Office Visit: Dr. Kevin Axx by Sam Mittelsteadt, editor, Dentaltown magazine

Dentaltown Magazine

This Townie endodontist, who moved to the right city at the absolutely wrong time, explains how he hustled his way back into success, happiness and practice ownership.

by Sam Mittelsteadt, editor, Dentaltown magazine

Dentists spend most of their working hours in their practices, so they usually don’t get many opportunities to see what it’s like inside another clinician’s office. Dentaltown magazine’s recurring Office Visit profile offers a chance for Townies to meet their peers, hear their stories and get a sense of their practice protocols.

In this issue, we introduce Dr. Kevin Axx, an endodontist who practiced in Manhattan before heading west to enjoy sunnier days (literally). His arrival in Phoenix coincided with the economy’s bust, however, which left him scrambling to survive as an associate in a suburban practice in a city where he didn’t know another soul. Here, he discusses how he overcame those challenges and recently returned to practice ownership, where he believes the specialty is headed, and his suggestions for Townies who are thinking about opening their own practices.

Office Highlights

Tell us how you decided to get into dentistry.

I took pre-med classes at the University of Rochester in New York because, growing up, I knew that I was headed for medicine. But during my sophomore year of college, I became close with my best friend’s family and her father was a local dentist. He and I talked quite a lot, and he’d say that I was making a mistake choosing medicine because dentists work for themselves, work better hours, have a better quality of life, etc. He gets the credit for changing my mind—and my life!—and encouraging me to take the DAT and apply to dental school. Looking back, he was grooming me to return to Rochester and join his practice, but life is unpredictable and took me in a different direction.

Right after you finished your endo residency at Temple, you opened your own practice in Manhattan. How much of a challenge was it to be in charge of your own place so soon?

Manhattan is a unique place; people aren’t lying when they say it will either make you or break you. I was fortunate to be able to build my practice by renting space from one of my mentors, who taught me so much about the business of being an endodontist—the hustle and the methods that helped him build his successful practice. We didn’t get that in residency!

Too many new grads just out of dental school and postgrad residencies expect that when they get their first jobs, the patients will just be flowing in and their schedules will be full. That couldn’t be further from the truth—especially in a city with as much competition as New York. I knew that if I didn’t hit the pavement every day—going into dental offices introducing myself and pleading for an opportunity for a patient, even if it was at 5 p.m. on a Friday—that I might not pay the bills.

In 2007, you moved to Phoenix, where you didn’t know a soul—when you landed at the airport, the person who picked you up was the salesman you’d bought a car from over the phone. What led you to move 2,000-plus miles from your home state of New York, and how did you settle in to clinical work?

Moving from Rochester to Buffalo to Manhattan to Philadelphia, all for different schools, I was well versed in moving to new places and starting fresh. And having grown up in Rochester and getting my entire education in the Northeast, I was tired of the cold and the snow.

My first thought was to Miami, because everyone from New York goes to Florida for winters, but I expanded my options and also looked at practices in Las Vegas, San Diego, Los Angeles and Phoenix. Miami summers are brutal and the practice I’d been looking at still had damage from Hurricane Wilma, so Miami was out. I just couldn’t see myself enjoying life in Las Vegas, so Vegas was out. San Diego and L.A. were at the top of my list, but the dental market there was so incredibly saturated, compared with Phoenix. So by default, I decided to give Phoenix a respectable try—and if I wasn’t happy, I could keep going west to California. That was 12 years ago.

Settling into clinical work was pretty smooth. I joined a practice in Gilbert, Arizona, in September 2007 and was very busy for the first few months. Then, in November, everything started to slow down because of the stock market crash and the beginning of the recession, and I thought I’d ruined my life. The suburban practices in the Phoenix metro area got hit the hardest and, being the associate, I knew that the owner’s schedule would take priority and it was I who’d lose patients first.

There was no way I was going to just sit back and watch that happen, so I hustled. I knew what I had to do to find new referral sources, because I’d done it in New York. I found a part-time job at a group practice in central Phoenix, where the doctor had more patients than he could see in a week. Eight months after joining him, I left the Gilbert practice and went full time in the new practice, where I stayed until I opened my own practice in 2016.

Dentaltown Magazine

What led to the decision to open your own place?

