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The Indescribable Value of Autonomy

September 9, 2015

Filed under: ARTICLES,Happiness — Tags: , , — Barry @ 9:10 AM




For old timers like me this film clip is one of Hollywood’s most iconic ever.  Go ahead and watch…and if you’re too young not to remember this scene from Nicholson’s Five Easy Pieces…enjoy.

The scene is Jack Nicholson at his best.  It illustrates why he has so many fans — he is the renegade in all of us.  He is truth, justice and the American way.

Oh if we all could just behave like that when we are being shit on.

Five Easy Pieces was made in 1970.  Yet watching this clip tells me things haven’t improved much…and maybe in the world of health professionals has gotten worse.

Most dentists go to school to be free from micromanagement.  We want to be masters of our own destiny.  But that is not happening today.

Autonomy is the word I like to use.

Another word might be discretionary, or being allowed to use one’s own judgement.  That’s probably the reason I never accepted dental insurance—it was the Jack Nicholson in me.

I always had a difficult time writing letters to “beg” for approval—the equivalence of “holding the chicken salad.”

A few years ago I was asked to be on a panel for the Huffington Post (See the blog post Dentistry Looked Bad – May 2013).  On the panel was two patients, an insurance company fraud specialist and myself.

What a joke!  The fraud inspector said it all.  Probably like the waitress in the film clip, there was such a lack of trust that it is hard to do a good job.  That’s where we have come over the last forty five years.

No one likes to be surveiled.  No one wants someone looking over their shoulder.
We want the freedom to do our jobs to the best our our abilities…that’s how we build our self-worth.  Through our work.

And I am not just writing about doctors and dentists.  We need to trust our employees enough to do the right thing.

Take a look at Jack’s reaction.  How often do we feel like that when speaking with an uncooperative service provider?  How does it feel?

What’s worse though is the stifling effect it has on the provider.  It can destroy trust in the entire system.  Whether it’s getting something as simple as two pieces of toast or getting your cable turned on in time for this week’s football game—we need people to have the freedom to use their judgement and behave with a sense of autonomy.

Dentists, as well as doctors are feeling this more and more.  The ideology of insurance companies and now corporate dentistry, is putting constraints on health professionals in order to become more efficient and more profitable…at the cost of losing autonomy.

When autonomy is gone…so is passion.  It’s just a job..and that’s not why we went to school.




Dental Screening is it Necessary? Part I

May 18, 2015

Filed under: ARTICLES — Tags: , , , — Barry @ 11:02 AM




When my mother passed away some years ago she took one of the ugliest wisdom teeth you will ever see to the grave with her.  For years I looked at her x-rays and defied everything I learned in dental school.  I chose to leave it alone…and happily spared her some pretty gruesome surgery.  I wish I knew more about radical prostatectomies a few years ago when I was asked about that choice.  Things have changed in the world of urology since then.  And hopefully they’re changing in the entire world of medicine and dentistry.

From wisdom teeth to breast and prostate cancer, applying wise clinical judgement may be a patient’s best defense.

A recent article in USA Today asked the question about wisdom teeth: Should they stay or should they go?

We live in a time of what Dr. Atul Gawande calls, over-diagnosis….that goes way beyond the question of wisdom teeth.  I have included links below to discussions of Gawande’s recent article in New Yorker magazine, Overkill.

I highly recommend that you click on the link to Gawande’s New Yorker article…it is worth reading, and if you haven’t read his recent bestseller, Being Mortal…I recommend that as well.

What I found most interesting is that Gawande refers to the research of Dr. H. Gilbert Welch, an epidemiologist from Dartmouth University.  Coincidentally I recently read Gilbert’s new book Less Medicine More Health.  It was the impetus behind one of my recent blog posts about managing vs. fixing conditions.

Two things I took away from that book were his excellent metaphor or conceptual model of cancer he calls the  “barnyard pen of cancers.”
Basically Welch claims that all cancers do not kill, and many of us have small cancers “that never bother us during life – particularly cancers of the prostate, breast and thyroid.”  The goal, he says is not to let any of these cancers escape the barnyard pen to become more deadly.  There are three types of animals in the barnyard…turtles, rabbits and birds.  Most of the above mentioned cancers are turtles, and they’re not going anywhere.  You can read more about this model in Gawande’s article or in Welch’s book…fascinating stuff.

But in the meantime, we scan and probe…looking for rabbits and finding and treating turtles.  Forget the birds—-too late.

What I really found interesting in Welch’s book is how many times he referenced dentistry.

