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Office Visit: Dr. Elizabeth DiBona by Kyle Patton, associate editor

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Categories: Practice Management, HR and Accounting;
Office Visit: Dr. Elizabeth DiBona 

by Kyle Patton, associate editor
photography by Allegra Boverman, except where indicated

Dentists spend most of their working hours inside their own practices, so they usually don’t get many opportunities to see what it’s like inside another doctor’s office. Dentaltown’s recurring Office Visit profile offers a chance for Townies to meet their peers, hear their stories and get a sense of how they practice.
This New Hampshire Townie is a third-generation dentist who has transformed her father’s old practice into a robust, multidisciplinary office. Dr. Elizabeth DiBona and her husband, a licensed architect, purchased the plot of land just across the street from her father’s old spot and built a 4,000-square-foot facility where she continues the family tradition.

With more than 1,000 hours of continuing education and a growing collection of implant accreditations, DiBona has transformed herself into an implant expert and is one of three general dentists under the practice roof.

In our exclusive Q&A, she lays out common implant mistakes and how to avoid them, explains why she ditched insurance, what to plan for in a remodel or new build, and more.
Office Highlights

Name:
Elizabeth DiBona, DMD, FAGD, AFAAID

Graduated from:
Boston University:
dental school 2007; AEGD 2008

Practice name:
DiBona Dental Group
Exeter, New Hampshire

Practice size:
9 operatories, 4,000 square feet

Team size:
3 general dentists,
1 periodontist,
1 endodontist,
4 dental assistants,
4 dental hygienists,
2 front office/patient coordinators,
1 practice manager,
1 treatment coordinator,
1 insurance coordinator

How’d you get into the profession?

Honestly, I didn’t decide to become a dentist until the spring semester of my senior year of college. I had taken most of the premed courses, thinking I might do medicine. Then I dabbled in architecture, getting a bachelor’s degree in architectural studies (and meeting my soon-to-be husband).

But when the reality of getting out into the real world hit me, I thought, “My father is a dentist and he seems to enjoy it, and his father was a dentist and seemed to love working with his hands.” I also love working with my hands, and I love science and studying the human body.

My father and grandfather also had exciting, flexible careers that provided a stable income for their families, so that inspired me to get into the profession!


How was the transition of taking over the patient base from your father? Were there ups and downs? Difficulties?

When I started as an associate, some patients would say, “I remember when you were born!” I also had a lot of patients who were “Mark-only” patients, probably because he was incredible with anxious patients (something our practice excels in).

A lot of associates can probably relate to this, and it’s not the worst thing in the world. … I at least met most of my father’s patients through hygiene checks, so when my father retired after about 10 years of us working together, patients were happy to have me take over with their dental care.

It turns out my father and I have similar chairside manners: We both take pride in a gentle local anesthetic application, we are both very sympathetic to anxious patients, we both treat our assistants with respect (which patients pick up on), and I hope I can say we both are good at what we do. And what we’re not good at, we always loved taking continuing education about and learning as much as we can.


What is it about implants that excite you so much? Any tips for doctors on the fence about implantology?

I get such satisfaction doing implants. I’m not exactly sure why; I think it’s because it’s a blend between surgery, biology, physics and aesthetics. It never gets boring. And technology is just making it more accurate and faster. Patients are often surprised at how quick and easy it can be for me to remove a premolar, place an implant, put a temporary crown on a temporary abutment and send them on their way with a “tooth.”

I would say any dentist interested in getting into implants should take as much continuing education as possible. You don’t need to fly to a foreign country to place a bunch of implants—but you do need lots of training that involves case planning, case selection, soft-tissue management, flap design, anatomy, reading CT scans, etc. The list is long.

Personally, I completed an Advanced Education in General Dentistry postdoctoral program, where I got to restore (but not place) implants, and then I did the American Academy of Implant Dentistry MaxiCourse in New York (and made lifelong friends with colleagues who were training along with me.)

Over the past 13 years, I’ve also done about 1,000 hours of CE in dental implants. I also became an associate fellow of the AAID, which involves presenting your implant cases during an oral exam, and after passing the American Board of Oral Implantology written exam, I’m now board-eligible for diplomate status and will take the oral exam in the spring.

So, I guess that’s a long way of saying: Take as much CE as possible, and try to further your status within organizations such as AAID and ABOI so you’re being reviewed by your peers.  


 Tell us about how you approach case acceptance.

It’s about gaining—and earning— patient trust, as well as case presentation. I use a lot of strategies here.

First, I have an amazing dental hygiene team, and they usually know so much about the field of dentistry, they’re able to present the patient with information and intraoral pictures during the hygiene visit.

Then I usually sit down and review the findings with the patient, using a photo on a large screen in front of us. I try to have the patient understand the diagnosis and the risks.

Next, we go to treatment options and I don’t push treatment on anyone. If they’re ready to start, great. If not, we say, “Let’s review again next time you’re in.”

