Every producer of these packages has testimonials and positive reviews on their website. They all say they do the really important stuff that we dentists need them to do. So, how can you really choose which one might work best for your office?

The answer is that each and every one of them will work for you. The pluses and minuses that each has washes out in the end if the software is continuously updated by the manufacturer. And most of the popular packages are updated regularly.

In the end, as so many things in life are, word of mouth carries the greatest impact in choosing a package. Packages that people have used or seen in other offices, that staff learned in school, and that people hear others speaking of positively will tend to generate more sales. Social media is a great way, if not the best way, to market your product with that word of mouth thought behind it.

Unfortunately word of mouth advertising can kick you in the ass and if you decide to open up the web as your mouthpiece, expect that you might have some bad stuff indelibly placed on the web for all to see forever…

When I opened my first office with a couple of buddies we had to decide on a practice management software package. There were a ton out there on the market then, and even more now. We chose to purchase Dentrix then because of some familiarity with it and the fact that it had potential to grow with the office. Dentrix back then worked very well as a clinical program but when it came to the front office stuff we found that it had some shortcomings. This was a while back so I can’t exactly remember what the issues were but I do know that they were fairly minor.

When I left that group practice to set up my solo practice I decided that I wanted to support a Canadian software company, if possible, and that it was more important for a package to work well from an administrative/accounting/scheduling/insurance perspective than for it to work well with respect to clinical stuff. I didn’t have a problem writing my patient notes by hand and we weren’t on to digital xrays. Because my office is small and we use just a small portion of the available dental procedure codes, communicating treatment and treatment plans from the back to the front the old fashioned way wasn’t a problem.

I chose Abeldent based on word of mouth, some usage at an office I had worked in, and the fact that it was used commonly enough in many offices that a large proportion of dental staff had some familiarity with it. Sure, it couldn’t do prescriptions then, clinical charting and notes sucked, and it had really minimal reporting and support that was relevant to a specialty practice. Abelsoft advertised widely, however, that they were working on all of these things — watch for them soon.

I think the package cost me about 10 or 12 grand to buy with four licences. I signed up for a maintenance package for about 3 grand a year that included fee guide updates and free software updates. Tech support cost was per use, but after setting up the program, why would I need to use tech support really? Everything that we’d need to know should be in the documentation and regular updates should fix any bugs that existed.

Really? Wrong.

Turned out that Abel updates happened once a year (for us anyway), maybe twice a year. Every update bloated Abel substantially and slowed down key parts of the package. Every update introduced random bugs in the software. Many updates changed the database so that we wouldn’t be able to uninstall the newer version of the package and revert to an older one (as far as I know). Abeldent continued to bloat. New updates added features that slowed things down even more, but never really addressed usability or fixed many obvious bugs. Customer satisfaction surveys that I filled out went unheeded.

By version 6 we had a decent balance between a stable system that we could work around bugs that we knew of, we were starting to get used to the slower modules and developed personal routines that we did while waiting for something like the prescription list to populate. When insurance companies or patients or even their lawyers wanted copies of my clinical notes for whatever reasons I resigned myself to doing screen captures of my notes page and printing them as graphic files because there was no way that I could find in Abel to actually print notes for more than one day at a time.

Abel’s solution to the slowdown was to require faster hardware for later versions. I was sent version 7 and then version 8 which required hardware beyond what I was running in the office. My patience, which had been wearing thin for years, broke and logic kicked in.

Yes I could spend money to update the hardware, but really how would I know that the software would be any more useable than it had been to this point. Abel’s software documentation was practically non-existent, changelogs were non-existent (and the documentation spelling out the major improvement or additions with each release never addressed bugs), and given their development track record I was pretty sure I’d be asked to update hardware at some point soon again. No, I had had enough.

I decided to cancel my maintenance agreement with them. We decided that we would enter fee guide updates by hand. I would keep version 6 running on existing hardware for as long as possible and just shelve versions 7 and 8. I would save at least $1000 a year, and after a few years I could look into upgrading hardware and software again. At that point, though, I would have saved enough money to allow me to buy a completely different practice management software system. It would provide me with more options.

Needless to say, Abel was quite surprised when I quit the contract. I had been paying into it for years and they probably expected that I was going to continue to do so forever.

Other offices must have decided to do the same as I had.

About 4 years ago we all received a letter from Abel informing us that they would only provide product support (which you have to pay for anyway) if we were on their maintenance contract. If not, you were shit out of luck. Of course, you could sign back up for the maintenance package for a few thousand dollars and then you’d be right back on track again.