In the first instance he writes about the value of screening…asking whether it’s a good idea.  He uses oral cancer as his example.  He chose oral cancer because a health reporter contacted him about an article she was writing about the benefit of oral cancers screenings.  He admits that he doesn’t know much about oral cancer.  Just that about 8000 Americans die from it every year, compared to lung cancer which kills 160,000 people.  It’s number twenty on the list of cancer deaths.  What Welch said he did know something about was screening.

There seemed to be a discrepancy.  In a recent Consumer Reports article it was recommended that only people who were at risk should be screened for bladder, lung, skin and oral cancer…but the Oral Cancer Foundation and the American Dental Association recommends oral cancer screening on everyone.

So what’s the harm?  I guess, as a dentist who actually screens all of my patients, that’s a natural question.  But the answer, according to Welch, reveals much more about screening in general.

I might say, as a dentist, that it doesn’t cost anything, unless the dentists is using fancy screening applications, the number of new cases of people without known risk factors keeps growing (at least that’s what I am being told), and there is evidence that people being diagnosed with early cancer did much better in later stages.

But when I thought about these answers they didn’t jibe with my experience.  In all of my years of visually screening for oral cancer I have found only four cases —and they were all birds.  I couldn’t have missed them.  They were all smokers.  Only one is still living.

Then I thought about another harm.  For a few years I was using more sophisticated methods of screening…and I found a bunch of false positives.  Off to the surgeon for biopsy.  I actually set off a series of events that lead to unnecessary worry, not to mention the cost and the surgery.

I am not blaming myself…nor do I blame the dental community.  This is what we are intuitively lead to believe—that the anecdotes are true, that more treatment is better and better to be safe than sorry.  Welch takes the counter-intuitive view…and after my own medical history and my experiences…I agree.  I still look, but I don’t get carried away.

Welch went on to write about wisdom teeth—but this blog post is too long…to be continued.


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Dental Advertising? What’s Your Opinion?

February 17, 2015

Filed under: ARTICLES — Tags: , — Barry @ 10:53 PM



When Mike came in for his six month check-up I asked him the routine questions most dentists ask their patients.  “Have you been flossing?”  I already knew the answer, I get my information from much more reliable sources, but I always ask because this is class time and I’m a teacher as well as a dentist.

The look on his face said it all…he said, “Yes, I use one of those gadgets and I do it while I’m in traffic.  I don’t really believe in flossing anyway.”

“Okay…let me ask you a question (he should have known he was getting set up).  Do you remember that movie Cast Away with Tom Hanks?”

He nodded yes, and even knew the character’s name: Chuck Noland.

So I said, “If Chuck wanted to save his teeth, which would be pretty important for his long-term survival on a deserted island, what one tool would he most want to find in those broken Fed-Ex boxes that were washed up in the crash?”

Mike is an apt pupil and a pretty smart guy…so he chose floss…but he also said he would take Wilson the soccer ball as his real first choice.

Yes, we both concluded that floss is probably the first tool to use for long term retention of teeth.

But that is being challenged these days.  The other day I saw “new research” that claimed chewing gum was more effective than floss.

Chewing gum?  C’mon man!

It seems that everything I know about dentistry is being challenged these days.  No, this is not your father’s dentistry.

It made think about what informs our culture…where we get our information about dentistry.

When dentists ask each other to explain how much the profession has changed they usually resort to the usual suspects: the economy and insurance, but maybe it was a change that occurred in the mid-eighties: lifting the ban on professional advertising.

Organized dentistry opposed advertising for years.  A 2008 article in the Journal of the American Dental Association states what our founding fathers were concerned about by lifting the ban:

Advertising by dentists is a complex and significant issue. It does not affect just the business of the practice of dentistry but also—and more importantly, from a professional perspective—the public’s perception of dentistry.

Advertising is a sophisticated science.  In the early 1900’s advertising executive Claude Hopkins was hired by the inventor of Pepsodent toothpaste to help sell his new refreshingly minty new product.  At the time America was in a recognized dental hygiene crisis.  New recruits to the Army for World War I had horrible oral hygiene and the military considered dental disease as a national health crisis.    Hopkins, the author of the book Scientific Advertising was a specialist in changing people’s behavior.

Before his Pepsodent campaign, only 7% of America had a tube of toothpaste in their medicine cabinets.  Ten years after his campaign that number jumped to 65%.  Claude Hopkins successful campaign also had some impressive side effects.  It helped raise the public’s consciousness of oral hygiene and dentistry in general.

