Case Study – Drink Beer Out of a Can instead of a Bottle

Drink beer out of a can instead of a bottle.

Click on the picture for the blown up view of today’s before and after for the chipped tooth.

before-and-after-front-chip

I heard an all-to-familiar story today. A patient was relaxing with his friends and was enjoying a beer. But, he made the fateful mistake of drinking it out of a bottle.

I have been practicing for 10-years and anterior chipped teeth are frequently caused by drinking beer out of a bottle. I have great advice… drink your beer out of a can.

Sincerely,

J. Russell McFarlane DDS

TAP-3 Appliance (Snoring, Sleep Apnea, TMJD)

Dr. McFarlane: “So, we came to deliver the TAP-3 appliance, today… to follow-up. We delivered it last week. And now, we’re following up to see, ‘How does it feel?’”

Patient: “It’s great.”

Dr. McFarlane: “OK. Now, tell me a little bit about what you were telling me earlier about sleep. How was your quality of sleep?”

Patient: “Well, before, you know my snoring would wake me up.”

Dr. McFarlane: “OK.”

Patient: “[With this appliance] I could tell the first night that I slept all the way through the night. And I actually woke up, earlier than the alarm. And it felt good! I didn’t feel really tired!”

Dr. McFarlane: “Alert?”

Patient: “Yes.”

Dr. McFarlane: “For the first time in…?”

Patient: “A long, long time – Several years.”

Dr. McFarlane: “And you were comparing that to falling asleep on the couch?”

Patient: “So, when I didn’t have it in… so, I wore it for about a week and then on the weekend I didn’t wear it and I woke myself up in the middle of the night. And I could tell the difference.”

Dr. McFarlane: “And the reality was, you were snoring possibly losing airway function.”

Patient: “Yes. This is so much better than having a tube running around on your face. Like a CPAP.”

Dr. McFarlane: “So, you’re describing a CPAP. What do you think the issue is with a CPAP when you describe that?”

Patient: “Well, I’ve never had one on. But, it just looks like it would be very cumbersome and when I turned over I might jar it loose.”

Dr. McFarlane: “We know the success rate on CPAPs is about 49% at 1-year. People can’t tolerate wearing it. But, you’re not the first person that when we look at the guard has said, ‘Man, that is changing my life.’ (That after wearing it for a few days,) you start going, ‘Man, I am not going back.’ And tell me, you said, ‘it was kind of like biofeedback for you.’ Talk to me about that.”

Patient: “Yes, the first night I wore it I could feel some tension in my jaw. And I’ve had some issues with TMJ. It made me really relax and not hold so much tension in the joint. So, after 3 or 4 days then I was not even really aware of it. It wasn’t like hurt, like deep pain. It was just sore, at first.”

Dr. McFarlane: “At first, you felt some soreness. You’ve been clenching you jaw shut, for who knows how long, to hold your jaw in a certain position when you sleep and that grinding has been associated for you with probably some snoring, (maybe sleep apnea events – we don’t know.) But, what we do know for sure is that your airway (when it’s open,) you can actually relax your jaw. And that’s holding your jaw forward.”

Patient: “And my teeth looked whiter. But, I know that’s not the cause.

Dr. McFarlane: “[Joke] Even whiter teeth – what are you going to do?”

Patient: “Yep. I’m happy.”

Opioids (think: Vicodin, Oxycontin, Codeine)

There is an ongoing opioid epidemic in the USA. This map from the CDC shows US prescribing rates. That map is from the collated prescriptions per 100 people. The CDC shows that the rates of prescriptions are starting to slow down, but, for every 100 people there are 59 prescriptions for opioids, as of 2017. That’s insane. The distribution of these prescriptions skew heavily toward a handful of states: Arkansas, Mississippi, Alabama, Tennessee, Louisiana, Oklahoma, West Virginia, and Kentucky. These states have opioid prescription rates near or above 100 Rx per 100 people.

Texas has remained relatively lower than these other states with an opioid prescription rate at closer to 58 Rx per 100 people, closer to the national average. How has Texas remained somewhat* insulated from the epidemic. According to Ernie Luce, Medicaid reimbursement for these drugs in the state of Texas leaves these drugs essentially uncovered so people get them at a lower rate than in other places. *I say somewhat insulated from the effects of this epidemic because I see this rate of prescriptions (as of 2016, 58/100) as too high and probably not the best medical care.