I chuckled when I read this. To me it meant one thing only — Abel had been getting fat and lazy from money generated from these maintenance contracts instead of directing more of that money towards software development. Now that enough of their clients had smartened up, they were starting to get nervous. I chuckled again.

Fast forward to today.

Abelsoft continues to try to generate revenue by being lazy rather than innovative:

1. In order to attach my new associate endodontist to the software, we had to purchase a key from Abel. Abel initially refused to sell the key to me because I am not on their maintenance contract. After unleashing my office manager on them the issue was escalated and one of their managers eventually decided to allow us to buy the key without me having to be on retainer with them. Isn’t that awesome business practice? Making customers beg to pay for a software feature that should be a free part of any package.
2. Over the years, through hardware attrition, the computers in the office have slowly been upgraded and are now compliant with the requirements for Abledent version 8. I recently decided dust off the version 8 CD and installed it. As usual, many modules are grinding away even slower than before. There are new features, reworking of older features, and 2 new bugs. One has to do with printer dialogue issues, the other is shown in the picture above. Abel refuses to address these issues because we are not on a maintenance agreement with them. It’s almost as though they deliberately release buggy software in order to entrap your commitment to them.

So Abelsoft’s downside all stems from outdated licensing models and IT business practises. They are already feeling the effects of their stubbornness to treat their customers more respectfully. This friction to change can only lead them in the same direction as Research In Motion.

As one RIM ex-employee recently wrote, “Success cannot be borne of a 2005 status quo when the world looks a lot different now than it did even 12 months ago.”

Abel’s upside is their tech staff. Over the years, the people that we’ve had to deal with for tech support have always been exceedingly knowledgeable, efficient, and courteous.

Unfortunately that upside is not enough to keep me as a customer and where I go so will others. Online business practices and customer service have evolved in all spheres on the web over the years and consumers expectations continue to rise.

Abelsoft refuses to keep pace.

UPDATE, January 15th, 2012:

About five months ago Abelsoft offered to get us back onto a maintenance contract without charging me the restart fee. I agreed to this because they assured us that version 10 of Abeldent was more stable, less buggy, and solved many issues that I had with previous versions. I only had to upgrade the server to get it running.

I can report after using this new version for a few months that it is much less bumpy to use. Yes, there is buggy behaviour as before, but so far they have been minor issues (that I can’t even remember off the top of my head).

I’m now a satisfied customer again. I’m leaving the post above standing because there’s still a difference between a satisfied customer and a happy customer.

© Periapex for The Periapex, 2011. | Permalink | 8 comments |

My post-op film:

Too many canals spread wide to get them all in one shot. In the mirror, lingual is to the right, mesial is to the top of the picture:

In the mirror, from top left to bottom right we have MB, M, ML canals:

In the mirror, you can see DB and D canals:

In the mirror there are D and DL canals:

© Periapex for The Periapex, 2011. | Permalink | One comment |

What a not-surprise. So all you people that believe the pariahs (because they are always the loudest voices) might now be a bit confused after reading that.

Those quacks are laughing at how gullible you are because you believed them when they told you that vaccines will kill your children. They are still trying to understand how a bit of misinformation about government and business conspirators worked so well to make you not have your flu shot.

What another not-surprise that our emergency departments here in Ontario are overloaded this year with patients suffering from the flu.

Listen to people who actually know what they are talking about. Weigh the benefits and risks. What are the chances of dying from a serious illness that the vaccine can help prevent or minimize versus dying from the vaccine itself?

It’s one thing to ride the slipstream of an immunized population. Chances are if you’re not immunized you won’t catch the germ anyway because nobody is carrying it. That’s all gonna change as more and more of you people decide to let your bodies handle disease “naturally”. Death is quite natural. Transmission of viruses is quite “natural”. And those two things will increase as that slipstream you’ve been riding slows right down. That slipstream will slow down as fast as people are gullible.

*shaking head and rolling eyes at Jenny McCarthy*

© Periapex for The Periapex, 2011. | Permalink | No comment |

And let’s say that as i dwell on these feelings I develop an urge to give something back — something unique, helpful, and selfless.

I’m a dentist.

I was forced through crazy challenges in school to get to where I am. I’ve been through another school — the school of hard knocks — through my career, and I’ve survived. In fact I’ve become an awesome dentist because of Hard Knocks.

I need to give back, but I don’t want to give my hard earned money away anonymously to local charities that I don’t know anything about. I’m pretty content with the couple of bucks I give to my church every week or ten. My skills are too valuable to not utilize as much as I possibly can fixing people’s teeth, so I don’t have time to volunteer at the food bank.