When I was growing up in the fifties and sixties, oral hygiene advertising combined with the idea of seeing the dentists twice per year and the association with the ADA’s Seal of Approval really helped dentistry’s public image.

I grew up with Bucky Beaver, Colgate ads, and of course Crest’s- Look Ma No Cavities.  Ahh…those were the days.

Then the ban was lifted.

And the non-professional advertisers entered the game.  The amateurs have effectively ruined the image of dentistry. 

Now I am not against the reasons why the Federal Trade Commission lifted the ban...for freedom of speech and anti-trust reasons related to non-competition.  Today professional advertising and the liberal approach to the ADA’s guidelines have created a Wild West scenario.  Discounts, coupons, groupons, creative insurance pricing…but what really gets me is the false claims made by those outside of dentistry.  I saw an ad last week by a dental lab that manufactured impression material for home use that when sent into the lab would give them enough information to create snap on veneers.  There seems to be no limits these days.

Let’s take a look at what that 2008 ADA article concluded:


That is why a significant concern about professional advertising is the potential loss of credibility and possible degradation of the image of the dental profession. This occurs when professionals conduct their practices more as tradespeople and entrepreneurs do, making dentistry appear more like a trade than a profession dedicated to health care. As a result, the public may perceive that dentistry more aptly fits the picture of a business or a trade rather than of a profession.

So, legality notwithstanding, many dentists believe that aggressive marketing practices such as discount ploys not only are in bad taste, but also diminish the profession in the public eye and may give the appearance of a greater interest in profit than in quality and integrity of service.


The real shame to me is what the power of advertising can do when professional marketers get involved.  Claude Hopkins changed people’s behavior and along the way helped create dignity for our profession…why can’t we do that again?












Four Approaches to Health Care

February 12, 2014



Biologically, man hasn’t evolved in 50,000 years.  Culturally we are evolving faster than any other time in the history of the world.  The human masticatory system hasn’t changed.  Our understanding of it may have changed but the biology has remained the same.  What has changed is our culture.

Cultural evolution more than biologic evolution is the dominant and most powerful engine of change.  This is now the most powerful force on the planet… And one that is radically transforming our bodies.

Dental caries and periodontal disease is what the modern biologists call mismatch diseases…like heart disease, diabetes and some forms of cancer.  Our biology is mismatched to our current culture.  In many ways, because of these mismatches, we may be devolving rather than evolving.  This “mismatch hypothesis”applies evolutionary biology to health and disease.

Theodosius Dobzhansky prominent geneticist and evolutionary biologist says, “Nothing in biology makes sense except in the light of evolution.” Now add cultural evolution evolution to that.

The biggest changes from the Agricultural Revolution through the Industrial Revolution and now to the Information Revolution has centered around how people think and behave differently.

We have a unique and totally unprecedented ability to innovate and transmit information and ideas from person to person.  “Greatest cultural advances occurred thanks to more effective methods of transmitting information…language (human speech), writing, printing press, telephone, photography, Internet, downloads etc,” according to Harvard paleoanthropologist, Daniel Lieberman, author of the book The Story of the Human Body.

Cavities and gum disease were not issues for the hunter-gatherers – that picture above just about says it all.

Besides the diet and the overabundance of processed foods available today, the way we provide health care is devolving as well.  Health care sometimes neglects the real science of prevention and uses technology to bail us out of the mess we behaved our way into.  What I mean is that we confuse science with technology.

Today’s technology is amazing…but it’s value lies in helping us to do our tasks better and faster…and sometimes much more expensively.  Culturally we have created problems in such great numbers that we have become dependent on the technology to save us.

How’s that working?

That’s why there is such big interest these days in the Paleo movement.  I’m not arguing for a diet filled with meat and fish but rather for a simpler way of life…a way of life that made more sense for our overall health.  Hunter-gatherers were more in tune with their circadian rhythm and ate, moved and slept so that they didn’t have to adapt to processed foods, driving, and sleep deprivation which leads to the aforementioned mismatch diseases.

Before cooking and food processing… Losing your teeth could be a death sentence.  Today, as we evolve, dentists are more and more concerned about fixing the disasters rather than preventing them.

Lieberman suggests that there are four ways to approach health care...and like him, I don’t judge because we are where we are in time.  But I do have my preference…but that comes with certain responsibilities:

  1. Let natural selection sort the problem out.  Most of dentists know how that works.  Think chronic inflammation and visceral fat.

  2. Invest more in biomedical research and treatment.  Let’s just keep throwing more money at this giant health problem.  How does 58 billion sound on heart patients?