Opioids have a lower effectiveness than a combination of Tylenol# and ibuprofen# (#if the Tylenol and ibuprofen are taken together at the same time.) When taken together, they have an NNT value of 1.5. What that means is that if you give 3 people 500mg of Tylenol at the same time as 400mg of ibuprofen, within about 30 minutes, 2 of the 3 people would experience a reduction in pain of 50%, for dental pain. None of the opioid drugs comes anywhere close to that in terms of effective NNT. The traditional Tylenol No. 3 with Codeine and Tylenol has an NNT of 12.7, which means that if 13 patients are given Tylenol No. 3, 1 of the 13 will experience a pain reduction of 50% and 12 of the patients will not experience any meaingful reduction in their pain. Ibuprofen alone, is effective in 1 out of 2.5 patients at 600mg and 1 out of 2.7 patients at 400mg.

So, the takeaway message is that for moderate to severe pain a combination of Tylenol and ibuprofen is more effective than most opioid drugs.

Dental Implants – (the 5 Ws of Critical Information)

Dental implants

By: Dr. J. Russell McFarlane DDS

I will try to demystify the process of implants by answering the critical questions that every journalist is expected to address, the 5 Ws – who, what, where, when, why.

Who is a candidate for a dental implant? If you have lost a tooth, then, you may be a good candidate for a dental implant. If you have a healed area, where a tooth has been removed, you may be a good candidate for an implant. Pro Tip during extractions: Patients who undergo ridge preservation bone grafting at the time of the extraction tend to have much more robust bone with which to work. In answering the question of who is a good candidate, we must also address who is not an ideal candidate. The patients at highest risk for implant failure are patients who have a history of periodontal disease. Another factor that plays into how well individuals will heal is their medications. The prescription drugs most likely to cause problems are bisphosphonate drugs, which are often used for bone density, in cases of osteoporosis. These drugs are also being used to reduce recurrence of cancer, and the most significant problems are found with the injection variant of these medicines. Lastly, smokers have decreased healing capacity as it cuts off bloodflow to the peripheral blood vessels.

What is a dental implant? A dental implant acts as a tooth replacement, with a root form and attaches to a crown. A dental implant is a carefully manufactured and sterilized precision root replacement. They range in diameter size from 3.0mm to 5.0mm for the vast majority of dental implants. A small window is made in the tissue, then, the implant is placed into the bone to heal. After 3 months of healing, a crown can be made that connects to the root component. The crown portion of the implant is the part that most people think of when they think of a tooth, (the tooth colored top part that comes out of the gums.)

Where can you place an implant? Any site that has adequate bone can be replaced with an implant. Some of the most common implants are used to replace front teeth (incisors, central and lateral, canines, premolars, and first molars.) If there is no bone in an area, then, a bone graft with a guided tissue regeneration may be required.

When is the right time to get an implant? There are 2 distinct times that an implant can be placed for tooth replacement. 1. Sometimes an implant can be placed immediately at the time of extraction (at the time the tooth is pulled.) It is only possible to complete immediate implant placement when the tooth being extracted is not infected and generally only when the tooth comes out easily in one piece. 2. More commonly, we extract the tooth, and place a bone graft. The bone from the graft material will turn into your bone over the course of a few months. We like to place the implant after the bone has had 4-months to heal.

After the implant is placed, then, we wait for the implant (root form) to integrate with your bone. On scanning electron micrographs, there are images that show your body placing bone directly onto the implant. Titanium is very biologically compatible.

Why should you replace a tooth with an implant? This will help create a healthy and well-supported bite.

 

Quarterly Special for Veneers 10% off Celebrate 10 years in Practice at McFarlane Dental

Celebrate our Year of Jubilee with a Special for Veneers 10% off our normal veneer fee.

In celebrating 10 years in practice, McFarlane Dental is saying thank you to patients by giving 10% off veneers.

Celebration of McFarlane Dental 10th Anniversary
10th Anniversary celebration balloons

This will be part of our August 2018 – October 2018 Quarterly Specials.

