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837: Are You Playing Checkers or Chess With Patients? – Dr. Jim McKee

If dentistry were a game, it’s checkers and chess. But how do you know when a case is one or the other? To help you win no matter which game you're playing, Kirk Behrendt brings back Dr. Jim McKee, founder of Chicago Study Club, to share how to distinguish simple from complex cases so you can increase treatment success. Stop playing chess with the rules of checkers! To learn how to master the game you're playing, listen to Episode 837 of The Best Practices Show!

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Main Takeaways:

  • Know whether your cases are like checkers or chess. Is it simple or more complex?
  • Learn how to give patients realistic expectations when discussing treatment.
  • Become a physician of the masticatory system, not just a tooth carpenter.
  • Develop your occlusion and TMD skill sets to boost practice growth.
  • No one wants to do TMD and occlusion. So, be the one to do it!
  • Occlusion and TMD are in more demand than you realize.

Quotes:

“When are we playing checkers, and when are we playing chess? Let's start from the patient side. Everyone has patients who come into their practice that when you see their name on the schedule, you're super excited. You love the patient. The patient loves the staff. They get there 10 minutes early for their appointment. They pay their bills. It's a wonderful experience. However, we also have patients that when we see their name on the schedule, you get a pit in your stomach and you're like, ‘Ugh. I don't really want to see this patient.’ These are the patients, a lot of times, that'll cancel their appointments at the last minute, or they won't pay their bills, or they're rude to your staff. They're the patients that when you look at the schedule, you're like, 'Eugh.’ Those are the patients that we’re playing chess with, but we don't know it.” (2:53—3:43) -Dr. McKee

“I think the determination of whether we're playing checkers or chess comes from the clinical side. The easiest way to think about it after trying to put this into context is, if we have to do dentistry at the tooth level, we're playing checkers. If we have skeletal issues, such as irregular occlusal planes where you've got teeth in the lower anterior that are over-erupted, and the lower posterior are flat, and you've got a roller coaster arrangement of teeth, that's a difficult case. If you've got someone who's got a canted occlusal plane where one side is way higher than the other, they come in with a facial asymmetry, you're playing chess and not checkers. If you've got someone that's got structurally altered jaw joints, which many times is the genesis of all these problems, as opposed to normal joints, we're playing chess instead of playing checkers. If we have an airway problem, we have a good chance we're playing chess instead of checkers. Really, the easiest way to think about it, if we have a normal growth of the maxilla and the mandible, we're playing checkers. If we have an abnormal growth of either one of those — the likelihood is if one doesn't grow, the other doesn't grow as well either — then we're playing chess. And it's two different games. The problem is, if all we know how to do is to play checkers, and all the patient thinks they're going to do is come into the office and have to play checkers, but in reality, they present with a problem where now we have to change the rules and play chess, that's where the conflict comes in at the office because, quite frankly, many of us don't know how to play chess. That's where things become difficult.” (3:50—5:50) -Dr. McKee

“Let's say you have to do a crown on a lower second molar, and you prepare the tooth for a crown, and you go to check a hygiene patient. Your assistant starts to make the temporary, and they say there's no room — and you know that you prepared the tooth, so there's enough room there. What really happened was, that was probably the first tooth that was touching when your joints fit in the socket, and when you reduced that tooth, there was a shift of the lower jaw or the mandible relative to the maxilla. All that preparation space that you had worked so hard to get exactly where it would be so your lab would have enough room has changed because the position of the skeletal base changed. You're playing chess there. And if I'm not able to frame the patients’ expectations with that discussion, those are the cases that keep us up at night. They're the ones that burn the stomach lining. They're the ones that have patients leave bad reviews. Those are the patients that, generally, our staff get stressed out, we get stressed out, you go home in a bad mood, you can't enjoy your spouse, and you can't enjoy your kids because that case keeps going through your head. So, if we can help frame our patients' expectations, we can help frame our own expectations. Not only the patients’ expectations — it's really about framing our own expectations. Really, what this comes down to, I think, is enjoying dentistry.” (7:28—9:09) -Dr. McKee

