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 doctor’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. Nicholas Roy, a Townie who recently received his mastership in the Academy of General Dentistry and practices in rural Maine. Roy prides himself on maintaining his practice’s small-town feel while providing top-notch care. In 2018, his practice, which was previously housed in an 1812 farmhouse, won the Outstanding Design Innovation award in the ADA Dental Office Design competition. In addition to maintaining his award-winning practice, Roy treats veterans through his organization Smiles for Maine Vets. Read on and check out Roy’s practice and see how he makes a lasting impact with a high standard of care.
Name and credentials:
Nicholas K. Roy,
University of Connecticut, 2007
Saco River Dentistry,
7,900 square feet
Let’s start with the basics. What inspired you to get into dentistry? How long have you been practicing?
I’ve been practicing dentistry for 11 years. I’d always known I wanted to be a scientist, but also loving people, I looked to medicine as a profession that combined science and humanity.
During a medical specialty program in high school, I spent time with physicians in several areas of medicine and it became apparent that medicine was not what many in the profession hoped it would be. The days of being a true “family doctor” had seemed to disappear with the advent of managed care. During these shadowing sessions, several physicians said that if they could do it all over again, they’d be a dentist.
Not growing up with regular dental care, I didn’t know what to think, so to find out more, I shadowed a dentist, and within five minutes I was hooked. He spent three minutes talking to his patient, a lovely elderly lady about her cat, Fluffy. It was wonderful to see this personal connection. So, what inspired me to get into dentistry? It was Fluffy.
In 2018, Saco River Dentistry won the Outstanding Design Innovation award in the ADA Dental Office Design Competition. What do you think earned your practice this distinction?
When I bought my practice in 2013, it had five operatories and was housed in an 1812 farmhouse. We quickly began to outgrow a dilapidated facility. After doing the demographic analysis, we decided on a 13-operatory facility. Knowing I wanted to do this only once, I made sure I did it right. Upon designing, I had no idea there was such a contest. Instead, what drove us was a desire to create a state-of-the-art facility that maintained the small-town feel. Countless nights of design (and redesign) later, we feel proud to have created something great.
Buxton, Maine, is a relatively small town in a rural state. Are there any disadvantages to your location?
The short answer is no. But let me explain: Years ago, I attended a lecture where the presenter showed cases and said, “This is all my patients can afford, so here’s what I did.” He was referring to the fact that his patients’ financial demographic could not benefit from higher levels of care based on affordability, and as a result, his “outcomes” were less than ideal. Near the end of the lecture, one dentist in the crowd raised his hand and asked if he could provide some insight. The attendee said, “Dr. Smith, I’ve been sitting here listening to you talk about how your patients can’t afford higher levels of care. I looked up the average median household income of your town and compared it to mine. Your community is $25,000 more wealthy per household than mine, and so I must conclude that it’s not the money, because I do comprehensive care daily. Instead, maybe it’s you and your inability to create value in higher levels of care.”
It was an intense moment for me to watch this battle, but one that shaped the trajectory of my career. After the lecture, I approached the dentist in the crowd and talked with him about what his thoughts were regarding value building during treatment planning. He went on to talk about the fact that dental school prepares us for single-tooth dentistry and not much more, but most patients with single-tooth problems have oral systemic problems (problems with the gnathologic system). He recommended Spear, Dawson, Pankey, Kois, etc., as a means to learn how to increase value in the eyes of our patients. And he was correct, because all of these advanced treatment concepts focus on the entire gnathological system for answers, not a single tooth or isolated problem.
A classic example is metal show-through on a PFM crown on #18/31. An easy conclusion would be the porcelain just “wore away.” But the answer is much more than that—specifically, a manifestation of a broken system. I guess what I’m trying to say is that a patient’s ability to afford treatment changes as we get better at treating comprehensively and presenting with a value-building approach. Therefore, although I’m in the “sticks,” I’ve found that patients will find means if you can increase the perceived value of the proposed care. Done ethically, comprehensive treatment planning is not deception, but instead, proper education. What ends up happening is improved delivery of care, increased enjoyment for the clinician and increased predictability to treatment outcomes. A win–win for everyone.
1. Rubber dams. A bit general, but I can’t imagine doing any restorative dentistry without a rubber dam. It’s better dentistry and a better experience for both patient and clinician.
2. Triad Gel by Dentsply. This is like dental duct tape for me. Although it was designed as a lab product, it has a plethora of clinical applications. Specifically, it does a great job on rubber dam clamps, Tofflemire band holders, Bioclear matrices and more.
3. Blue Sky Bio products. For my cost-conscious implant patients, I enjoy offering a “second-tier” option for implant dentistry. I’ve used BSB products for about six years and I’ve found success rates equal to
the major implant companies. As a result, I can offer implant dentistry to more patients than I would have been able to otherwise.
4. Cytoplast Titanium-Reinforced PTFE Membranes. Stability of grafts is imperative to convert grafted bone into native bone. These membranes provide this better than previous generations of membranes.