Veneer Special – we are giving patients 10% off to celebrate 10-years. Normally, $1250/tooth. When we deliver a case of veneers August 1st, 2018 – October 31st, 2018, we will offer the service for 10% off. [Instant Rebate: $125/tooth.] Schedule your consultation today online, or call: 512-454-2744.

 

Thank you to all our wonderful patients!

Sincerely,

Dr. J. Russell McFarlanelogo-combo

10th Anniversary of McFarlane Dental – Invisalign Special $1,110 off!

In celebrations of the 10th Anniversary of McFarlane Dental, I want to say thank you to

Celebration of McFarlane Dental 10th Anniversary
10th Anniversary celebration balloons

patients by celebrating for an entire year – the Year of Jubilee.

We will be offering Quarterly Specials that will run for 3 months apiece. The first quarterly special will run from August 2018 through the end of October 2018.

Invisalign Special – we are taking the pricing back 10-years. Normally, $5610. If you pay in full between August 1st, 2018 – October 31st, 2018, we will bill it out at the same fee we did in 2010, $4500. [Instant Rebate: $1110.] Schedule your consultation today online, or call: 512-454-2744.

Exciting news about how we approach treatment: [We’ve learned a lot in 10 years.]

  1. We co-diagnose the case. Meaning: the doctor and patient look at the case together to decide what needs to be fixed.
  2. We collect all your records in 1 visit. 1. You will need a panoramic x-ray 2. You will need a full set of photos of your teeth. 3. You will need an impression (or) scan of your teeth.
  3. We can now scan your teeth digitally. Meaning: We can now scan your teeth directly into the computer and send the scan (digital impression) directly to Aligntech (Invisalign). We no longer have to make an impression with the gooey impression material sitting in your mouth for three and a half minutes per arch.

The result of digitally scanned cases so far has been: 1. better fitting trays. 2. you don’t

have to come into the office as often because the cases track more accurately. 3. the trays fit so well you may only have to wear each tray for 8-days instead of 2-weeks like we used to do 10-years ago!

Background on Invisalign: When I graduated from dental school in 2008. I went directly to the AGD (Academy of General Dentistry) National Meeting in Orlando, FL. I was so excited to start doing Invisalign that I took the course before I even took over the practice. I sat through the course enthralled. The reason the course was so fun and exciting was because it debunked some major myths. It answered the quintessential question of: “What moves teeth?” It might sound like a simple question, but, in fact, there is some unique nuance to this question. Force moves teeth. But, the idea that only brackets and wires can move teeth is a lie.

Light forces move teeth better than heavy forces. Do you want to know why? Light forces before-and-afterocclwebapply a mild pressure to one side of the bone in the tooth socket and pull lightly on the other side of the socket stretching the PDL fibers. The response of the bone around the tooth is to remodel, effectively allowing the tooth to pass through with no damage to the supporting structures. This explains why Clear Aligner Therapy (Invisalign) can be faster in some cases than brackets and wires. What type of force does brackets and wires apply? You guessed it – heavy forces. What happens when you apply heavy forces? The side of the socket in the direction of the movement experiences excessive pressure causing necrosis of that side of the bone. This causes ‘jump movement’ of the teeth, whereby the bone dies and is then removed by osteoclasts and replaced by osteoblasts. This movement hurts and is much more caustic to the patient than Invisalign. For this same reason, you do not see root resorption with Invisalign, but, you do see root resorption (root damage) from brackets and wires.

Patients in Invisalign often describe the mild discomfort of feeling the light pressure on beforeandafter2018standardswebtheir teeth as a good pressure as it feels good and they can tell that the teeth are moving.

The lab fee for a comprehensive Invisalign case is $1779.00; this cost represents the practice overhead for starting an Invisalign case as of 2018. A typical case requires somewhere on the order of 10 visits, 28 trays, 1-year of management, and possibly refinement. I do not offer specials on this service regularly. This special is truly just an opportunity to say thank you to my patients who have been so kind to me for the past 10-years. I am grateful and so I thought I would try to do something nice.

Thank you to all our wonderful patients!

