Safe & Reversible Techniques for the Worn Dentition

Episode #379 with Dr. Dennis Hartlieb

As you move into more complex dentistry, you will attract a more demanding population. So, how do you financially and emotionally protect you and your practice from those patients? One way is reversible dentistry, and it can even help you enjoy your career! And to teach you how, Kirk Behrendt brings in Dr. Dennis Hartlieb, CEO and founder of Dental Online Training, to share his learnings about techniques for worn dentition. By doing more reversible dentistry, you can make your patients, your practice, and yourself happier. To learn more benefits of safe, minimally invasive, and reversible treatment, listen to Episode 379 of The Best Practices Show!

Main Takeaways:

Minimally invasive, reversible dentistry is safer for patients and dentists.

When you don't do reversible treatment, the patient owns you.

Reversible techniques can reduce the opportunity for conflict and surprises.

Be skilled with composite and porcelain so patients can decide what's best.

Understand the relationship of worn dentition to joints and airway.

The problem isn't below the nose, it’s above the nose.

Quotes:

“What was good about being an average student was that I had to work harder than my classmates to be decent at dentistry. And it’s been a real advantage for me. I was the person in the lab at night that was re-prepping teeth, and re-prepping teeth, and re-prepping teeth because it didn't come easy to me, and it wasn't natural to me.” (3:16—3:37)

“I've probably prepped more plastic teeth than I have human teeth, and I've been doing this for 30-some years. But as they say in football, to get ready for Sunday, it’s all about Monday through Saturday. And I think in dentistry, it’s not just about the days that you're seeing the patients, it’s the days you're not seeing the patients and how you're getting your skills better.” (3:49—4:08)

“Mentorship, I think, is the key to dentistry. It’s key to everything in life, but especially in dentistry because of the skillset that we need, the techniques that we need to learn. It’s so difficult to learn them just haphazardly.” (6:29—6:45)

“I allow the patient to make the decision that's right for them. Some patients, it’s all about durability, ‘Give me the strongest material. I want something that's going to last the longest. I don't want to worry about it. I travel a ton.’ That's fine. Porcelain is the answer. Other patients are like, ‘Don't drill my tooth. I don't want you to touch my tooth. If you can minimize how much you drill the tooth, then I will own the fact that there's going to be more maintenance with a composite veneer than what there will be with porcelain veneers.’ I think the key for dentists is to have both skillsets so that you can allow the patient to make the determination and not you choose. And I'll tell you, it’s really rewarding because when patients have made the choice, then they own their choice, for better or for worse.” (13:26—14:06)

“The challenge, I think, is when you're looking at these patients with worn dentition, very often, what's happened — it happens in my practice, as much as I hate to admit it — there are a lot of patients who've been long-standing patients in your practice, and you're just very slowly watching their teeth wear away. And you don't know what to do. You don't know how to intervene. It’s certainly not something that we’re taught in dental school, and the only intervention techniques that we are taught are full-mouth reconstructions.” (15:19—15:46)

“Corky [Willhite] had talked to me about a case he had just done where he had used bonding to open up somebody’s bite. And I said, ‘Corky, this is brilliant. You've got to start teaching this.’ And the very next case, it was a worn dentition case, and the patient came in, and I said, ‘You know what? We’re going to be a little safer with this. And instead of prepping your teeth, we’re going to do this in a more reversible, safe way,’ so that if you are the patient that I say I wish I hadn’t treated, I can literally take off the bonding, write you a check, give you your money back, and send you on your merry way. I've done that a couple times in my practice where I've literally taken off the bonding and said, ‘You know what? This isn't working between us.’ And it’s been great. And it’s saved me a bunch of headaches from patients who otherwise would've caused me a lot of stress, and same for my practice and my team members.” (17:11—18:00)

“As you start doing more and more complex dentistry, comprehensive dentistry, and cosmetic dentistry, you're going to attract a population that’s going to be more demanding. And most of the patients are awesome, and most of the patients are super great and super appreciative, and they're great to work with. But there are going to be some that aren't awesome. And the problem isn't below the nose, it’s above the nose. And what their perception is and what reality is can be very, very different.” (18:51—19:19)

“I have learned, and I think all of us who've done dentistry for longer than a week, that you're going to run into patients that what they perceive and what you're seeing is just going to be completely different.” (20:26—20:34)

“I think the more we can do minimally invasive, reversible dentistry, the safer we are, the healthier we’ll be mentally in our career, and the more we’ll be able to enjoy our career.” (20:42—20:52)

“When you don't do reversible treatment, when you put a bur on a tooth, the patient kind of owns you. And it’s very expensive when things go poorly, not only financially, but it’s really devastating to the practice, emotionally, for the staff. This is the person who’s on the schedule that you just don't want to see. They're the ones that make our world so much harder and so much more challenging. So, part of the “why” is to reduce the emotional and the financial cost of treating patients in the unpredictability of which patients are going to be problematic, as far as being able to get them happy with the aesthetics, but also with the function, with the occlusion.” (24:43—25:30)

