One Patient’s Story
July 25, 2012
This is the story about a woman I met recently named “Carol”. Carol’s story is the reason I do what I do every day and brings me back the next day. The interesting thing is that it has absolutely nothing to do with performing the actual physical work of dentistry.
Carol is in her 70’s and for most of her life has gone to the dentist infrequently. She presented to my office a couple of months ago for a second opinion. At our first appointment Carol brought her most recent x-rays, a treatment plan from another dentist, and a page-long list of questions. She was well-prepared for the complimentary consultation I was giving her and seemed to know exactly what she wanted.
About 8 years ago, Carol visited a dental office that touts itself as “holistic”. Carol had about $10,000 of dentistry done at that office and unfortunately had not seen a dentist since. Her reason for visiting that particular office was because she was/is very concerned about her health and believed that a “holistic” office could provide her with what she was looking for. Now, only 8 years later, her teeth were falling apart.
Carol had eight crowns done on her upper back teeth at that time. The crowns, still in her mouth, were failing due to recurrent decay. More importantly to Carol, her front teeth were in severe breakdown. Carol had her mind made up; she wanted full dentures.
Carol sought out a local dentist, presented her desires, got a written treatment plan with fees, and then came to me for a second opinion. She brought that treatment plan with her and it appeared very reasonable – take out all remaining teeth and place full dentures. The first thing I noticed was that Carol had 6 lower front teeth that have been decay-free and have had excellent bone supporting them for 70 years. However, her mind was made-up, she wanted everything taken out. She did not want to have to deal with maintenance of teeth any more.
Over the next two consultation appointments I had with Carol, we discussed many different treatment options. We thoroughly reviewed the advantages of keeping these lower front teeth each time we met. Carol brought a list of questions to each of these meetings, which we discussed in depth. It was decided – Carol was moving forward with full dentures.
We have had two more appointments since then. Because of the location of the dental laboratory that I use, those appointments were spread-out over a few weeks. At this point, we had done some procedural steps to get her ready for full dentures, but the teeth are still there. They would not get taken out until the dentures were ready to be delivered.
At each appointment I discussed a different aspect of why it would be such an advantage to her to keep those lower front teeth. Her mind was not changed. Yesterday, Carol walked into my office to tell me that she has decided that she wants to keep her lower teeth.
Okay, so what’s the point? The point has nothing to do with what Carol’s final treatment is. Carol has every right to decide on what she feels is right for her.
The dentistry Carol received 8 years ago was good technical dentistry on the teeth that were treated. However, the “holistic” dentist did not treat her as a whole person and left the rest of her mouth destined for failure.
The local dentist she got the treatment plan from provided a very reasonable treatment proposal. They had one visit, decided on treatment and her next step was to go to the oral surgeon and have all her teeth out.
Far too many times I see patients and dentists rush into treating teeth. Taking the time to engage in conversation and treat the person as a person and not a tooth is less common than it should be in my opinion. My point of this story is not that I got Carol to do what I felt was best for her, but that I gave her my time, answered all her questions, and allowed her to decide what was best for her. She needed the time.
There are few things we have to rush into in life.
Media Spin on Dental X-Rays
July 22, 2012
For the past couple of months, every dentist in the United States has had to deal (in some form or another) with the story on the front page of the Cleveland Plain Dealer newspaper entitled, “Dental X-rays Linked to Brain Tumors in Yale Study”. The story made national headlines, and why wouldn’t it with a title like that?
The reporter did publish excerpts from a meeting with ADA (American Dental Association) spokesperson Matthew J. Messina, DDS to get the dental communities’ perspective; however that was published on page A-4. As Dr. Messina explained, “Like a courtroom trial, the prosecution went first. Page 1 included the first six paragraphs of the article. The ADA’s defense was well presented, but after the ‘jump’ to page A-4. It required that a person be committed enough to understanding the story, to be willing to actually open the paper and read the article to the end. And that is one of the problems that ‘we’ will always face as a profession.”
For the rest of us who don’t live in Cleveland, or read the Cleveland Plain Dealer on-line, we got our story from the national news media. All I heard was that dental x-rays cause brain tumors. As a consumer and someone concerned about my health it raised an eyebrow. As a dentist I knew there was more to the story.