5. Endo Activator by Dentsply. Activating endodontic solutions is a surefire way to adequately clean the irregular spaces found in teeth. Since starting using this simple tool, I’ve obturated so many more accessory canals. I wouldn’t do another case without it.
You’re very involved with the veterans in your community, and have founded the nonprofit Smiles for Maine Vets program. Tell us about the program and what inspired you to start it. How many people are involved? What type of treatments do you provide?
In 2014, I went home for lunch one day, and as I was making a sandwich, SportsCenter replayed the ceremonial “first pitch” from a previous night’s baseball game. A lucky girl got to throw out the first pitch to a masked catcher, who sported the jersey of the home team. After completing the pitch, the catcher approached the young girl on the pitcher’s mound and pulled his mask off, and she instantly began to cry because it was her father, home from the war in the Middle East. His daughter’s such strong emotions made me start to cry, and I thought about the sacrifices veterans make for our freedom.
Then, a day later, a patient sat in my chair and shared an astounding fact: Although he was a 90%-disabled veteran, he wasn’t eligible to receive dental care coverage from the VA hospital because he wasn’t 100% disabled. He came back with PTSD so bad that he could barely hold a job or muster the gusto to brush his teeth enough to keep them healthy, and yet because of his debilitation and the lack of government care, he lived outside any safety net that would keep his smile healthy.
That day, instead of complaining about the misallocation of federal funds, I decided to be part of a solution. Fast-forward five years, and we’ve transformed the lives of 17 veterans, while creating Smiles for Maine Vets. This program, in partnership with a local VA, can act as a template for other U.S. dentists where local programs don’t exist—our website includes a phone number so other dentists can learn about the simple, yet effective protocol that can help veterans in need.
One interesting, yet sad, aspect of this issue that I became aware of: 60% of veterans who are receiving psychiatric care at VA centers are victims of sexual abuse from other military members. This astounded me; I’d originally thought the patients in our program would have PTSD as a result of the horrors of war. To help with this aspect of the cause, my female colleagues, Drs. Kristian Richardson, Jessica Hines and Elle Donnelly, have embraced these victims of sexual abuse. As the old proverb says, “It takes a village,” and I feel blessed to have others around me sharing in this, and similar causes.
- All-Bond Universal, Bisco
- Fuji Plus, GC America
(for zirconia and PFM crowns)
- Variolink Esthetic DC, Ivoclar Vivadent (for e.Max crowns, onlays and inlays)
- Choice 2, Bisco (for veneers)
- Blue Sky Bio
- DeVantage (in-office
- Lending Tree
- Dentrix (planning transition
to Evidentiae in 2020)
Biolase diode laser
- iTero scanner
What have you enjoyed the most about this program? Tell us about one of your more memorable cases.
I’ve enjoyed the process of seeing my colleagues enter into the world of altruistic dentistry. Seeing their faces as they discover that giving back can be more satisfying than making more money to upgrade their house or car has been awesome. God gave us the skills, so we’d better do some good with it!
Although each and every case is special and memorable, Jason stands out. As seen in Jason’s “before” photo below, PTSD got the best of him, and as a result his oral health suffered. Being a productive member of society is difficult with teeth in that condition.
To get Jason the confidence he desired, we did upper and lower “All-on-4”-styled implant fixed prostheses. His confidence went through the roof, he obtained a job, improved his health and lifestyle, and found love. Having a skill set that allows us to provide such life-changing experiences is something that all of us consider a blessing.
You say your main goal is to provide comprehensive care under one roof. How do you aim to do that in your practice on a daily basis?
Patients in rural settings often complain about having to travel to see specialists, because it can take several appointments to execute care. When possible, we try to increase our skill sets to offer care in our office. In today’s day and age, obtaining additional postdoctoral education is so easy. With dental implant MaxiCourses, MasterTrack through the AGD, the Pankey Dental Institute and a plethora of online educational platforms—Dentaltown CE courses, Dental XP, Spear Online Education, etc.—increasing skill sets is easier than ever.
I’ve also seen the inefficiency of the “patient shuffle”—from one specialist to the next, only to end up without comprehensive care. In contrast, we’ve found that with proper treatment planning and clinical training, excellent care can be delivered under one roof. As we progress forward, we are looking to have each dentist within the practice focus on a specific skill set. For predictable cases, we can provide a service for the patient without the aforementioned challenges. For the tougher cases, we have a wonderful network of specialists to refer to.
Walk us through an average day at your practice. How many patients do you typically see in a week?
I see anywhere from one to four patients per day. I focus on comprehensive care and sedation. A common day includes a patient with a compromised dentition and multiple needs, including dental anxiety. We do moderate oral conscious sedation, remove hopeless teeth, perform socket preservations and endo where needed, prepare all of the necessary teeth and deliver PMMA long-term provisionals. It can be a long day, but the patient leaves with removal of disease, a new provisional smile, new functionality and, most importantly, nothing removable, which is always better over the surgical sites. These can be long days but always gratifying, because we’ve provided so many services, all under one roof in a single visit.
You’re very passionate about sedation dentistry. What do you like about it, and how has that helped you in your practice?