I feel the need to give back though. Where can I apply my unique skills and knowledge to help people? Where can I do this and show them how skillful and knowledgeable I am, where these people would love me and line up to see me, where I would be “The Man” to them. El Hombre….spanish…latin….

Guatamala, Honduras, Mexico. Hmm.

Wow. I see it now! I can collect equipment and supplies from donors from whom I buy lots of stuff at my practice. I might be able to enlist some dental students to come and help out. I don’t care if I have to pay to travel and stay down south because it’s money well spent to help people. The homeless here in my town don’t need my money like these people do.

When I get down there I’ll show them how much better dentistry in Canada is than in their impoverished community. I’ll put in white fillings, save their teeth rather than pull them, use anesthetic, and wear a mask and gloves. I’ll *help* them. The line to see me will be days long. Unfortunately, as much as I’d love to help these people forever, I have to come back home to make some money. Maybe I’ll stay for a week or two.

I do wonder, though, what might happen after I leave. Might these people not want to see their tooth-pulling, painful dentist anymore? Will they wait and wait and wait for my return while losing tooth after tooth unnaturally? Will that be because they’ve lost confidence in the entire medical or dental system in their country? Would I have caused that?

There would be no lines to see their dentist and so no encouragement of the local profession to improve. I would have decreased national morale among both dentists and their patients and I might not be welcomed back again. I might single-handedly cripple an already precariously perched medical/dental system — all because I wanted to feel good about myself.

So…maybe what I’ll do instead of all of that is take my supplies and equipment and dental students and go to the local health department down there. I’ll tell them that we’re only there for a couple of weeks and we want to help. Have no doubt that we will help. We will suction, mix, clean, and offer advice to the local dentists. We will show them how to use the materials we are supplying. We will show them how we do things by allowing them to do the things themselves while we watch. This is positive, this creates growth, this is beyond ego, and is the greatest thing that we as a human can do.

But how many of us who volunteer do this? How many of us would even want to be seen as subservient to the local professional in that small community you want to help? How many of us need to grow up a bit?

© Periapex for The Periapex, 2010. | Permalink | 7 comments |

Resting In Peace near Hector, by the stream that runs behind our house, surrounded by the very Nature that she loved.

She is survived by 1 cat, 2 dogs, 6 fish, 3 parrots, and 2 humans.

7 Months old on April 10, 2010.

© Periapex for The Periapex, 2010. | Permalink | No comment |

Just as you can’t please every patient, you can’t be everything to every dentist either. The patient comes first, and if they get more streamlined, effective care via a different generalist-specialist combination, I’m fine with that.

You two or three constant readers of my blog know that I have no problem with patients or dentists looking elsewhere for treatment if they don’t want to abide by my office policies. My treatment philosophies and office policies are what they are for very good reasons and were developed through my years of practice from both scientific evidence and experience.

And yet there are still dentists that try to bully me every now and then. I still have a few things to learn about dealing with them. I react impulsively and aggressively.

Thanks to my co-workers I’ve been able to keep myself under control with this latest episode. They really are the best and I am unfathomably lucky to have them watching over me.

The case in discussion is that back molar.

A different dentist than the patient’s current idiot DDS did the root canal work and then the crown. From the film, you can see that the restorative work was not done well. There’s a poor restorative margin that is probably leaking (causing the recurrent root canal infection) and there is no satisfactory ferrule for the crown.

Retreatment of the previous root canal work is the obvious way to attempt elimination of the current infection. However, with the inadequate coronal restoration kept in place, the prognosis of the retreatment over the long-term is poor. This is simply because the probability that leakage of bacteria under the crown is occurring will not change unless the restoration is improved.

My recommendations for treatment were for the patient to have her dentist remove the crown and possibly the core, then assess restorability and/or the need for crown lengthening. If he thought that the tooth was workable from that perspective, I could redo the root canal and say that the prognosis is good.

Here’s his first email to me:

Hello [me],

I opened the crown on #37 today and accesed the pulp chamber and 2 treated canals. Because the mesial wall (composite) is intact and selaed from a pulpal aspect,  I closed the case and have referred back to you for retreatment of the case.  I will then restore the access and mesial wall with bonded amalgam to establish as good of a coronal seal as possible as pt. cannot afford to replace the crown at this time.

Although the mesisal and distal canal seemed centered in a rather mutilated pulp chamber, I am concerned that if the coronal seal was ok is there an untrreated canal?

You are seeing L later this month for the retreatment.

Sincerely,
[him]

This is my reply. I was concerned, maybe a little pissed, that my instructions weren’t followed. On top of that he’s suggesting that another canal might be the problem. Did he tell the patient this? If so, what if I see that there isn’t another canal? Will the patient then be confused as to why there’s infection in the tooth (since he apparently saw that everything was sealed well internally)? Also, the pulp chamber seems far from mutilated on the pre-op film. What problems has he caused me now by trying to help me out in his own way?