Here are the facts as presented by Dr. Messina:
How common are the brain tumors? (Six per 100,000) How did the researchers find a link between dental x-rays and brain tumors? (They asked people with brain tumors to remember how many x-rays they had over their lifetime) Is there a problem with this type of study? (Yes, it’’ called “recall bias”) Are dental x-rays different today than they were even 10 years ago? (Yes, the amount of radiation in current dental radiography is dramatically less than in years past) What should patients do with this information? (Talk to their dentist about any concerns so that their dentist can give them accurate information and reassure them)
While there is strong evidence that ionizing radiation may cause cancer, the question remains whether low doses lead to an increase in risk. Regarding dental x-rays, the effective dose is far below the yearly exposure received from natural background radiation. In the case of brain tumors, the cerebral (brain) region is not even in the primary radiation field of most dental x-rays. This was not even considered in the study.
Where do we go from here? If you are in the approximately 50% of the population that does not see a dentist on a regular basis, this information does not mean that much. If you are in the other 50% that understand that oral health means so much more than having your teeth cleaned or a tooth filled, I would recommend the ALARA rule (as low as reasonably achievable). Dental radiographs are a safe, essential and effective tool in identifying dental decay, gum disease, pathology, as well as monitoring proper growth and development.
As a society it is my hope that we are willing to move past the skimming of all the information that is available to us and ask questions when things relate to us. We (dentists) as a profession will continue to work towards educating our patients and providing the safest, most effective care.
Is there a Dental Link to Alzheimer’s?
July 9, 2012
Alzheimer’s disease (AD) is one of those diseases you would not wish on anyone. I have it in my family. My grandfather died from it about 30 years ago.
Since its discovery more than 100 years ago, there have been many scientific breakthroughs in AD research. In the 1960s, scientists discovered a link between cognitive decline and the number of plaques and tangles in the brain. The medical community then formally recognized Alzheimer’s as a disease and not a normal part of aging. In the 1970s, scientists made great strides in understanding the human body as a whole, and AD emerged as a significant area of research interest. This increased attention led in the 1990s to important discoveries and a better understanding of complex nerve cells in the brains of AD patients. More research was done on AD susceptibility genes, and several drugs were approved to treat the cognitive symptoms of the disease.
More recently, researchers have found long-term evidence that periodontal (gum) disease may increase the risk of cognitive dysfunction in healthy individuals, as well as those who are already cognitively impaired. The evidence shows that gingival inflammation may contribute to brain inflammation, neurodegeneration, and Alzheimer’s. My own observations in practice show that as the disease progresses, home care becomes more challenging for patients, which leads to more inflammation, and may contribute to progression of the disease.
Previous research has shown that patients with AD had a significantly higher level of antibodies and inflammatory molecules associated with periodontal disease in their plasma compared to healthy people. One of the tests used to evaluate cognitive function is called the Digit Symbol Test, which is part of the standard measurement of adult IQ.
Researchers found that periodontal inflammation in tested subjects at age 70 years old was strongly associated with lower test scores. Participants with periodontal inflammation were 9 times more likely to test in the lower range in this particular test compared to participants with no periodontal inflammation. Amazingly, this strong association held true even in those subjects who had other risk factors linked to lower testing scores, including obesity, cigarette smoking, and tooth loss unrelated to gum inflammation.
Obviously, the research will continue. Another obvious fact is that I continue to read more and more connections between poor oral health and systemic issues. And, the last obvious fact is that I am trying to educate patients on a daily basis about the significance of good oral health. The mouth is the link to the rest of the body.
I had three patients this week who flat-out refused to accept the fact that they have a problem because they have no pain. They think I am trying to pull the wool over their eyes. I say it over and over; lack of pain is not a good indicator of a problem. Your teeth can be practically falling out and I would be willing to bet you have no pain. Dentists wish that gum disease did hurt. It would be easier to get patients to improve their health.
