The fluorescent light overhead hums in a low, flat B-flat that seems to vibrate right through my skull, flickering exactly 11 times before I finally look away from the practice management software. I have been staring at the extraction metrics for the last 31 minutes. It is a quiet Tuesday, the kind of day where the silence in the hallways feels heavy, almost expectant. I just finished alphabetizing the spice rack in the breakroom-a nervous habit I picked up from my mother-and now I am faced with a set of numbers that simply do not make sense, or perhaps they make too much sense in the worst possible way.

Forty-one percent. That is the number glaring back at me. According to the data, 41% of all single-rooted extractions performed in this building over the last quarter were billed as “surgical.”

I look at the names attached to those codes. These are not cases involving impacted third molars or complex multi-rooted teeth that required a trap door access and a week of recovery. These were mostly premolars and incisors-teeth that, by all laws of physics and biology, should have been straightforward. Yet, nearly half of them required the removal of bone or the sectioning of the tooth. At least, that is what the billing says. Nobody on the clinical team thinks this number is strange. When I brought it up in the huddle, I was met with 11 blank stares and a shrug from the lead associate who muttered something about “difficult bone density” in our local patient population.

I used to believe that. I used to tell myself that the patients in my chair simply had denser cortical bone or more fragile roots than the ones they showed in the textbooks. It was a comforting lie. It protected my ego. If a procedure took 51 minutes instead of 21, it wasn’t because my technique was lacking; it was because the case was “surgical” by nature. But lately, I have started to suspect that “surgical extraction” has become a billing euphemism for “the tooth did not cooperate and we are not going to examine why.”

There is a specific kind of frustration that comes with realizing your professional growth has been stunted by a coding category. When the financial incentive removes the friction from a more invasive approach, the less invasive approach quietly disappears from the workflow. We stop asking why the root fractured and start asking where the surgical handpiece is.

The Memory of Paper

Zoe D.-S., an origami instructor I met at a weekend retreat three years ago, once told me that paper has a memory. She spent 21 minutes showing me how to fold a simple crane, explaining that if you force a crease against the grain of the wood pulp, you aren’t just making a mistake; you are wounding the material. Zoe would watch her students struggle, their fingers trembling as they tried to force the paper into a shape it wasn’t ready to take. She called it “the violence of the impatient.”

“The violence of the impatient.”

– Zoe D.-S., Origami Instructor

In my operatory, I see that same violence. When an elevator isn’t working, the instinct is to apply more force. When more force leads to a crack, the drill comes out. We justify it by saying we are being “decisive,” but Zoe would say we are just failing to listen to the fibers.

In the dental world, the grain of the paper is the periodontal ligament. If you don’t sever those fibers cleanly, you are fighting the entire structural integrity of the jaw. This is where the periotome comes in-or rather, where it should come in. In the 11 cases I reviewed this morning where a simple extraction turned into a surgical one, the periotome was never even pulled from the sterile wrap. We went straight from a luxator to a bur.

It is a subtle shift, but a profound one. Once you reclassify an extraction upward, it solves a coding problem. It pays better. It justifies the time spent. But it creates a massive learning problem. If every failure of technique can be rebranded as a “surgical necessity,” the clinician never has to ask whether a more refined instrument or a more patient approach at the start would have made the sectioning unnecessary.

I’ve made this mistake myself more times than I care to admit. I recall a 21-year-old patient with a fractured upper first premolar. I was in a rush-I had two hygiene checks waiting and a crown prep in the next room. Instead of taking the 11 seconds to properly engage the ligament space with a fine-tipped instrument, I grabbed a standard elevator and gave it a heavy-handed twist. The “crack” that followed wasn’t just the sound of a root breaking; it was the sound of a 15-minute procedure turning into a 41-minute ordeal. I billed it as surgical. I felt justified. But looking back, I wasn’t being a surgeon; I was being a butcher who knew how to use a computer to hide his tracks.