As for gaining patient trust, I think you must stand behind your work. We warranty our work for five years, although obviously we’re aiming for it to last 25 years!

One thing I’ve learned over the years: It’s OK to not want to start treatment on someone, particularly if you feel like the patient will become difficult to work with or seems to constantly distrust you or your team. You can’t be everyone’s dentist, so pick your cases wisely—especially the complex ones. You’ll own the work and have to work with the patient for years down the road, so be OK if you need to allow the patient to find a better-fitting practice.


Which practice management styles have you found to be successful? Which approaches would you never go back to?

I am constantly learning in this department, especially with the high turnover of health care workers in general. I’m reading some great books:
  • How Leaders Can Strengthen Their Organization’s Culture: 28 Simple and Effective Ways by Tim Burningham.
  • Crucial Conversations: Tools for Talking When Stakes Are High by Joseph Grenny, Kerry Patterson, Ron McMillan, Al Switzler and Emily Gregory.
  • Leaders Eat Last: Why Some Teams Pull Together and Others Don’t by Simon Sinek.
I also created a mission statement and a list of five core values, which I try to review and demonstrate myself. I aim to be a professional, kind and supportive boss. I always try to give my team positive praise, because often this can be forgotten. It can be as simple as thanking them for a fantastic X-ray because, let’s face it, it’s awesome to have someone chairside helping us be amazing dentists!

My weakness in the past was not letting toxic employees go sooner. I went to a lecture where the presenter talked about “coupling.” She said if you have employees who go off in twos—maybe into a treatment room, or are whispering on the side—address it immediately. Gossip and talking about others (rather than directly to the person) can be so detrimental to the team.

If there are concerns or complaints, your team should have a flow chart of exactly whom to bring those concerns to.


You have a lot of doctors under one roof. What is that environment like? How are business-side responsibilities delegated?

Working with other dentists is the best! We show each other X-rays, talk about cases, take photographs of our cases to share, and cover for each other when we’re out of the office.

If you practice independently, join a study group and have other dentists look at your work so you get feedback. I’m so fortunate that all my dentists are extremely talented and professional, and we have an excellent working relationship.

Having specialists on the team also allows for good case collaboration. No HIPAA inconveniences when sharing case notes—we just all look at the charts or talk in person about cases, which is a superefficient way to help patients get comprehensive care.


A lot of thought went into the design of your new practice. How was the space designed? What elements are you most proud of?

The reason I built a new space was out of necessity. I wasn’t intentionally growing but when my father started the practice, it was from scratch back in the 1970s—how they did it back then—and he went from a two-operatory office to six by the time I joined the practice in 2008.

The practice space was small, not accessible, and the rooms were hard to standardize because they all had slightly different layouts and equipment. It became very cramped, cluttered and not at all efficient. My goal was to have a space that looked professional, clean and modern and allowed for an efficient flow.

The piece of land I bought was just across the street. It was an ideal location, but very tight. After visiting several companies and doing a lot of research online, I gave my husband, who’s a licensed architect, my vision. He took all my requests and designed an incredible layout. He also hired a interior designer colleague to help him select materials, colors, etc.

I showed the floor plan to my team and colleagues, and we tweaked only a few things here and there.

My husband said it seems like a lot of dentists think they need to hire people within the dental field to design a good dental office, but any good architect—especially one who has health care experience—can provide dentists with a functional and beautiful space.

The part of the office I love the most (and frequent the least!) is the waiting room. My husband designed built-in seating with a very minimal aesthetic, with lots of wood. It’s just stunning.

A few other elements I appreciate:
  • I enjoy having a room dedicated to periodontal surgeries and dental implants.
  • The 5-foot-wide corridors are amazing. Go wide with your corridors if you can—you won’t regret it!
  • I love the position of the windows in the treatment room. Patients can see the sky, trees and birds, all while they rest back.
  • It’s important to have a treatmentplanning room, where patients can sit down and review photos, X-rays and patient-oriented videos. We positioned this room across from the checkout area so the treatment coordinator could check out as many patients as possible and answer any lingering questions about treatment.
  • Another subtle feature is that we have no thresholds on the floor when you go from room to room, which allows for carts (like the intraoral scanner cart) to be moved without going over any bumps. It’s subtle, but it makes a difference.
Top Products

Vatech CBCT scanner. We’ve had a CT scanner in the office since 2009, and we purchased the new Vatech unit last year. I can’t imagine placing dental implants without it. My endodontist uses this on every root canal case as well, so it gets a lot of mileage. The software is easy to use and their support is great.

Versah implant drills. I have these set up for most of my implant cases. They help condense bone, as well as do minimally invasive sinus lifts. This is one of the most exciting new techniques/ instruments I have in my practice! I sat through the Versah lecture in Chicago thinking, “This makes so much sense. Why didn’t someone think of a product like this sooner?”

OptraGate Retractor. I put these in almost everyone’s mouth. It retracts the lips/cheeks well, and almost opens things up like a curtain for great visibility and accessibility.