Made in China
May 29, 2012
I just returned from my semi-annual journey to my dental lab in Georgia where I meet with a group of dentists who share both the laboratory we use and the passion for excellence in what we do. The topic of dental restorations made overseas came up. Mr. Terry Fohey, certified dental technician and owner of NuCraft Dental Arts, one of the finest dental laboratories in the country, believes that a dental patient should have the right to know where the materials are coming from that are being put in their mouth.
China and other countries can claim to use specific materials, but there are no regulations in place to verify the information. There are also no regulations that allow a dental patient the right to know where the materials came from that are being placed in his/her mouth.
With the help of a State Senator from Georgia, Mr. Fohey is proposing legislation requiring dental laboratories to disclose to the dentist the material contents and point of origin of every dental restoration. It would also require the dentist to disclose the information to the patient should the patient ask. Would it make a difference to you whether or not your crown was being made in the United States or not?
Why are some dentists and dental laboratories farming out dental restorations overseas? Like everything else in the world, money is the reason. I get advertisements in the mail daily of dental laboratories able to make crowns for ridiculously low prices. It apparently sounds enticing to some practitioners.
Wonder why some dentist’s fees are higher or lower than others for this service? There are actually many factors that go into the creation of a fee for a procedure that requires a laboratory expense. The patient never sees the laboratory expense in most cases because it is built into the total fee. Clinical experience, clinical skill, office overhead, time required, and nature of the practice are all things that go into the creation of a fee.
The cost of the laboratory procedures also greatly affects the cost for the dental procedure. Let’s take crowns for example. I have seen laboratory fees advertised as low as $39 per crown and know of other dental labs whose fee is a few hundred dollars per tooth. Some patients would accept a lower quality product going into their mouth for a lower cost and others would not.
There are even machines you can buy that can fabricate crowns while you wait. There are many choices. It is basically up to the dentist to decide what he/she feels is in the best interest of the patient based on knowledge and skill.
In my experience, laboratories that cost more tend to make a better product. That better product which gets put in your mouth is a direct reflection on the dentist placing it. Excellent lab work, however, does not make up for less than perfect clinical skills. I have been in practice for 16 years. It took me a good 7 years to find a laboratory that meshed with what I try to accomplish for my patients…..and believe me, it was painful getting there.
We live in an ever-changing world. I try to buy American as often as possible, but realize that it is not always feasible. Mr. Fohey summed it up this way, “This bill is simply about disclosure. It does not restrict anyone from importing dentistry. Instead, it just makes us all play by the same rules.”
7 Traits of the Ideal Doctor
April 26, 2012
What makes for an ideal doctor? Patients shared their views in a study which appeared in an issue of Mayo Clinic Proceedings. It’s based on nearly 200 patients treated at the Mayo Clinic in Arizona and Minnesota.
In phone interviews with people who had no professional ties with the Mayo Clinic, the patients described their best and worst experiences with their Mayo Clinic doctors, with confidentiality guaranteed. The doctors seen by the patients came from 14 medical specialties.
Who made the list?
Here are the seven traits listed by the patients, along with the patients’ definitions of those traits:
• Confident: “The doctor’s confidence gives me confidence.”
• Empathetic: “The doctor tries to understand what I am feeling and experiencing, physically and emotionally, and communicates that understanding to me.”
• Humane: “The doctor is caring, compassionate, and kind.”
• Personal: “The doctor is interested in me more than just as a patient, interacts with me, and remembers me as an individual.”
• Forthright: “The doctor tells me what I need to know in plain language and in a forthright manner.”
• Respectful: “The doctor takes my input seriously and works with me.”
• Thorough: “The doctor is conscientious and persistent.”
That list isn’t in any particular order. The researchers didn’t check whether confidence was more important to patients than respectful treatment, for instance. The Mayo Foundation funded the study.
The traits covered doctor’s behavior, not technical know-how. That finding “does not suggest that technical skills are less important than personal skills, but it does suggest that the former are more difficult for patients to judge,” the researchers write.
They add that patients may tend to assume that doctors are competent unless they see signs of incompetence, the researchers add.
One patient put it this way in the study: “We want doctors who can empathize and understand our needs as a whole person. We want to feel that our doctors have incredible knowledge in their field. But every doctor needs to know how to apply their knowledge with wisdom and relate to us as plain folks who are capable of understanding our disease and treatment.”