“The second part of the “why” in why would we do this in a transitional phase, what I call prototypes, is because not everyone’s occlusion is the same. The way people function and their eccentric movements, they’re all different. They're like snowflakes. And trying to understand each person’s patterns, you can do that in provisional restorations. But you've always drilled the tooth, and you are committed to the treatment. And that can be fine, but it can also be kind of scary. And so, I like the opportunity of reducing the opportunity for conflict and reducing the opportunity for surprises by doing something that's in a transition phase that's reversible so that both the patient and I can excuse ourselves from our relationship, if we decide to.” (25:31—26:21)

“The problem, I think, that we have in dentistry is that, and this is a real challenge with some of our laboratory technicians, they have in their mind what they think the aesthetics of a case should be like. Well, that may not be what our patients want. That's, I think, one of the beauties of direct resin bonding, is that I can change the contour of my bonding if the patient is not happy. You want larger embrasures? We’re going to open up the embrasures. You want line angles moved over? I can do that. And I have more control with direct resin bonding.” (27:33—27:58)

“When we’re looking at worn dentition, the question I have is, is there a joint relationship to this? What's going on in the joints? Is that relating to what's going on in the occlusal wear? If it is, that's okay. We just have to understand it.” (29:51—30:04)

“There are some basics we’ve got to know. Are the joints healthy? What are we doing with the joints? Is there an airway disturbance issue? Is this going to need to be managed? And if so, that's a bigger issue, quite honestly, than worn-down teeth. If someone is not breathing at night, if someone is suffocating while they're sleeping, that's a way bigger issue than their teeth wearing down. And so, just getting patients to understand that, ‘Hey, there may be something that's a bigger deal than your worn-down teeth. Let's get that checked out.’ I've had so many patients who have thanked me for getting them in the hands of their sleep physician and getting them on CPAP, or if we made them a dental appliance, whatever, to help them breathe when they're sleeping. So, I think learning that stuff is really critical.” (30:44—31:28)

“If you don't have the hand skills, then you're going to be completely dependent on your lab technician for all your dentistry. And as talented as my lab technicians are, it’s not infrequent when I have to go back and do some shaping and contouring to the ceramics just to blend it in better, to make it more formed to the patient’s face and to their smile. And I think it’s absolutely critical to get good at doing things, hand contouring, so that you can do better for the porcelain work that you do.” (42:51—43:22)

“Treating the wrong patient is just so exhausting, and it takes so much out of the practice. And if you can do things to minimize your risk, I think that you're better off — through our prototype phase, our transitional bonding, making sure that we understand what the patient’s hopes and desires are, that we’re able to manage their occlusion, that we’re going to have functional success before we move into the final definitive porcelain. And I'll be honest, when I do transitional bonding or prototype bonding, it’s the least stressful of my appointments. Because, you know what? It doesn't have to be perfect.” (43:42—44:16)

“When I first started doing this, I undersold it because I thought, ‘I'm going to do this transitional bonding, and then everyone’s going to just pay me for the porcelain.’ And it turns out, at least 30% to 40% of my patients I do transitional bonding on, they don't want to move to porcelain because they say, ‘It looks great! You know what? I don't want you to drill down my teeth. This looks fine. And if it doesn't maintain, we’ll redo it.’ So, I charge a premium for that, and it is the least stressful procedure I do.” (44:22—44:50)

Snippets:

0:00 Introduction.

2:46 Dr. Hartlieb’s background.

6:21 Dr. Hartlieb’s journey with Dr. Buddy Mopper.

7:26 Favorite Buddyisms.

11:14 Tooth conservation is what it’s about today.

14:25 Why this is an important topic in dentistry.

18:01 Dr. Hartlieb’s learnings about safe and reversible treatment.

20:52 Changes in materials.

23:54 What dentists get wrong about worn dentition.

26:23 Higher expectations from patients.

29:03 Other things dentists get wrong about worn dentition.

32:15 Advice for young dentists.

35:19 Dr. Hartlieb’s virtual learning platform.

41:53 Dr. Hartlieb’s thoughts on digital.

43:22 Last thoughts.

46:19 Dr. Hartlieb’s contact information.

Reach Out to Dr. Hartlieb:

Dental Online Training: https://www.dothandson.com/

Dr. Hartlieb’s email: hartliebdds@dothandson.com 

Dr. Hartlieb’s Facebook: https://www.facebook.com/DennisHartliebDDS

Dr. Hartlieb’s social media: @hartliebdds

Dr. Dennis Hartlieb Bio:

Dr. Dennis Hartlieb is a graduate of the University of Michigan School of Dentistry. He maintains a full-time practice, Chicago Beautiful Smiles, in the Chicago suburb of Glenview, Illinois. Dr. Hartlieb is an instructor at the Center for Esthetic Excellence in Chicago and is an Adjunct Associate Professor at the Marquette University School of Dentistry in Milwaukee, Wisconsin. He lectures extensively to dentists throughout the U.S. on the art and science of anterior and posterior direct resin techniques. Dr. Hartlieb is an Accredited Member of the American Academy of Cosmetic Dentistry. He is also a member of the prestigious American Academy of Restorative Dentistry, and the American Dental Association. He is the president of the Chicago Academy of Interdisciplinary Dentofacial Therapy, and officer for the Chicago Academy of Dental Research study club. His dentistry has been seen in many dental publications and he has contributed articles on his techniques in restorative dentistry.