We have become a profession that is very good at managing the aftermath of our own impatience. We have built entire billing structures around the idea that extraction is a traumatic event. But what if it isn’t the extraction that’s traumatic? What if it’s the tools we choose to ignore?

I’ve been looking at the instrument kits from Deutsche Dental Technologien lately, and it struck me how thin the line is between a successful atraumatic procedure and a “surgical” mess. It usually comes down to about 0.1 millimeters of stainless steel. A periotome is designed to go where an elevator cannot. It is designed to sever, not to pry. Yet, in the rush to meet production goals, many practitioners skip this step because it feels “too slow.”

The irony is that by skipping the delicate work, we end up spending more time on the heavy lifting. We spend 11 minutes drilling away bone that didn’t need to be touched if we had just spent 121 seconds properly luxating the tooth. But because the D7210 code exists, we don’t feel the sting of that wasted time as much. The insurance company pays for our lack of finesse.

This creates a feedback loop that is incredibly difficult to break. If the office manager sees that surgical extractions bring in an extra $101 per tooth, there is no incentive to encourage the clinicians to buy better periotomes or take a course on atraumatic techniques. In fact, there is a perverse incentive to keep doing it the “hard” way.

I find myself thinking back to Zoe D.-S. and her spice rack. She once mentioned that people who don’t know how to cook use too much salt to hide the fact that they burnt the onions. In dentistry, surgical codes are our salt. We use them to flavor over the charred remains of a procedure that we should have handled with more grace.

A Patient in his 51st Year

Yesterday, I had a patient, a man in his 51st year, who came in with a non-restorable lower molar. Everything about it screamed “surgical.” The roots were divergent, the bone looked like granite on the 2D film, and he had a limited opening. My assistant already had the surgical tray out. I could see the high-speed handpiece sitting there, ready to go.

I took a breath. I reached for the periotome instead.

I spent 11 minutes just working the circumference of the tooth. I didn’t push. I didn’t pry. I just felt for the “yield” Zoe talked about. I felt the fibers giving way. It wasn’t a sudden break; it was a slow surrender. When the tooth finally came out, it was whole. No bone was removed. No sutures were needed.

I looked at the chart afterward. I had to bill it as a D7140. I made less money for that procedure than I would have if I had just broken the tooth and drilled. For a second, that old ego-driven part of my brain felt cheated. I had worked harder, been more skillful, and was being paid less for it.

But then I saw the patient. He was stunned. He told me he had an extraction 11 years ago that took two hours and left him bruised for a week. He was waiting for the “bad part” to start, and it was already over.

That is the clinical norm we are losing. When we let coding drive our clinical decisions, we stop being healers and start being technicians of the billing cycle. We trade our finesse for a higher reimbursement rate, and we call it “progress.”

I am going to change the way we order instruments next month. I think we need more than just 1 or 2 periotomes in the office. We need enough so that no clinician can use the excuse that they weren’t available. We need to stop rewarding the “surgical” label and start celebrating the “routine” one. Because if a routine extraction is done correctly, it is a testament to a level of skill that no surgical drill can ever replicate.

The 21-Day Initiative

It’s about the memory of the tissue. It’s about the grain of the paper. It’s about realizing that just because you can bill for a bigger hammer, doesn’t mean the hammer was the right tool for the job.

I walked back to the breakroom and looked at my alphabetized spices. Cumin, Ginger, Nutmeg. Order. Precision. I realized I don’t want my clinical work to be “salty.” I want it to be honest. I want to look at a 41% surgical rate and feel a sense of failure, not a sense of profit. Because the moment we stop being bothered by the “unnecessary” surgery is the moment we stop being the kind of doctors our patients deserve.

I’m going to start by talking to the associates. I’ll tell them about Zoe. I’ll tell them about the paper crane. And then I’ll show them the periotome, the little piece of steel that keeps us honest. We have 21 days until the next quarter begins. That’s enough time to change a habit. That’s enough time to remember how to listen to the tooth.