The opposite of those seven traits would be: timid, uncaring, misleading, cold, callous, disrespectful, and hurried. Can healthcare ever be high quality if the patient-doctor interaction is any of these? Technically, the care can be high-quality but is it really a place that you want to be treated?
Ethics in Advertising
April 2, 2012
I was listening to the radio on the way home from work the other day and heard an advertisement for a dental office. The ad stated that they were specialists in cosmetic dentistry and implants and that they are the “premier” dental office in the area.
There is no recognized specialty in cosmetic dentistry or implants. Therefore, claiming that you are a specialist for either of these two areas is both illegal and unethical. While it is not illegal to say that you are the “premier” office, it too is unethical for advertising in dentistry.
While I have no problem with legal and ethical advertising in dentistry, what concerns me is over-advertising. The last thing the field of dentistry needs is the public looking at dentists in general as opportunists, and not as dedicated and concerned professionals. How this plays out in the long run will be decided by the ethical standards practiced in dental offices and the rules and regulations enforced by the governing within the profession.
Ethics is about doing good and the concept of right and wrong. Things that may be legal may not be ethical. On the same note, procedures that a dentist is not properly trained in or does not have the technical ability to perform, at least within the standard of care, may be legal for that dentist to do but not ethical. “”Do no harm”, should be the first item on the list of any dentist or any other healthcare provider.
Unfortunately there are healthcare providers, including dentists, who think they are doing people good but don’t realize they practice outside of their true ability. In 1952, the legendary (in the dental world) Dr. L.D. Pankey said, “It’s the moral obligation of the dentist to bring his ability up as close to his capability as possible in accord with his talent. Learning the technique is not enough. A dentist needs to learn how to take care of the whole person.” That is as relevant in 2012 as it was in 1952.
A healthcare professional’s core protocol should be prevention and the quest for determining an individual’s risk for future disease even before the patient has expressed concern. There is a push in dentistry to treat patients based on more objective data, which is commonly referred to as evidence based dentistry. Basically, information about a particular situation is fed into a database containing a multitude of clinical research and “the computer” spits out the best treatment options for that situation based on research. What this does is to minimize the emotionally and empirically based part of the clinical decision making process. My only issue with this is that the empirical, or practical experience of the provider, plays a key role in deciding what is best for a particular patient based on an individual’s unique circumstances.
Cosmetic dentistry poses a different challenge because it is highly discretionary. The dentist, or cosmetic surgeon if we are talking about medicine, must be the patient’s advocate and remain more concerned about the patient’s issues and wellbeing than their own. The benefits of treatment should always outweigh any possible negative consequences. Sometimes the best treatment is no treatment. Sometimes the best treatment for an individual patient is cosmetic enhancement because the benefits of this treatment will have a positive impact on their life.
Any general dentist does “cosmetic” dentistry and most at least do parts of implant procedures. As in any profession, there are varying degrees of talent. Your comfort level with the dentist and the office in general is most important. If you are interested in something that you hear advertised, ask your dentist. He or she probably offers those services.
Holistic Dentistry
March 9, 2012
For whatever reason, I have had a group of patients migrate to my office from a “holistic” dental practice in a different part of the state. The Merriam-Webster dictionary definition of “holistic” is –“relating to or concerned with wholes or with complete systems rather than with the analysis of, treatment of, or dissection into parts. Holistic medicine attempts to treat both the mind and the body.”
Most of us are probably more familiar with the term “holistic” in the medical world than in the dental world. I have done a little research on “holistic dentistry”, and to be honest, I have a lot more research to do. In the future, I plan on writing more about my research on this subject.
I make most of my clinical decisions in practice based on peer-reviewed, published scientific evidence. I like facts. However, I am also an avid student of the psychological and emotional side of what I do. My initial research into “holistic” dentistry has found both things that I am attracted to as well as borderline quackery.
For the purposes of the column this week, I am going to comment on the Holistic Dental Association’s philosophy taken from their website. I have commented on each individual paragraph below:
We believe that Holistic involves an awareness of dental care as it relates to the entire person.
Most people are now well aware that the mouth and the rest of the body are connected. We know that there are connections between dental health and systemic health as it relates to things such as heart disease. The holistic approach seems to go beyond this.