Sincerely,

Dr. J. Russell McFarlanelogo-combo

Payment Plans, Crowns, Invisalign, Fee For Service, Insurance

Background

When I acquired the practice of Sir Hal Moore, the practice did not have a program in place for payment plans. There are myriad reasons why payment plans can become problems for dental offices, which I will detail below. But, technology has come a long way since the days of having to mail in a check for a monthly payment plan.

“Finally a system that is secure and allows patients to say yes to the care they need.”

Payment plans

When we recently changed our credit card processing company, the new company was able to introduce us to the most modern platform, which uses technically savvy methods of safely storing and accessing financial information. I thought to myself, “Finally a system that is secure and allows patients to say yes to the care they need.” Now, patients who need Invisalign, or extensive restorative work, or root canals and crowns, or 4 quadrants of scaling and root planing can get the care they need.

The way our new system works allows us to securely store a patient’s credit card on our credit card processor’s (Best Card) secure site, where the numbers are immediately upon storage scrambled into a mix of numbers and letters, encrypted so that they cannot be viewed by us (or anyone else) again. This allows us to maintain PCI compliance. PCI compliance is our promise to protect your personal information as it relates to payments. I have explicitly told the staff that I do not want us physically writing down any credit card numbers on paper, nor do I want them stored on our computers in an unencrypted file. This longstanding office policy has meant that we did not have a feasible way to set up payment plans, as many patients would have liked. Until now.

Moving forward, we have a simple way to store and access the credit card of a patient’s choice and set up recurring billing, without having to write down the patient’s credit card and without exposing their financial information to would-be hackers. I have put together some sample documents showing our two main options as they exist today. We have a 4-pay option and a 10-pay option.

Crowns

Let’s take an example where a patient has a severely broken tooth that needs a build-up and a crown. As of July 2018, the cost for the build-up is $294 and the crown is $1250. When teeth break unexpectedly, after chewing ice, a crouton, or biting into a fork, or after a period of undiscovered caries, a patient may not have had time to prepare financially for the immediate $1544 to fix their tooth. So, here is an example where a payment plan sample-crown-payment-plan-contract-2018 would allow that patient the flexibility to receive the care they need today and pay for it over the next 4 months.

Invisalign

Take an alternative scenario, a patient has decided they are finally ready to straighten their teeth. Historically, patients are required to pay for their desired Invisalign treatment completely up front. But, it might be a more approachable treatment if patients could start receiving treatment today and pay for it as we walk through the trays. Here is an example of what it looks like sample-invisalign-payment-plan-contract-2018 if a patient is ready to move forward and would like to make their Invisalign payments over the next 10 months. When we are completing a larger project like an Invisalign case, one thing many patients don’t know is that there is a significant lab fee. So, the initial payment made on day 1 would include the lab fee and small fee for carrying the payments over 10 months.

Fee For Service

Patients are likely better served in a fee for service delivery model where they are able to use their money for the procedures and services that they want. To help patients achieve this freedom and independence to apply their cashflow to the procedures they want without having to wait inordinate amounts of time (saving up) required a shift in my thinking. So, I believe that offering payment plans will attract new patients to the practice who don’t have insurance, but, still want to take care of their teeth. I have heard people ask, “What if I don’t have dental insurance?” So, I really had to start thinking about the reality that payment plans are the answer that allows those independent fee for service patients to say yes to treatment, and not have to pull teeth (extract teeth) that can otherwise be saved by crowns and root canals. It should also allow patients who want to replace a tooth with a dental implant to say yes.

Insurance

What drives decision making? Incentives. We have a growing number of patients whose insurance is covering fewer and fewer procedures. What is happening is that insurance companies are finding new ways to deflect costs onto their consumers, our patients. Take an example where a patient sits down into our dental chair and the insurance company has brought tricks from their medical insurance business and brought it over into dental insurance. Deductibles. When I started practicing 10-years ago, 2008, deductibles in dental insurance were unheard of; the primary reason you did not hear about deductibles is because insurers were not in the business of balking at paying their 50% of $400 for 2 fillings. But, little by little, they try to fool patients by showing them charts of all the things they cover at 80%, 50%, 100%, all the while avoiding paying their share, requiring narratives for simple procedures like single crowns. When an insurance company demands a narrative, they effectively delay payment and hope that many doctors and patients will simply give up, ending with the patient paying for a procedure that they have coverage for or the the doctor writing off significant portions of work that has already been completed and delivered.

