Four Out of Five Dentists…

We’ve heard the “four out of five dentists” phrase and the humor behind it. It’s not far from the truth. As dentists, we also have all been in rooms in which heated debates were taking place because there were one or two, or more, of us who were drastically departing from the consensus. This is likely becoming a more frequent scenario, given the explosion of dental technology and materials available to us today.

I recently had the pleasure of attending a respected study club gathering and the honor of meeting several accomplished dentists and specialists. We reviewed a couple of cases and the discussions ensued. I was reminded of the classic “what would you do?” question frequently asked among dentists in social circles. Naturally, everyone has an opinion. While there was a general agreement as to which direction the cases should go in, the typical response of “it depends on who you ask” also was starting to take shape.

Ask a periodontist to view the case, and he or she would like to solve the problem, or at least offer his or her thoughts, by working on the periodontium. Ask the orthodontist on the other hand, and the patient now has braces. The general dentist might have a diagnostic approach — place the patient in a temporary phase and evaluate the tissues and bite or other conditions before determining what needs to be done.

What is even more remarkable is that there are differences of opinions between the general dentists themselves or between the dentists within the same specialty. They may have had variations in their basic training just as general dentists’ skills differ based on their extent and type of continuing education. Moreover, a case might need to be completed ideally with the collaboration of several of the various disciplines all at once. If there’s internal disagreement on the approach, it can get pretty tricky to formulate the “ideal” treatment plan.

Can it get more complicated? Absolutely. Add to this pot of textbook recommendations another ingredient: a blend of patient limitations — the primary one being finances. So, in fact, what was supposed to be the ideal treatment plan beautifully crafted by stitching together the work of multiple specialties sometimes ends up fragmented or headed in a completely different direction.

If I was the patient, my “second opinion” would become more like a fifth or sixth opinion. Dentistry has evolved to be so multidisciplined that each branch has its role in a patient’s treatment. And we may all provide our individual insight on how to proceed with a case. That leads to a plethora of options patients might have to choose from, and that might not be a bad thing. I suspect four out of five patients would agree with me.

Zeynep Barakat, DMD, FAGD

In Sickness and in Health

One of the biggest reasons I became a dentist is because I wanted a career in which I could connect with people and help them with their overall well-being. I never realized the extent of how that would end up impacting my life and how priceless that is to me.

I am a fee-for-service, sole practitioner who has been in private practice for more than 16 years. I have seen my pediatric patients grow up, go to college, start careers, get married, and have kids who are now my patients. I have heard of travels and adventures that make me feel as if I have been all over the world. These are the things that I had dreamed of being a part of as I began my practice.

But I never thought of the sadness that I would witness. I remember a patient of mine who used to share stories of how he loved to swim nude every day in his backyard pool, and I remember the day he told me he was diagnosed with Parkinson’s disease. I remember watching him emaciate with every appointment. He would come in monthly toward his end because he could no longer brush his teeth and nobody was doing it for him. I remember the last time I saw Lee. He was a 6-foot-4, hardly 95-pound man who could no longer walk. I have watched married patients lose spouses due to illnesses. I’ve seen the sadness and the exhaustion in one as he or she takes care of the other — and I’ve seen that same patient try to find strength to move on after the loss.

I remember after I had my first son, a patient of mine came in for a routine visit. She was a divorced single mother with two boys. At the time, the older son was 11 and very sweet and outgoing. The younger son was timid and quiet, only 8 years old then. The eldest had gone on a hunting trip with his father and was shot killed in an accident. When Mom came in, it reminded her of all those visits where she would bring her boys together, and she began to cry. I knew her horrific story and told her she didn’t have to be here. She stayed. We both silently cried as I did her exam. I wish I could have been a stronger person, but having kids of your own makes things hit you in a whole other way.

You see, if I wasn’t fee-for-service, I would never be able to spend time like this getting to know my patients. I wonder: If I was riddled with insurance or a part of corporate dentistry, would I have been able to attain my real dream?

It is a privilege to be trusted and allowed to treat a person. I am forever grateful to my profession, because it has provided me with an avenue to be a doctor, a partner, and a friend to so many people. My team and I truly impact our patients and improve not just their oral health, but also their lives. While some of these memories weigh heavily in my mind, these people, their stories, will resonate in my heart forever.