We believe that health care practitioners and recipients should be provided with appropriate information to make informed choices that will enhance personal health and wellness while feeling loved, accepted, and understood.
Much of the “holistic” approach is a frame of mind. Different people need different amounts of information to make an informed decision for their particular situation. It is the communication and relationship between the patient and the doctor that is most important.
We believe that Holistic Dental Association membership provides physical, emotional, and spiritual support while we expand our awareness and skills.
No comment.
We believe our educational growth should be nurturing, affordable, and encompasses basic information, experiential knowledge, and leading edge ideas.
Experiential knowledge means knowledge gained from direct experience. I would agree that many of the things we do are based on our own experiences and often that information can benefit someone else. However, I do not see anything in this statement that relates to published scientific data.
We believe in openly sharing resources. We believe in an inter-disciplinary approach to health that facilitates the individual’s innate ability to heal her/himself.
Most organizations, when it comes to learning, are open to sharing resources. Most practitioners use an inter-disciplinary approach to provide what they feel is best for the patients. The last part of the statement is the more “holistic” part.
I will share more about specifics in “holistic” dentistry in the future.
The Survey Results Are In
March 1, 2012
A few weeks ago I posted a survey on my office Facebook page that I mentioned in this column. The question was – If someone offered you $1 million, would you allow all of your teeth to be removed? If you haven’t taken the survey and would like to, please go to the Facebook page listed at the end of this column. If the numbers change on this survey I will report them at a later date. For now, here are the results:
75% of respondents were female
12% are missing more than 2 teeth not including their wisdom teeth
75% of respondents consider themselves dentally healthy while the other 25% consider themselves “sort of” healthy
62% visit a dentist every 6 months
100% would not take the $1 million to have all of their teeth removed.
Although there was not one person who would allow all of their teeth to be removed, let’s look at who took this survey. First, it appears that most respondents were readers of this paper and probably frequent readers of this column. I would make a blanket statement that frequent readers of this column put their health relatively high on their priority list.
However, only 62% visit a dentist at least every 6 months. The national average is around 50%. It does surprise me that only 62% of those who are “more dentally educated” see a dentist at least every 6 months.
When I am quick enough to use them, I like to use analogies. I analogize with cars frequently. Teeth and cars are two things that we use daily and often take for granted until something goes wrong. Would you drive your car until something happened without ever changing the oil? What could possibly happen if you did that? It would probably mean catastrophe. You would probably be told that the car is junk and you need a new one or it would be very expensive to fix.
I see the same thing the mechanic sees. Failure to perform routine maintenance will lead to problems. The extent of the problems will depend on factors such as how well the car was built, how often it is used and/or abused, and how well YOU take care of it. Those who take meticulous care of their car and get regular routine maintenance will keep their car much longer and have many fewer problems along the way.
I was also a little surprised that no one would take the million for their teeth. For $1 million you could have as many dental implants as you wanted to replace the teeth and still have plenty of money left over. However, it is a long road that apparently no one is willing to go through.
In case you were wondering what my answer to the question would be, here it is. As a dentist, knowing what would be involved to take a dentally healthy person’s teeth out, I would also not take the million. The physical, and more importantly emotional toll that this would put on me is hard to put a price on.
We all take too many things that we rely on daily for granted. Think about the things in life that are important to you. Think about what it would mean in your life if they weren’t there. The moral of the story – take meticulous care of the things that are important in your life.
Wanna Be a Dentist?
February 15, 2012
I’m sure you have heard that dentists are always at the top of the list for suicide, divorce, and substance abuse. I did a little research just to verify that is actually accurate…..and yup, it is. I could go into why I think that is the case, but I’ll let you ponder that one on your own.
Despite the many challenges of this profession, if I could do it all over again, I would still choose to be a dentist. I didn’t decide to go to dental school until late in my senior year of college. People ask me all the time, “What in the world made you decide to look inside of mouths every day?” Believe me, I asked myself the same question when I decided to apply to dental school. It was a last minute decision.