Even though for a long time I’d said I wouldn’t go solo, I had to evolve my strategies. For seven years, I enjoyed the comfort of working four days a week for someone else, doing the endodontics that I love, without the headaches of ownership and administration. But I knew there was no potential for an equity stake in that practice and even though the owner-doctor wouldn’t discuss this with me, I had to consider what his exit strategy was going to be. With the size of his practice, only a large national corporation or a DSO could buy him out, and I wasn’t willing to consider working for a corporation. So, my choice was clear and I took the leap of faith again.

I chose the practice location based on the referral relationships that I’d spent years developing. I knew that many of them would easily be able to locate me—how many Dr. Axxes do you know?—and continue referring patients, so it worked out. Plus, my office is just under a mile from my home, which is incredible.

My associate in practice, Dr. Collin Clatanoff, is an Arizona native who served in the U.S. Army for eight years and planned to return to Phoenix after his commitment was done. He reached out to me and, even though I wasn’t looking for an associate at the time, we set up a meeting. A mentor once told me that it’s not every day you meet someone outstanding who shares your work ethic and you’d love to have work in your business. When you do meet someone like that, if you don’t have a position for him or her, you make one. Don’t lose that person!

What were your biggest takeaways from the design and construction process?

First, hire and consult with the right people. This was my first time building an office, but thousands of dentists have done this before—some multiple times—and there are professionals who build them for a living. Dentaltown is a great resource for this: We have, at our fingertips, an entire community of doctors who’ve done exactly what we’re about to do, and they’re willing to give you advice from their own experiences. Townies have already made the mistakes; they’ve already gone through trial-and-error. Take advantage of that so that you don’t have to make the same mistakes.

Also, talk with your local vendors. I built great relationships with most of my vendors before ever owning a practice, because they have their fingers on the pulse of the community. They have so much knowledge about the local market and so many resources for office design, functionality, equipment do’s and don’ts, and what’s worked or hasn’t for your colleagues.

Another pearl that a colleague gave me is to hire a third-party professional negotiator to negotiate insurance fee schedules on your behalf before you sign a single contract with any insurance plan. There are so many alliances and linkages between major insurance companies that signing up for one PPO plan that has very low reimbursement rates can unknowingly also commit you to in-network status with other insurance carriers at the same horribly low rates. Don’t try to navigate this yourself! There are several negotiators who do this every day and it can change your profitability overnight. Even practices that have already been in contracts for years should enlist help, because the negotiators can clean up the messes that were already made.

Walk us through a typical day in your practice. How does it compare to when you first started practicing?

I complete about 1,500 cases a year, which translates to about 30 per week, and I’m much more efficient at this point in my career than when I first started practicing. It took several years to get here and now my process is very streamlined.

Generally, I book six 75-minute treatment appointments per day, including root canal therapy and re-treatments with or without the Sonendo GentleWave System, root end surgery (apicoectomy), extractions, grafting/ridge augmentation, and surgical implant placement. Consultations, emergency patients, follow-ups and recalls are all put in a side column and are seen concurrently with treatments.

I enjoy doing surgery because it gives me clinical satisfaction and breaks up my day. I also started offering implant and sedation services because we’d always have patients asking for them: When a tooth is cracked and the patient is already numb and in my office, they’d ask why I couldn’t just extract it for them. Now I’m able to do that and preserve the site for the implant.

When surgeries run on time, I can usually do them in the normal 75-minute slot. But as anyone who does surgery knows, things don’t always go as planned. So I prefer to schedule my surgical procedures in the last appointment slot of the day. If I run into a complication and the procedure is running late, I’m less stressed knowing that it’s my last procedure, and there’s not another patient in the reception area I’m going to run late for because of this.

You’re a big proponent of the GentleWave System. What have you been seeing with the patients you’ve treated?

I’ve been using it for 15 months and it’s produced such great results that recently we bought a second unit. So many patients were requesting it that we were running into a wait when my associate and I both needed the device.

GentleWave allows us to treat, debride and disinfect a larger amount of the root canal space—including lateral canals, accessory canals and other portals of exit that we previously left untreated or had no way to get into. And we’re able to do all of this without having to use any rotary instrumentation larger than a Size 20 or 25 .04 taper file. It’s incredible the amount of root dentin and cervical dentin that’s being preserved.

The preliminary findings and SEM studies are showing cleaner dentinal tubules and walls than we’ve ever had in the past. Granted, the technology is new, so there are no 5- or 10-year studies yet to provide an evidence-based assessment, and the early studies that have come out have been funded, sponsored or approved by Sonendo. But from the 600-plus cases that I’ve treated in my office, we’re seeing a significant reduction in postoperative pain and follow-up calls. Re-treatments are being completed in a single visit because the disinfection is so much more effective, and our typical 10–15?percent flare-up incidence is down to less than 5 percent.