  3. Educate and empower.  The one I rely on—for me and my patients—mostly for me.

  4. Change the environment (Make it law)–Sure…good luck with this—freedom is more precious than good health

I don’t know about you but I vote for number 3.  I have become fanatical about truly understanding the science—and only relying on the technology when necessary.  This works for me at a personal level – but as I attempt to empower my patients n- it works for them too.

I encourage all health care providers to see our health care problems through the lens of evolution – because if cultural evolution got us into this, then shouldn’t cultural evolution be able to get us out?


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Guess What Day it Is?

December 16, 2013

Filed under: ARTICLES,Marketing — Tags: , , — Barry @ 10:31 PM



I love great ads.  I try to deny that they influence me at all, but with all the money they spend on trying to make me spend my money, I suppose they work.  The best ads, the most creative ads are the ones that stop me in my tracks.  They command my attention.  I love the stuff that comes from GEICO.  I can’t get enough of that camel crying out, “Mike Mike Mike Mike Mike…Guess what day it is…it’s hump day!”  Love it.  Love the gecko too.

He’s some little character isn’t he?  Did you know that his name is Martin?  Did you know that his voice is that of English comedian Jake Wood?  And by default, we know he is from New Zealand because he eliminated Australia and England in some of his episodes.

And the camel?  His name is Caleb.  And the pig…his name is Maxwell.  See how much I love these commercials?

I don’t know if they have changed my purchasing habits.  I just like them.

And what about the highest rated ad campaign of all time:  “WHERE’S THE BEEF?”

In the world of advertising the thing that makes an ad successful is how much it is liked.  Likeability is the key to success…for ads and for people.

Go ahead, don’t be shy, if you like this post go ahead and click the like button.  The one right over Clara Peller’s head.

Liking is the second component of the marketer’s triad : Know, Like and Trust, so it’s no surprise that we can’t trust something we don’t like.

President Lyndon Johnson, a master at persuasion developed his ten point formula for success…to improve his likeability.  Oh, to return to the days when presidents were liked.  Here are LBJ’s Likeability points:

  1. Learn to remember names.
  2. Be a comfortable person to be around.
  3. Acquire the quality of being relaxed and easy going.
  4. Don’t be egotistical (arrogant).
  5. Be interested and interesting.
  6. Get the scratchy stuff out of your personality.
  7. Attempt to heal all grievances.
  8. Practice liking people until you learn to do so genuinely.
  9. Never miss an opportunity to congratulate someone on their achievements, or to express sympathy in sorrow or disappointment.
  10. Give spiritual strength to people, and they will give genuine affection to you.

The other night during a podcast interview the host asked me, “What advice I would give to a young dentist starting a practice today?”

I said I would would be like Donnie Brasco, the undercover FBI agent who spent two years working his cover in a New York uptown bar building trust.  He did it slowly, getting to know the regulars.  He made sure he was liked…and then gradually built a trust.

Today’s advice is probably what Clara Peller told her children when she wasn’t yelling, “where’s the beef.”

Be nice…be likeable.






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What Happy Dentists Know

February 12, 2013

Filed under: ARTICLES,Business of Dentistry,Philosophy,Uncategorized — Tags: , , — Barry @ 10:00 AM



I have a pet peeve.  It bothers me when dentists look at the very best people in the field and believe they will never achieve that level of success, because they don’t have the “hands” or the technical skills necessary to do great work.  This problem isn’t restricted to dentistry...artists and writers look at great works and judge only the result rather than looking at the process that the person went through to achieve the result.

No matter how many times I hear the story about what Michelangelo told an admirer when she called him a genius, he said,   “If you knew how much work went into it, you wouldn’t call it genius, ” and I truly get it…so many of us turn to the beautiful photography on Facebook or the work displayed by dentistry’s masters, and say we can never do that because they are “genius’s”  and I just don’t have the hands or the skills to do that work.

The other day a dentist commented on some work I did, saying it wasn’t up to the “Pankey” standard.  He expected that every piece of work would be perfect if done by a Pankey dentist.  Well we’re all on the same journey.  When starting out our work can be just plain shitty.  Then after a few years it just sucks.  But eventually it gets good with the potential of becoming great.  The problem is that most people expect great every time.  Maybe the masters can do that and I certainly shoot for that, but the reality is we do our best and grow to be better and better.

And that’s all we can do.