Pamela Marzban, DDS, FAGD

Giving a Holistic Approach a Chance

Is there such a thing as “alternative dentistry?”

We’ve co-opted the label “family dentistry” from “family medicine,” so why not the “alternative” from “alternative medicine”? What would “alternative dentistry” consist of?

If my experience with alternative medicine tells me anything, it would mean treating cavities with acupuncture and cod liver oil and meditation. Because those are natural treatments. “Ancient Chinese medicine,” ya know.

My experience with an autoimmune disease has been frustrating, to say the least. I’m sure some of my dental patients have been equally as frustrated when they have to suffer with the oral manifestations of their disease. But I wonder now if they seek out an “alternative dentist” to hopefully solve all their problems.

I know I did.

It started with a conversation with my orthodontist partner. Glenn is a smart, talkative, friendly guy and a superb clinician — not a quack. But he related his experience with an herbalist naturopath that actually sounded interesting. He suggested I give Edna a call. And I did.

I drove with my girlfriend to Edna’s office in an old house in a small Mississippi town about two hours away. She greeted us at the door — an 81-year-old spark plug of a woman. White hair piled up in a neat, tight bee-hive. Sharp gray dress. As soon as she shook my hand, the observations started, “Honey, he ain’t the marrying kind!” “You’re a perfectionist and like to get your way!”

Thanks, Edna.

Edna proudly announced that she hadn’t seen a real doctor in over 40 years and had no plans to ever see another. “I don’t want to leave a paper trail for those butchers” was how she put it. She told me about how she treated this guy in the waiting room with herbs and supplements after he nearly died at the hands of conventional medicine. She also talked about how she treated her daughter’s terminal cancer with grapefruit water or something. I smiled.

She took a perfunctory history and then started with a numerological look at my birth date and that of my mother. She scribbled something and then stated that her numbers showed a mineral imbalance that was biblical in origin. I nodded my head like I knew what she meant, but it flew by as nonsense.

In fact, most of it was nonsense. I played along and listened, but I was questioning each and every statement of hers. None of it was scientific or rational, but I went along. My girlfriend was furiously scribbling notes and focused like a laser on Edna. She took my hands and rubbed and squeezed and turned them over to examine my palms and made more comments. My girlfriend scribbled.

Then Edna had me sit back, took my feet in her lap, removed my shoes and socks, and proceeded for the next hour to thoroughly examine every square inch of them. She would squeeze and poke a spot and ask about my spleen or my liver or my kidney. She showed me a drawing of the human foot and how it is divided into regions that correspond with a particular organ since they all have origins in the feet. Did you know that? Me neither.

I had heard of the term “reflexology” but had no idea that it involved a connection between the organs and systems of the body and the feet. I heard anecdotes from my friend and my aunt about how Edna was able to discern physical problems of theirs by examination of their feet. I was amazed but suspicious. But more than anything I was hoping that Edna could do something effective for me.

She ended up suggesting that I take herbs such as corn silk, slippery elm, and hawthorn. They came in capsule form, and of course, she sold them.

And they did nothing — at least, not from what I could tell. But why had her treatment worked for others but not for me? Were they wrong? Was it my fault for not being completely mentally sold on her treatment? Was her treatment simply snake oil, or was there a lack of “faith” on my part?

Are dental patients like that sometimes? Is their dental problem in their mind?

I have a colleague nearby that is something of a snake-oil salesman, if what some of his patients and even his employees tell me is true. He told one woman that if she would “acidify” her body pH, she would prevent cancer. He has all sorts of concoctions to drink to prevent various ailments. He’s a dentist, mind you, trained in a scientific understanding of disease but has gone off the rails of rational thought.

It makes me wonder how many other dentists out there are open to alternative or holistic dental therapies. Anybody?

Bruce M. Scarborough, DMD, FAGD

I Have Been Coming Here for 25 Years

As a dental practice owner, I have so many things to think about.

I want to get better as a clinician. I want to make enough money to pay everyone and maybe keep some money for myself. I want to have a place that is nice to come into. I have to worry about marketing the practice. I need to make sure the sprinklers are working outside so the grass doesn’t die. (Speaking of the grass, that reminds me: I need to ask the lawn guy to trim the hedges next time he is here.)