We’re also seeing teeth with apical pathology and osseous breakdown heal in 3–6 months postop instead of the traditional 12–18 months with conventional treatment. I don’t think anyone is sure at this point why the bone is healing faster, but it is, routinely. There are users on Dentaltown and other forums who post their own results and we’re all seeing the same thing: better outcomes for more patients.

How many of your cases are GP referrals, and how many are patients who find you on their own?

The majority of our patients have been referred to us from another office, but an interesting thing has been happening recently: For the first time in my career, the number of self-referred patients in each of the past three quarters has been larger than the number of patients coming from my top referral source. That was eye-opening and is changing the way I think about my business and my marketing strategies.

As specialists, we generally earmark our marketing budgets toward our target audience: dentists and prosthodontists, mainly, and some other specialists. Now, I’ve started to develop new strategies to target the public and improve our online presence. I can’t ignore that there’s a population who make their dental treatment choices through word of mouth and online reviews. We work really hard to make sure that every patient has a “five-star hospitality” experience and we use Review Wizards, which is a service that texts patients after their treatments to give them an opportunity to write a review on Google, Facebook or Yelp.

What’s something that remains a challenge for you?

The biggest challenge is staffing the office. We’ve been growing consistently for the past two years but have had a challenge finding the right team. With unemployment so low, the applicant pool hasn’t had great qualifications and all of the current employees feel overworked. We offer a great benefits package—health care, vision coverage, 401(k), paid holidays and paid vacation—but staff retention still remains low. A lot of my colleagues in Phoenix are having the same issue and it makes running the office efficiently a challenge. We’re constantly evolving our interviewing and hiring processes, so I know we’ll find the right team soon.

Dentaltown Magazine

What do you think is the most challenging problem for endodontics today?

The what part of that answer is easy: The biggest challenge in endodontics is the diminishing body of patients who need endodontic treatment but aren’t given the option to come to our office.

The why is more complex. There are many reasons patients don’t make it to our office. General dentists coming out of school with mountainous debt and a less-than-busy schedule keep more specialist-type work in house and do it themselves. Practice consultants encourage dentists to hire roving specialists to work for them and keep treatment in-house. More and more patients with teeth that can be saved through root canal therapy or re-treatment aren’t being given the option to save their tooth, but instead are being advised to have their teeth extracted and replaced with implants.

Endodontic procedures are difficult to do. Some dentists do them well. Some dentists don’t do them at all because they understand that the technology we have as specialists can deliver a superior result to what can be achieved in a dentist’s office. And some dentists do procedures that often don’t meet the standard of care.

I think every specialist has a few referring dentists who we know refer us patients only after a complication happens, or after they attempt a difficult procedure but can’t complete it. Many of those complications arise from poor case selection and should’ve been referred to a specialist in the first place. But the reality is, for any number of reasons, those cases are not referred and it’s the patient who suffers. As a profession, we all need to make a conscious effort to put the welfare of our patients, and best treatment practices, above any other factor in deciding what treatment to recommend.

Outside of the office, you also volunteer your services at other locations throughout the Valley of the Sun.

I feel fortunate to have the life I have, and I owe much of that to dentistry, so I love to pay it forward. For more than a decade, I’ve been the lead endodontic faculty at the Brighter Way Dental Center, a nonprofit organization run by a fellow Townie, Dr. Kris Volcheck, that offers comprehensive dental care to Phoenix’s homeless community and U.S. veterans, provided by dental students from A.T. Still University and volunteer local dentists. One day a month, I go to Brighter Way to teach the fourth-year dental students clinical endodontics.

For the past four years, I’ve also taken my entire staff to AZ Mission of Mercy events to help provide free dental treatment to anyone who shows up and waits in line. It’s astounding how many people line up overnight or longer to get cleanings, fillings, root canals, Cerec crowns, extractions and even immediate dentures. Each year I go, I provide about 20 root canals a day to these patients. All of us who participate with AZMOM know the value that the patients get from it. But I’ve realized that the experience is as valuable—or even more so—to me and my staff.

Describe the most successful or rewarding experience in your professional life.