Hi [him], thanks for the email.

Without crown (and possibly core) removal there is no way to be certain that the current restorative margin is not carious. The current restorative situation with this tooth is wholly inadequate. Coronal leakage can be occuring at a microscopic level (since I’m talking about bacteria, not saliva).

It is possible that there is another canal, however, the best sealed canals will eventually become infected if the restorative seal fails even minimally over time (with recurrent caries or structural failure).

I’ll take a look around and clean things up the best I can once I get into the tooth. L will be told that the prognosis of the tooth from my perspective, though, is now guarded.

Thanks again for the heads up.

This was his reply:

Hi [me],

Firstly, please forgive my frank approach with you today but I am going to be brutally honest.

I am fully aprised of what bacterial leakage is, and what it can yeild as far as reinfection.

But from a restorative perspective I am not going to take the crown off #37or further impair the coronal seal as it exists because I may not be able to restablish as good of a seal temporarily( due to concerns about control of mesial marginal blood/fluid contamination below the tissue level for bonding seal) as currently exists to satisfy your desires prior to an endo retx. I determined this after opening the case because you would not. And taking the crown off entirely commits the patient to a new crown which she can’t afford. So alternatively should we just extract the tooth? No, I think with your endo expertise, and my restorative epertise we can collectively establish an accetable seal endodontically and restoratively so that the pt. may function with this tooth for some time.

And she is aware of the risk. I agree the crown is not pretty, but aside from the mesial margin it is not that bad form a marginal perspective. In fact from the outer dimensions of the crown and the dentist who did it may have been under-prepared.

So even if is leaking somewhat, big deal! Do the endo retx!
Then I can restore this case with a panavia bonded amalgam resoration in short order (as already explained), which will allow a one peice sealed resoration with amalgam posts, and mesial wall recreated in amalgam. BELEIVE ME I HAVE DONE IT MANY TIMES SUCCESSFULLY. If in the future L can afford a new crown, I will replace the crown at that time gladly.

You can’t have everthing perfect for every case my experience, because not every patient can afford the time nor the expense for your desires. But you can’t simply cast these patients away, can you?

Yes I agree, removing the crown and endo retx and possibly castpost core and a new crown would be great, but L can’t afford it. She has already having to absorb the cost of time off work, travel, etc.

So again, I have completed a liberal access so as to remove almost all the existing composite core (under 12x magnification) except for the mesial wall which is intact with some affected dentin left in place. Now you can complete the endo retx with your expertise and see if a canal has been been missed. Then I will restore the case with bonded amalgam. Yes the case is compromised and has a guarded prognosis, but the patient is fully aware of this as I have reviewed it with her at length.

I don’t refer to you regularily because I established endo referral sources when I worked as an associate at Yonge and Eglington for 4 years. But I can tell you this, in TO I would have referred this case had it retreated in one appointment, and now I would be shortly restoring it, case finished for obsevration.

I remember in my 4rth year at UofT when you were trying to take alginate impressions of B, your endo classmate, for a hockey mouth guard and failed on several attempts in clinic next to me. And I thouht to myself , this guy has no clinical experience at all as a restorative dentist. Now that I have been practising general dentistry as long as you have endodontics, I need to rely on your expertise, and you need to rely on mine as well.

Additionally, now that your office office has spoken with L and confused her, and clearly undermined my clinical judgement, she will certainly now have doubts about both of our capabilities, a rather unfortunate and inexperineced move on your part don’t you think? Next time you may wish to consider just picking up the phone and calling the dentist personally to discuss the case.

In closing, I suppose you can choose to not treat L, but instead I would suggest you do, and we move foward with and perform the best service we can collectively for L given the limitiations of this case.

Sincerely,

[him]

My reply:

That gave me a chuckle.

As I said before: L’s consent form for endodontic retreatment in my office will say that the prognosis is guarded.

Then he sent me something again saying it’s not a chuckling matter.

I decided to not bother continuing the inane conversation. My thinking is that if Patient L doesn’t have the money for a new crown, she shouldn’t be spending what little she does have on an expensive retreatment that will fail at some point.

Patient L ended up calling to let us know that she decided that she will go ahead with the crown after all. I’ve decided that her consent form will read that the prognosis of the retreatment is good (about 85%) depending upon the quality of the final restoration.

Because idiot dentist hasn’t properly worked the case up for a new crown by evaluating the prognosis or need for crown lengthening and providing that cost information to Patient L (all as I previously requested), poor Patient L will likely not improve her odds with this tooth by spending the extra money on a crown at this point.

