bite; advanced decay on most teeth; intrinsically dark color; generalized root canal involvement; high bruxing forces; and tragedy-born, deep-seated needs. This was a full-mouth problem—several dilemmas I had seen before, all rolled into one case.

I fed his hope, took diagnostic impressions, and took a deep breath.

Then I called Dr. Barnes.

He came to my office that very day. I was really surprised, having never met him before. I have since learned how committed he is to the doctors he serves.  We went over the diagnostic models and what I was thinking. I had decided on a full arch on top and posteriors on the bottom. Those were the teeth that needed the most help.

Now for the important part of the story.  Dr Barnes had been a good listener and now asked, “Why aren’t you planning to do the lower front teeth, too?” The truth was I did not have the courage, or the conviction, to tell someone they needed a crown on every tooth at once. I was still learning how to really see my patient, his needs, and his entire mouth as a whole.

Dr. Barnes explained, “When you put these beautiful teeth in everywhere else, your patient won’t be happy with these lowers, even if they don’t have broken-down fillings.” I knew he was right. And there I was, facing my fears of presenting and then doing a full-mouth case. I inhaled and looked Dr. Barnes in the eye. “OK,” I said. And I was on my way to being that “better dentist.”

Now, the story could stop there, but what about the money? Dr. Barnes continued, “What are you planning to charge?”

I didn’t have the courage to tell him what I thought the patient could afford.  Dr. Barnes looked at me and said, “Jeff, to give him the outcome he deserves, tell him it’s going to be, sensed my $37,720. Tell him, just like that.”

“See, it’s more than just a per-unit charge,” he continued. “You have to account for difficulty level and all the things that go into a full-mouth case. You need to feel that you can comfortably do a nice job, have good restorations made, and do everything needed without cutting corners.”

When Tom came back in, I told him we needed to do all his teeth. I inserted that they could be done in one visit. I knew his results-oriented, time-conscious style.

To the “every tooth” reality, Tom looked pained a second and then said he knew that was coming. He acknowledged that the number of visits was a big factor.  Then he presssed, “So, what’s the bottom line?” he asked before I could say it.

“$37,720,” I said. And I shut up.

He paused, straightnening, then responded, “That’s less than my buddy paid. But are these teeth going to fall off? He had his whole mouth done and he’s had some come out already.”

I was stunned a moment at his reply. “Tom,” I answered, “if you do this case with me, I’m going to do it right. My crowns are not going to fall off.”

Dr. Barnes was right. My job was to present complete dentistry at a price that was fair to both of us. At that point I would find out my patient’s real fears and concerns. Tom’s were not what I had anticipated. They arose from his experiences and realities.  And I realized how important it was that I was charging enough to do a really good job.  I learned a big lesson about discussing treatment.

I didn’t want to practice “hope dentistry” anymore.


The most important part of our practice is knowing what is in our hearts and how we view our patients. It’s about learning to visualize, believe in and value what we can do. It’s about overcoming fears and committing ourselves to change.

Dr. Barnes was the coach I needed. I desired change, and like a Black Belt working with a White Belt, Dr. Barnes brought me to a new place within myself.

At the doctor’s suggestion, I arranged to have Dr. Jim Downs attend as I prepped and seated Tom’s case. This was a difficult first full-mouth. I wanted to seize this opportunity and build confidence from it.

Tom and I spent a few weeks doing clean-up. During these visits, I excavated decay, did buildups, and improved his periodontal condition. He had an extended sedation visit, where a long list of root canals was completed.

On prep day, I was nervous until Dr. Downs sat down with me, models in hand. We discussed our step-by-step approach for preparing Tom’s entire mouth.

We planned the order in which I would prep each mouth segment. We decided where to insert things like serial additions to the bite registration, anesthetic, impressions, and records. We taped our plan to the wall behind the patient.

Knowing our basic full-arch sequence, it was just a matter of applying it to Tom’s mouth and overlapping the steps to make it work for both arches without losing the bite. Then all I had to do was execute.

I highly recommend this. Visualize your performance. Sit and think through each case before you pick up a hand piece. Habitually follow a step-by-step list of the basic full-arch protocol, materials included, to help keep you and your assistants on the same page. Then, when you adapt it to each case, and tape up the specific sequence for today’s patient, you can all work together.

During this pre-planning step, we found a complication with the models and a matrix. The Technical Support team back at Arrowhead helped, and we were back in business in no time. These things happen, but when you are on a great team with your lab, you are not alone.

While prepping, the clear prep guide—complete with measuring holes—provides a reference for all of the fundamentals. It helps you visualize your pre-planned midline, the need to “move” teeth, axial inclination, and incisal-edge arch form.

We carefully unraveled tight and crowded teeth with a 330 on Tom. We kept all preps conservative and gentle, trying to visualize porcelain shape as an extension of prep-form. Additionally, we kept our bite by serially relining the Siltek bite registration.

Seat day was fun. We had found a comfortable incisor length in the temps, and Tom’s bite was settling in. Little clean-up was required under the temps.

The lab did an excellent job. I learned how to try in the Elite units, in different sequences, and feel where slight adjustments needed to be made. We all have to step up to the plate when it comes time to bond, but the rapid cementation technique gave me time and control. The crowns went down smoothly and turned out great.

What Dr. Downs said was true: outcomes are best if you “prep for success.” In Tom’s case, the proper gingival architecture, preps that set the right tone for the porcelain, and the Elite technicians at Arrowhead combined for an amazing result.

The impact was big when Tom looked in the mirror, and he was happy. His response was “Wow!” After a lifetime of dark, small teeth, it was hard to comprehend what he was seeing. A personal thorn, suppressed for years, was gone.

The 24-hour check was the real payoff. The numbness and chair-fatigue were gone, people Tom loved had responded positively, and he could really see his smile now. He liked the length of his teeth, and their color was new and wonderful. Tom smiled and laughed, getting used to his new look. He was genuinely grateful.


Dr. Barnes was right. The results would have been second-rate if I hadn’t done all the teeth. At the 24-hour check, we took a photo of Tom, Dr. Downs and me that symbolizes why I want to be a better dentist. It means: rewarding friendships, the joy of belonging to an amazing team, and the powerful impact one can have on someone’s life. Tom is a new man, and I am excited to be a part of that.

I am glad I nurtured my faith over my fear. And I am thankful I listened to the Black Belt, Dr. Barnes, instead of going it alone. Without him, this might never have happened.

Practice Perfect, Winter 2010

About the author

Jeffrey A. Hill received his DDS degree from the University of California at Los Angeles School of Dentistry. He maintains an aesthetic practice in Salt Lake City, Utah, oriented to families and working professionals.
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