The point I am making is that insurance companies incentives are not well aligned with patients. The result of this failing to connect on incentives has driven many patients to abandon their dental insurance altogether. A patient should not pay premiums month after month for years only to find out 5 years later, (when they are finally ready to use it to pay for a crown,) that they don’t qualify for the service. Even though the patients have paid into the system, the money they have paid in is not readily accessible and available to use for the procedures they actually want.

Insurance rarely* pays for sedation, regardless of whether it is conscious sedation (level 1 sedation), general anesthesia, or inhalation sedation with nitrous oxide (commonly “laughing gas.”) My front office staff member says it is a miracle if they pay for sedation (*because it is almost never.) They don’t pay for sedation regardless of the procedure, even if it is being used for the extraction of wisdom teeth.

Closing Thoughts

Austin, TX is a beautiful place to live. It is a beautiful place to practice dentistry. It is not getting any cheaper to live here. I met a man at Fresh Plus the other day who said he is “just barely hanging on,” referring to the ever ballooning costs of living here. These growing trends toward insurance avoiding their contractual responsibilities to patients, cost of living increases, and patients finding it hard to say yes to necessary treatment caused me to rethink my willingness to set up payment plans. So, I am making it known that we are here to help patients receive the care they need.

Special Offer for Invisalign for the month of April, 2018

Special Offer for Invisalign for the month of April, 2018

apr-2018-invisalign

Have you always wanted straight teeth but did not want to be a “metal mouth?” We have the solution for you, INVISALIGN. In under an hour Dr. Mobley can take pictures and impressions of your mouth and write a treatment plan. Within a few short weeks you will have custom made clear trays with an individualized plan for moving your teeth. You will get the benefits of straight teeth without the ugly metal and wires.

  • Full Case $5610
  • April promo $4610
  • (Treatment estimated to last over 6 months)

  • Express Case $4610
  • April promo $4000
  • (Treatment estimated to last 3-6 months)

All Invisalign patients MUST be free of cavities and receive ongoing cleanings, either at our office or another office. The best smiles are healthy smiles.

Wait no longer to get the smile you deserve! Invisalign promo will run until April 30th 2018.

CYBER WEEK Special: Professional Whitening In-office $200 off

CYBER WEEK Special: Professional Whitening In-office $200 off

Normally, $500 for 1-hour In-office Whitening, we are running a cyber week special, for $300.

  1. Go to the Pay Now page. Enter the information for the person paying for it, under First Name Last Name Billing Address, City, State, Zip Code, Country, Phone Number, and Email, all of these top fields should match the credit card billing information.
  2. In the space for Invoice Number/ Chart Number, type “CYBERWEEK” Under the space for Po Number/ Patient Name, type the name of the person who will be using the in-office whitening.
  3. In the space for amount, enter $300.

We will email you a certificate for the gifted In-office Whitening.

We never run a special, so get it before it runs out.

If you are looking for the perfect Christmas gift, you can give this to a family member or friend.

If a friend or family member comes in who is not yet a patient, as long as they have a home office where they have been seen within the past 12 months, they are eligible to do in-office whitening. If a person does not have a home office, but, wishes to redeem the whitening, we would strongly encourage them to get a cleaning, x-rays, and exam before moving forward with whitening. Otherwise, a person would need to sign a waiver that states that they understand that we cannot be held responsible for underlying caries, periodontal disease, or any other conditions, without a comprehensive exam. If a person who is redeeming the gift would rather use the money toward a cleaning, x-rays, and exam, then, the $300 will spend like cash and would cover a new patient visit (including cleaning, x-rays, and exam) assuming that the patient does not have periodontal disease. If the person using the gift certificate would rather have bleach trays made for at home bleaching and whitening, they can apply their credit to that, which would normally be $500, and it will completely satisfy the cost for whitening trays with 3 tubes of whitening gel. They will not owe $200, but instead will receive the same consideration, and the $300 gift will serve as complete payment.

If you have any questions about this promotion, call our office at 512-454-2744

This promotion will run from 11/29/17 through 12/15/17.