She, not I, is unfortunately the one who will suffer most from this guy’s inflated ego.

© Periapex for The Periapex, 2010. | Permalink | 4 comments |

Most times when a rotary file breaks in a canal, the fragment is either irretrievable or the risk to remove it is greater than the benefits. This is purely because they mostly break apically, around curves, and the fragment is often no more than 3-4mm in length.

Using ultrasonics to remove a fragment in a situation like that can very easily lead to excessive damage to the apical aspect of the root. Apical surgery is often a more predictable approach if the fragment must be removed. Many times, however, the prognosis of completion of endodontic therapy with the file fragment still lodged in the root (ie. obturation that incorporates the fragment) can lead to a decent prognosis still. It all depends on the presence or absence of preoperative infection within the tooth and the management of the tooth through the whole process.

I have found that when instruments break in canals like this, it often is more a manufacturer’s defect than poor technique.

Here you’ve got a fairly thick file that broke off leaving a long segment in the canal. The canal is fairly straight and the head of the fragment is visible in the coronal aspect of the canal. I was able to trough around the fragment to about 2mm beyond the head of it. The energy from the ultrasonic tip them unscrewed the fragment and it popped loose. Often applying the ultrasonic directly to a fragment will cause the fragment to further fragment, but this piece was thick enough, not around a sharp curve, and visually accessible enough that I was able to retrieve the file and proceed to complete the endo normally.

On the post-op film you can see how close I was to a perforation of the root even though I had good visibility of the fragment through my microscope. Imagine trying to do all of that troughing in the apical third of the root.

Note that this file has radial lands, a larger tip diameter, and a greater than 0.04 taper. It’s probably a GT file.

© Periapex for The Periapex, 2010. | Permalink | 3 comments |

Tumblr, facebook, Twitter, and reams of other organizations provide canvases for us to share, share, and share. To top all of that off, I have gotten myself involved in activities and hobbies that no longer leave me time to blog as I frequently as I once did — and I don’t really need to.

The people that matter most to me are on facebook and see snippets of my life, as I see theirs. My brother and I have a photography business on the side with its own blog and we both spend lots of time on flickr.

I just don’t have the time to write down my thoughts about movies, theatre, and books with the same obsessiveness I once had. I’d like to, but I like too many things.

So what the heck am I going on about?

I’m saying that this blog is still a part of my life, but it’s a much smaller part than it once was because I share my thoughts in lots of other places. This is probably a good thing too because as I become more famous and sought-after for my opinions on movies, theatre, and books, it becomes more dangerous to have my life laid out in a single public forum on the internet.

At this point, I’m thinking that I’ll focus this blog more towards my experiences in dentistry. I’ll probably throw some interesting personal-life stuff in every now and then, but those of you that truly are interested in my personal life (god knows why you’d be) are already my friends on other sites where I expose more of myself anyway.

Refocusing has involved pausing my twitterfeed aggregation and limiting my use of Twitter. Facebook’s changes over the last year, along with a really useful RSS app, allows my brother and me to do things that we could only do in convoluted ways via Twitter in the past.

Times change and technology follows suit. Although the infrequent posts to this blog leave me appearing stifled, I am in fact the complete opposite because of these continuous innovations in the social media landscape.

© Periapex for The Periapex, 2010. | Permalink | 6 comments |

The back-story revolves around a patient from this dentist whom I saw for a consultation last week. She’d had root canal treatment done fairly recently and is experiencing persistent, residual symptoms. In my letter back to the dentist I mentioned, among other observations, “poor interproximal restorative margins”.

So this patient’s dentist calls today and says that she doesn’t see poor restorative margins on the PA that she has of the tooth (a recent PA of which I have a copy). She’s not sure where my assumption of poor restorative margins came from and would like a copy of my PA to see what I saw.

Here’s my PA which is not really significantly different from her PA — and this is just what you can see on film. My explorer got stuck under the mesial margin so heavily that I could probably have pulled that whole filling out if I had applied more force.

© Periapex for The Periapex, 2010. | Permalink | 4 comments |

I’ve always preferred dogs to cats, but some convolutions of the universe knotted together to drop these two into our home: Our neighbour’s cat (a stray who goes to them for bed and breakfast) got knocked up and had some babies; We’ve had a crazy mouse infestation in our walls this year; When we saw these two, we knew they were way too cute for their own good so we decided that we’d better look after them.

They are currently in training. I’m getting them used to flash photography…

© Periapex for The Periapex, 2009. | Permalink | 4 comments |