“Today, we think of ourselves more as tooth carpenters instead of, as Pete Dawson would say, physicians of the masticatory system. If we can become physicians of the masticatory system, then we can get a leg up on knowing whether we are playing checkers or whether we're playing chess. I think that's the whole deal about framing the expectations.” (9:32—9:59) -Dr. McKee

“As a general dentist, we're the ones responsible for maintaining the occlusion. And I will tell you, without any reservation whatsoever, it is the Achilles heel for all dentists graduating dental school. We don't know anything about occlusion. Quite frankly, we know less about the temporomandibular joint. The clinical reality is those patients present with a far, far greater presentation than we think in our practice. Part of the issue is I think we've been led into a false sense of security about that discipline in dentistry. And really, it's one of the only disciplines in dentistry that hasn't changed their thinking in the last 20 years.” (12:16—13:03) -Dr. McKee

“Occlusion is still stuck from 50 years ago because, quite frankly, no one wants to do it. So, they just push people out of the office. The general dentist sends it to the orthodontist. The orthodontist sends it to the oral surgeon. The oral surgeon says, ‘I don't treat this.’ That's the problem. That's why TMJ patients are made out to be crazy. I will tell you, in my experience, those patients are not crazy. I'm not saying you don't get one patient that can have unrealistic expectations. But I don't think you get that any more than in any other discipline of dentistry. The reality is they are underserved. They've never been diagnosed. They've never had treatment options that really made sense because, as a profession, we have underestimated the amount of structural changes in jaw joints that occur in jaw joints. And I'll say it now. If you have a skeletal issue such as a Class II occlusion, a deep bite, an overbite, a gummy smile, a canted occlusal plane, facial asymmetry, a retrognathic mandible or maxilla, the odds are extremely high that you have a structurally altered temporomandibular joint. If I'm in Vegas, I'm going to bet heavy and I'm going to beat the house. I'll tell you, we always thought that those patients who came in had genetic problems. Those aren't genetic problems.” (13:21—14:51) -Dr. McKee

“The teeth are simply markers of the skeleton. If you have a malocclusion where the teeth don't fit, there's a strong likelihood you have a malocclusion at the skeletal level where the mandible and maxilla don't fit. The teeth are just extensions of the jaws. That's the issue that we have never embraced in dentistry. And I hate to say it, we're not getting any better at this. You're seeing specialty practices that developed today in terms of pain. Pain is great because you have to take care of people in pain. The problem, though, is you can have a temporomandibular joint problem, and by the time it hurts the horses are out of the barn. The most common clinical presentation of structurally altered temporomandibular joints is malocclusion. The pain is almost the last thing that happens. I don’t want to say always because that makes you sound dogmatic. But in 99% of the cases, you’re going to see a bite problem, a malocclusion. And honestly, the most common malocclusion we see is the Class II occlusion. So, I think we should talk about the prevalence of that a little bit because that’s where we get into playing chess.” (15:12—16:42) -Dr. McKee

“All these patients that are really playing chess, it starts way, way, way earlier than we think. We've made a mistake calling this degenerative joint disease. This is a growth issue. We're just seeing the downstream effect of it when patients are 20, 30, 40, 50 and we see these condyles that are trashed. And it's interesting, if you talk to radiologists who look at other orthopedic joints in the body, they will routinely tell you that the level of structural alterations at the bony level that you see, you don't see it in other orthopedic joints like the knee, the ankle, the shoulder, the hip, until patients are way later in life than you do with the TM joint. The reality is it's usually injured earlier. The three-year-old doesn't fall and tear their ACL. They fall and whack their chin on the coffee table. They fall and hit their chin on the tub. That's when the whole process starts. So, that's why I think that we have a lot more people that we're actually playing chess with than simply checkers. If it's a Class I occlusion and everything seems to be growing well and there are some minor crowding and rotations — easy. That's a checkers game. Fix the teeth, line them up, they're done. It's not as many as we think, though. I think far more times today, we're playing chess than we realize.” (21:49—23:24) -Dr. McKee