Today, I am glad I went into a profession that allows me to problem solve and can be both easy and challenging. I guess it is my approach. I see myself as an educator and a health care provider who wants to help people decide to what level of health they wish to achieve. I have also made the conscious choice to enjoy what I do every day. When things occur that I do not enjoy, I try not to focus on the negative. It is always a work in progress.
For a dentist, and for that matter anyone in any profession to be successful, they must know themselves and have standards they are able to communicate with passion and energy. One thing is very clear, behavior, with its impending results, is a choice. We make choices every minute of every day. What we choose to do with the paths presented to us is a choice. Being frustrated with your job, trying to copy others instead of discovering yourself as well as dental care is a choice.
All dental care is elective. There is nothing that you have to do. That is what makes this profession the most fun and rewarding for me. A dentist who worries about how much of a particular procedure they do, or tries to sell dentistry as a commodity will become frustrated. That is why there tends to be a high burn-out rate in this profession. It should be about education. It should be about people and caring about their health.
It is also about building trust with people. If any of my patients out there ever had a thought that I was trying to “sell” them something, there is an issue with trust there. I use the car analogy often. First, you decide that you are buying a car. It is only after you decide that you are buying a car that you pick the style, the brand, and the options. It is with that information that you make a decision on what car you are buying, based on what you want and feel is right for you. I look at dentistry the same way.
Dentistry combines health care, artistry, psychology and business all into one. As in any job, there are good times and not so good times. There is always room for improvement in all aspects of the profession and the options for continuing education to improve are limitless.
If you, or if you have kids in high school or college who are wondering about what to do with their life, introduce the possibility of a career in dentistry. Ask your dentist if they would talk to you or them about the profession or even do mentorship. It’s a wonderful profession.
What Your Mouth Says
February 2, 2012
A few weeks ago there was a large article in The Wall Street Journal entitled, “If Your Teeth Could Talk.” It was a basic review of some of the connections between oral and systemic health and also offered some newer research that I was unaware of.
I have written many times on the growing evidence linking periodontal (gum) disease with many systemic issues. The fact of the matter is the mouth is truly the gateway to the rest of the body. While some early signs of diabetes, cancer, pregnancy, immune disorders, hormone imbalance and drug issues can show up in the mouth long before the person discovers that there is a “problem”, an unhealthy mouth also puts you at greater risk for things like heart disease, stroke, diabetes, and pregnancy complications.
A study done at New York University in 2009 reported that 93% of people who have periodontal disease are at risk for diabetes. The issue is inflammation and the fact that periodontal disease and diabetes exacerbate each other. Inflammation from periodontal disease, a chronic non-symptomatic disease, makes it more difficult for people with diabetes to control blood sugar levels. High blood sugar accelerates tooth decay and gum disease, which elevates inflammation. It is a vicious cycle.
However, more recent studies show that treating gum disease improves circulation, reduces inflammation and can even reduce the need for insulin in people with diabetes. The estimates are that six million Americans have diabetes and don’t know it. The risk of not treating either disease can have irreversible consequences.
If you have ever had a planned surgery you probably were asked about your dental health, how often you visit a dentist and asked to get “clearance” from your dentist prior to surgery. The reason for that is because the type and quantity of bacteria present in uncontrolled gum disease is much higher than in periodontally healthy individuals. Bacteria from the mouth can travel through the bloodstream and cause problems elsewhere. Far too often patients come to me a month before surgery and say they need to get their mouth in shape prior to their procedure….an often impossible task.
There are also an increasing number of people on medication and the number of medications they are taking. Many drugs, including but not limited to blood thinners, bisphosphonates (ex. Fosamax), blood pressure medications, antidepressants and chemotherapy drugs can all have effects on the mouth that can be devastating if not closely monitored.
This is all “real” stuff. I deal with these issues in the office every day. I use this analogy a lot, “Periodontal disease is like diabetes, it is not curable, but in most cases it is controllable.” For most patients, good home care combined with good professional care can control this disease. Just as in the lottery, “you can’t win if you don’t play”. However, the consequences for not playing the dental game are more risky.
If you didn’t take the survey last week that I discussed, go to the Facebook page below to take it. I will be reporting the results in the next couple of weeks. So far, not one respondent would give up their teeth for a million dollars. Would you?