But there is a problem… (more…)

The Master Key to Success

April 19, 2012

I opened the curtains to let the sun in, hoping the tropical storm had passed.  It was still very early but I could get a sense of how the day would unfold.  At 7 A.M. the sky was steel gray and the the tide was high enough to reach the edge of the condo at our St. Maarten timeshare.  Looking down the beach I saw one solitary figure running along the water’s edge, skidding through the surf on his brand new boogie board.

“Josh, is that you?”

He just looked up and kept on going like the Energizer bunny.  Few people showed up on the beach that day, but we couldn’t get my son Josh off the beach till dinner time.  He spent hour upon hour practicing on that board.  He fell off and was swallowed up by the tide more than most people could bear.  Every time he fell, he just laughed and got back on…over and over and over again.  Some would call it crazy, but really I thought it was special.

Years later I would never forget that day. (more…)

One Change Leads to a Yes

August 4, 2010

Filed under: ARTICLES,Technical dentistry — Barry @ 2:20 PM

One moment she was okay, and the next she was one the ground holding her mouth.  She just got out of a taxi after the theater on a bitter cold March night in New York.  Her feet tangled as she stepped on the curb and down she went.  In that instant her circumstances changed.

The  driver put her back in the cab and took her to the emergency room.  After cleaning the wound which did not require stitches she was left with two broken central incisors, one of which moved into a new position, at least thirty degrees from the other.  But it took her weeks to visit my office.

Helene was a patient in my practice for over ten years.  I had tried to convince her to close a Terry Thomas type of diastema (okay…Lauren Hutton, if you insist), every chance I got.  Helene wouldn’t budge.  Talk about a resistance to change.  Most turtles are faster.  After a while I just never mentioned it.  Approaching seventy years of age I resigned myself to the old saying about old dogs.

Then came the fall.

Even after weeks of walking around with two broken teeth, she was resistant.  She never wanted to change her smile.  She said she liked the space…but now she said she had never seen crowns that looked like real teeth.  She hated that white square look, and she feared getting artificial looking teeth.

The first thing we did was a smile mock-up but this was difficult because of the gross malposition of the teeth.  We also had an endodontic consult and the teeth tested vital. So we did a wax-up.  Helene was still unconvinced.  She wanted to keep a small space.  Reluctantly she went forward because I promised not to finish until she was happy with the provisionals.

Helene had a tight neutral zone and a very long narrow envelope of function.  We worked out her occlusion in the provisional.  For a further discussion of this go to http://nichedentalarts.blogspot.com/  It was amazing to see how she responded to the tiniest adjustments on our Radica provisional.  Take a look at the wonderful job Sooji Lee from Niche Dental Studio did.  Our patient was so happy that she went down to the Reading Terminal in Philly and brought us three dozen chocolate chip cookies and a for me a gorgonzola cheese and fig bread.

So what can we learn from this?

1. For some people change is tough.

2. Even in the face of injury some people just hold on.

3. Never assume.

4. Get to the bottom of the problem…it wasn’t totally the diastema.

I am sure you have had similar issues in your practice…please share.

10 Ways to Become a Mediocre Dentist

April 7, 2010

Filed under: ARTICLES,Uncategorized — Tags: , , — Barry @ 10:22 PM

Okay, a touch of sarcasm in the title, but I think it’s quite appropriate for our times.  The future of dentistry is in the balance. Unless you live in a cave, you can’t  have missed a cultural shift in our profession.  It’s been occurring for years, and now we are in a definite realignment.  It all started with the fragmentation of dentistry.  First with the institution of dental insurance in the seventies, then the onset of professionals advertising and the loss of meaning of the original ADA’s Code of Ethics in the eighties.

The nineties brought us the proliferation of (more…)


March 29, 2010

Filed under: ARTICLES — Tags: , , , — Barry @ 4:09 PM

Yesterdays’ post had to do with showing dogs and standards.  I used the words apathy and complacency to show how we have become resigned to this lowering of standards.  Then it hit me…the word, “whatever” has been used so often in our culture that we have come to accept these lower standards.

As an aside, I was back at the dog show yesterday.  I met with a lady who actually introduced me to the boxer breed twenty years ago.  She is a judge today and the owner of some of the most gorgeous dogs in boxer history.   I respect her opinion more than anyone in this field.  Coincidentally in our conversation she revealed to me that she believes that before she dies she will actually judge a group of “white” boxers.  This has never been accepted in the AKC.  Of course we love all dogs, but dogs with potential genetic defects just don’t make the standard.  Politically correct and fairness really don’t come into play when we are talking about excellence and standards.  Free markets and competition is what made this country great.

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