I couldn’t imagine not having this arrow in the quiver. It’s not a secret that many patients fear what we do, especially those who have severely compromised dentitions, because they’re often in their position due to their dental anxiety. To perform this care in a predictable and safe manner, we think it’s imperative to remove fear from the equation by utilizing moderate oral sedation, which is successful in more than 95% of our cases.
In addition, many of these patients are medically compromised, and with proper case workups, use of sedation can actually decrease the risk for a negative situation, especially toward cardiovascular events.
Lastly, having a sedated patient makes the clinician’s experience far better. As I often tell patients who are on the fence, “Sedation helps us as clinicians develop better care, because a fearful patient with white knuckles never makes treatment easier for us.”
What are some of your favorite technological advances?
I am so glad to be part of dentistry during the digital revolution. Of all the advances, the CBCT is my favorite. Seeing the third dimension is such a valuable tool in what we do, from implant dentistry to endodontic diagnosis and treatment. Most importantly, it’s great to be able to see this third dimension during treatment planning, because it helps create a full set of solutions for the patient by preventing surprises during treatment.
We’ve also recently entered into the world of digital scanning with iTero. We do a fair amount of Invisalign treatment and calculated that we’d save money on these impressions alone. We do a cost analysis with all of our equipment purchases and it was time for digital scanning. Not to mention, the iTero can do smile improvement simulations chairside, so that patients can see what is possible before ever committing to anything. It’s quite an amazing piece of technology.
Over the next few years, we’ll be looking to add in-office milling and 3D printing to complete our digital workflow.
What gives you the most professional satisfaction?
Having four colleagues and a full team of assistants and hygienists who are all constantly wanting to improve and learn. Having a rich learning environment is very satisfying. As one of my mentors once said, “The day you stop learning is the day you retire.” This was also one of the reasons we built a larger facility—for professional camaraderie and learning as a team.
You recently received your mastership in the Academy of General Dentistry (MAGD). What does this signify and how did you achieve it?
The Academy of General Dentistry awards two designations that signify a commitment to continuing education in dentistry. The first, a fellowship (FAGD), is awarded upon completion of 500 hours of CE and successfully passing a written examination. The second award, mastership (MAGD), is attained after 1,100 hours of CE, which includes a large hands-on component and completion of hours in all areas of dentistry. To facilitate obtaining this volume of specific coursework, I entered into the five-year New England Master Track Program (NEMTP), which gave me most of what I needed to complete the coursework for the mastership.
I can’t emphasize what a positive experience this was for me—especially the camaraderie and friendships created from this top-notch program. I learned just as much from the high-caliber classmates as I did from the world-class lecturers. My current indirect bonding protocol was learned on a napkin over dinner and a bottle of pinot noir with one of my classmates, who was taught by Dr. Pascal Magne. Having such a rich collection of knowledge supercharged my own learning at each and every session. Thanks to NEMTP, my treatment-planning abilities are also better than ever, because I have a much more complete picture of each of the specialties.
What are some of the challenges that you face today? How do you try to overcome them?
As a business owner, there are so many hats to wear. But managing people is by far the most challenging aspect to running a business—especially one with 35 employees. With that said, my management team has worked steadily on learning how to become leaders, not managers. There’s an important and difficult distinction between these two concepts. Two books that have helped us in this endeavor are Emotional Intelligence and Extreme Leadership. These are two must-reads for anyone wanting to get the best out of their employees while yearning to maintain their respect. Today, I spend as much time on business and leadership training as I do with clinical training.
What do you enjoy to do in your spare time? What are some of your hobbies outside of dentistry?
I love the outdoors. I love fishing with my wife, Danielle, and two Labrador retrievers, Neely and Stanley. I also enjoy golfing, because the strategic nature to the sport draws many parallels with dentistry. My ideal relaxation is fishing on a remote pond in northern Maine while watching the Perseids meteor shower. Also, my wife and I have started doing CrossFit and Pilates. These two modes of exercise have removed all of the back issues I was having because of the ergonomic demands of our profession.
What’s something you’d like to see dentistry do differently, as a profession, within the next 10–15 years?
I’d like to see mandatory residencies—at least one year—for our profession. Some states already make this a requirement. Currently, there is so much to learn to execute the care with today’s technology that, in my eyes, four years is insufficient. There was a day when a dental student did 30–50 crown units in dental school. Today, I hear of students who only get three to five crown experiences. That is not the volume necessary to get future doctors what they need to be proficient on Day 1 of private practice.
In addition, the advent of the dental hygiene therapist (DHT) will force general dentists to learn new skills, because the DHT will do what most general dentists currently do. Additional tiers of providers happened in medicine, and it’s coming in dentistry, so I think dental students need more training because the current skill set will not be as valuable in future years. The glaring issue is the cost of education, which is rising exponentially.
We have some serious challenges coming down the pike. With DHTs, DSOs and significant changes in the insurance marketplace, we are going into uncharted territories. I’d love to say things are going to improve, but my intuition is unfortunately contrary. With that being said, I’m glad to be positioning my practice in a way to insulate ourselves from these changes.