Q-Optics Loupes. Prismatic/expanded field and headlight. I love that I can see an entire arch with these loupes, plus I have 3.5 magnification.

MouthWatch intraoral camera. We have one in every operatory. They’re extremely easy to use, very affordable, and do a great job showing patients one tooth at a time. They help with case comprehension and case acceptance.

What other big changes did you make that you’d recommend for other docs?

We’re getting ready to drop our contract with Delta Dental and become an unrestricted provider. I started considering this for two reasons. Firstly, they were just becoming so difficult to work with. And the pandemic and inflation had been causing our overhead to spike. Every day, I reviewed the insurance write-offs and thought, “There’s no way we can survive like this.”

When I started digging deeper, and listening to Gary Takacs’ The Less Insurance Dependence Podcast, I realized how much sense it would make for a practice like mine to drop all insurance plans and become a fee-for-service practice.

I heard a popular practice consultant mention that when dental insurance first came on the scene in the 1970s, it provided patients with $1,000 of benefits, and crowns cost about $150. Fast-forward to today and ... well, do the math.

Patients were mad at us—not the insurance corporations—for how little their plans covered, and I thought, “I’m going to break my body trying to do high-volume dentistry or I’m going to have to leave the insurance-driven practice philosophy and become a patient-driven practice.”

We made a six-month plan and began informing as many patients as possible, face to face, about why we’d made this decision and how they could remain at our practice. In the past few months, we’ve lost about 2% of Delta Dental patients so far, and I’m betting that many of them will circle back. Our official fee-for-service date was Jan. 1.

For other dentists who are considering leaving the world of insurance-driven dentistry:
  • Do your homework. (Podcasts were great for me.)
  • Get your office in beautiful physical shape—renovate, etc.
  • Build a great website with excellent SEO and get great Google reviews.
  • Remember, you must be likable: If your patients don’t like or trust you, you might have a big uphill journey.
  • Your team must be 100% on board, excited and confident about the process. Educate them and give them scripts. Start with your management team and the excitement will trickle throughout your office.
  • Oh, and do great dentistry. That’s what patients are paying for!

Where do you find inspiration?

I find inspiration knowing that I am positively contributing to society, and that I have a skill set and a talent to provide care to patients who might normally be terrified to go to the dentist. At the end of my day, it goes by incredibly fast, and that’s because I am fortunate to have a job where I get to work with my hands all day!

I also find talking to my father very inspiring. He’ll often tell me things that his father (who also was a dentist) used to tell him. One in particular that sticks with me every day is, “Don’t judge another dentist’s work unless you were there with him” (or her). Sometimes I’ll look at a crown margin and be critical, but then try to realize that perhaps the patient had been challenging to work on—maybe they couldn’t open their mouth very wide, or wouldn’t allow for the chair to go back. You don’t know unless you were there, so don’t criticize another dentist’s work in front of patients. I also think it’s unprofessional to disparage your peers in front of patients.

When I was feeling sorry for myself about having to run a practice, keep employees paid and provide health insurance through a pandemic-related closure—through which business interruption insurance did nothing to help—I’d complain to my father about how he never had to work through a global pandemic and he had no idea how stressful it was. Then he said, “Elizabeth, we had to work through the AIDS epidemic, and that was a death sentence if you got it.” That put things in perspective for me! Every generation has its challenges. The COVID-19 pandemic will be ours, and I hope we can make positive changes.


How do you find talented team members?

Many of my most talented dental assistants have come to us through a school externship-type program. If you’re shorthanded, go to the local dental assisting schools and offer to allow them to shadow you. Of course, you need to be willing to show them different procedures and teach them about dentistry, but it allows you to get to know potential team members before having to hire them. We try to pluck the best ones to work for our office.


Where do you see the profession headed in the next 10 years? And where do you want to be in your career?

I would like trends in dentistry to reemphasize quality. I still see crowns that were done by my father 40 years ago—gold, of course!—and I’d like today’s dentistry to hold up as long and as well. I want new dentists to have the time, energy and resources to take 10 years after dental school to do as much continuing education as possible, and to thrive and enjoy their field without the interference of the dental insurance industry.

Where do I think the profession will head? I think many practices will thrive by becoming fee-for-service practices, and perhaps many others will join forces with DSOs. What that means for our profession, I’m not sure. I’m just hoping some dentists are extremely talented, love their job and are not worked to the bone by the insurance industry, so in 20 years, I’ll have an amazing dentist to go to when I retire!


Give us a snapshot of your life outside of your career.

Outside the office, I’ve been trying to keep in shape the best I can. I work out at least a few times a week.

Our kids are 7 and 9, so we go on short family hikes and trips to the lakes or beaches in the summer. This winter, we’re gearing up for ski season again. I was a former ski racer as a kid but we’re taking a more casual approach with our kids—just weekends here and there, but it gives us something to look forward to in the winter. My husband and I enjoy putting the kids in ski school, and we go out on cross-country skis for the day.
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