One of the most rewarding experiences has happened recently: Last year, I started the masters program at Spear Education, which to me is a world-class organization and it’s right in my backyard in Scottsdale. I know that I’m well-trained in the practice of endodontics, but this experience is teaching me so much about the business of endodontics. It’s training that’s not part of any dental school or postgrad residency. I’m learning so much from the programs at Spear, but there have also been validating moments where I realize that some business processes that have proven records of success are ones I already use. And there have been eye-opening moments that have changed the way I look at and conduct certain parts of my practice.

Give us a snapshot of your life outside of dentistry.

Growing the practice takes the majority of my time lately. I see patients four days a week, but always have admin to do on the “off days.” The free time I do have I spend with my husband, Cameron, and our dog, Hadley. Cameron and I are both originally from the East Coast and we love to travel, both to see our families and for vacation. We spend a lot of time on Cape Cod, we’ve been on safari in Africa, we got married in St. Maarten, and we’re starting to make our way through Europe. We’re both working through the stresses of balancing business and personal lives and we’re trying to enjoy the journey.

I also love to do things that make a difference in our community. I’ve been a volunteer Big Brother in the Big Brother Big Sister program since 2009. And in 2012 I co-founded the QU Scholarship Fund for LGBT youth in Arizona, along with my friend Dr. Shel-Don Legarreta, an internal medicine specialist. We were involved with a local LGBT youth organization called One n Ten and realized that many of these youth didn’t have the resources or guidance to pursue a college education. We started raising money for a scholarship and what we thought was going to be a quick fundraising push to raise a couple thousand dollars in 2012 has, seven years later, turned into a $300,000 endowed scholarship program that has already awarded more than $100,000.

In addition to the monetary awards, we also pair each scholar with an academic and a professional mentor to help them navigate the transition from high school to college and to provide networking opportunities and guidance from volunteers already working in their perspective fields. I didn’t get to where I am today by myself—I had family, friends, mentors and an army of support that helped. Our scholarship provides some of the same support to the next generation of students.

If you could send a note back to yourself before you began practicing, what would it say?

“Kevin, you know you’re going to spend your life working hard. It’s who you are. But make sure that in all that work, you remember to take time on a regular basis to slow down, relax, and enjoy yourself, your friends and your family.”

The hardest thing for me is to slow down and enjoy the moment. I’m Type A to the max—if I’m not being productive, I’m anxious. It’s been a challenge for me to realize that my work is only part of what defines me and it’s OK to leave work at work. (I think a lot of Townies will relate.) Taking time to stop and smell the roses is some of the best advice I can give, and it’s proving to be some of the hardest advice to take.

Dentaltown Magazine

When a tooth is diagnosed as cracked, it should always undergo pulp vitality tests—cold, percussion, palpation, mobility and periodontal probing—to determine the recommended treatment.

Office Highlights

The first test I do after visual inspection is periodontal probing. Probing for endodontic reasons isn’t the same as probing in six spots for periodontal charting; when I’m searching for cracks, and vertical root fractures, probing should be circumferential in as many spots as possible, because I’m looking for any isolated vertical defects or bone loss. 

Next, I do percussion testing using the back end of a mirror. (I include the tooth in question and at least two other teeth in all tests.) I follow this with the palpation test by putting about 2 ounces of pressure with the pad of my index finger on the buccal maxilla or mandible, as close to the apex of each tooth as can be estimated. For mobility, I use the back end of my mirror and the back end of a cotton pliers to apply pressure in a back-and-forth motion from the buccal and lingual to assess any movement.

And, finally, I do the cold test with a cotton pellet and Endo-Ice. I always give the patients instructions before I start the test. I say, “I’m going to cool this cotton down and touch your tooth. As soon as you feel any cold or sensitivity, raise your left hand and I’ll take it off. Then, put your hand down as the feeling goes away.” We’re assessing intensity and duration, and if either of these qualities is abnormal relative to the normal teeth that are also tested, a pulpitis is diagnosed. 

If a pulpitis is diagnosed, or if any of the pulp vitality tests produce an abnormal result, such as pain or sensitivity, use the following flow chart to determine treatment.

I have a preoperative discussion with every patient and say that because the tooth is cracked, it’s uncertain preoperatively whether the tooth can be saved or not. It will depend on the health of the gums and bone (perio probing) and the severity or depth of the crack. If the tooth can be restored, the prognosis is guarded and there is the potential that the tooth may need extraction in the future.

— Dr. Kevin Axx


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