“When I first started doing this, I never had people referred to me — never. I mean, I was getting new patients. Someone would move into the neighborhood, and they'd move next door to someone who had been coming to me for five years, and they needed a cleaning. Great. I had patients, once I started doing this, that were now referred by orthodontists, by general dentists, by prosthodontists, by endodontists, and by periodontists. All of a sudden, what I realized is when a patient is referred to you from another healthcare practitioner, they come in at a different level. They come in more ready to hear what you have to say, more ready to pay a fair fee that allows you to pay your staff the highest wages in the community. So, you decrease staff turnover. You increase the staff's ability to support you in what you're doing. And, for me, once it started, it was like a snowball that took off going downhill, getting faster and faster, and more referrals and more referrals. It was awesome. Honestly, I never did anything to market the practice, and patients kept coming in and coming in, one case more interesting than the next.” (29:26—30:49) -Dr. McKee

“It's funny. We say we don't want to treat these patients, and yet we complain we're not busy enough when we have to sign up for insurance plans. The answer is kind of like The Wizard of Oz. There's no place like home. The patients are there. We just have to start understanding the process. I guess we've really made TMD and occlusion such a mystery that most dentists just throw up their hands and say, 'I don't want to deal with this.' That's okay. You can do that. But I think today, as you see demographics change, it becomes more difficult to do that.” (34:20—35:04) -Dr. McKee

“When I graduated dental school, and 26 years old, and I had a 26-year-old new patient come into the practice, there was a good chance they had MOD amalgams that were going to need crowns over the next 20 to 25 years. Today, you don't see patients coming in with MOD restorations that need full coverage crowns over the next 20 years. What you do see, though, is a lot of patients who've had orthodontics that have relapsed, or they've had problems not having their bite fit together, or they present with joint issues. I think you have to take what's in front of you. If you're a baseball player, you can wait for the perfect pitch to try and hit it. But you're not going to get that many pitches if you're a good pitcher. They're going to pitch around you. Learn to hit to all fields.” (35:05—36:01) -Dr. McKee

“Know the game you're playing. I think that the reality is we're playing chess more than we're playing checkers. Today, we’re taught that 5% to 10% of your patients have structurally altered joints. I think it's over half. If you really think about it, it's over half the patients that we see. Most of us aren't trained for this. If you can learn this — I guarantee everyone's not going to do it. So, you're going to be in demand in your dental community. Everyone that I work with in study clubs routinely tell me their production goes up almost instantaneously once they start getting their name out in the community because no one wants to do this.” (37:07—37:58) -Dr. McKee

“If you're looking to change your practice, start to understand which game you're playing. There are different rules for checkers and there are different rules for chess. If you're playing chess using checkers' rules, it's going to be a frustrating career. If you can play chess at a high level, it's awesome. It really is awesome. And I think the fun part of it is you can help so many people who really need help. TMJ patients have been made out to be crazy. They're just frustrated. They've been around the block. I mean, think about it. I just had ankle surgery six weeks ago. I went to four specialists to get opinions on my ankle. They all basically said the same thing, and I felt like I got good opinions from all of them. If you have someone who has a TMJ problem and they go to four different practitioners, they're likely to get four different treatment plans. And many times, none of them are close to being the same. Think about that if you were a patient. That's extremely frustrating. Lots of time, lots of money, lots of, ‘When am I ever going to get better?’ So, don't marginalize those patients. Bring them into your practice. The skill set is not that hard to develop. Develop the skill set, and I promise you it will lead you to an increased fulfillment in dentistry. It certainly has for me.” (37:59—39:28) -Dr. McKee

Snippets:

0:00 Introduction.

0:55 Playing chess versus playing checkers.

5:51 Frame your patients’ expectations.

10:00 Learn about occlusion and TMD.

16:44 Don't play chess with the rules of checkers.

23:26 Change how you talk to patients.

29:03 The fastest way to boost your practice.

32:04 Occlusion and TMD isn't as difficult as you think.

36:43 Final thoughts.

39:30 Dr. McKee’s future courses and Chicago Study Club.

Dr. Jim McKee Bio:

Dr. Jim McKee is a member of the Spear Resident Faculty. He has maintained a private practice since 1984 in Downers Grove, Illinois, where he treats a wide variety of cases with a focus on predictable restorative dentistry. He is a member of the American Academy of Restorative Dentistry and former president of the American Equilibration Society. He has lectured both nationally and internationally for over 25 years and directs several study clubs. Dr. McKee graduated from the University of Notre Dame in 1980 and earned his dental degree from the University of Illinois College of Dentistry in 1984. 
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