I have aging computers that need to be replaced. Come to think of it, my compressor is pretty old, and so are my autoclave and my vacuum system.

I feel my hair turning gray as I type this.

Things would be so awesome if the schedule was jammed-packed every day and all of those other things would work themselves out. Like everyone’s practice schedule, my schedule kind of ebbs and flows. I try not to think about it, because I know that the next month can be gang-busters. But for me, my schedule has been more lemons than lemonade for the past month or two.

And then Phil came in.

Phil is an interesting guy. He is an unassuming guy — one whom you would never know to be wealthy. He has told me he doesn’t work. His exact words: “I just manage my money.”

He came in for recall last week, and he had some beaten-up second molars. I said, “One day, you are going to need full coverage on all of them.” After he thought about what I said for a second, he said this: “I have been coming here for 25 years. I pay cash for all my work. I want to do all four crowns at once. What is the best you can do for me?”

What would you say?

I told him that I would take 10 percent off. He looked at me and shook his head. He said, “I want 20 percent.” I told him I had to think about it.

Here was my thought process:
This really is a good patient and family.
Lately, the schedule has been more lemons than lemonade.
I don’t usually negotiate.
I am doing just fine, and I don’t need to do these crowns.
He wants to give me something like $4,000 cash for a couple of hours of work (minus the overhead).
My fees are my fees.
It would be like if I offered a 15 percent coupon.
Am I cheapening my work?
He could go somewhere else.

I thought about it, and I said, “Yes, I will do it.”

I said yes for so many reasons. It had nothing to do with my schedule. I thought the patient was looking for an “I appreciate you as a patient” moment.

If I had said no, it would have put a strain on our relationship. And also, I didn’t want to leave that kind of cash on the table. I am a business man, after all.

So for that day, I made a patient happy. I had a good production day. I knew that I could pay my staff, and if the autoclave went down, I might have had a little extra to fix it.

Now I just have to worry about the other 364 days.

John Gammichia, DMD, FAGD

I Love a Parade

I love a parade. Not the deep genetic coding that results in, usually male, animals putting on a show to attract a mate, but the very human kind to celebrate events.

Like so many things, parades have their roots in politics and the military, as they forced the local population to witness the show of strength and cement their legitimacy as a ruler. They are a powerful way to connect to the community in the centuries and millennia before the recent globalization of information through the internet. Over time, they also became important parts of religious celebrations, most notably with Mardi Gras and its association with Lent.

Parades, as I have come to think of them, are an American phenomenon, made to become a big event by Macy’s Department Store in 1924. It was the first time a parade was used as an advertising vehicle where the employees also employed the use of animals from the Central Park Zoo. Now this parade is witnessed by millions, both in person and on TV, every year.

When I was 10 years old, my parents took us to Miami for the Christmas holiday. We stayed in a motel/hotel on the beach, and it was fun. My mother’s oldest brother was Percy Faith, the musical composer and arranger, and through him, my parents got to know Canadian actor Lorne Greene. As it turns out, the year we were in Miami, Lorne was the host of the telecast of the Orange Bowl Parade, and we got tickets to sit in the VIP section where the TV cameras would be able to film us.

It was a hot, sunny day, and the parade was long. I think my parents were melting, as it was not customary to bring water bottles with you to events back in the 1960s. But near the end of the parade, a float went by, and people riding on the float were throwing candy into the crowds. My sister and I were thrilled and excited, jumping up and down, and my parents were hot, bored, and tired. Luckily for my sister and I, and maybe unluckily for my parents, the TV cameras caught all four of us, in extraordinary contrast, and broadcast our activity across North America. My parents were teased relentlessly when we went home to Toronto early in the new year.

My favorite (not surprisingly) is the Calgary Stampede Parade. It is two and a half hours of grand displays honoring the history of cowboy culture, our native predecessors and their four local nations, the city of Calgary, and its neighborhood. Thanks to the quality of the Stampede Bands, a variety of other marching bands travel to Calgary from all over the world to participate in an international competition of good repute, and they also are featured in this parade.

Almost half the population of the city of Calgary comes out to witness the parade in person (Calgary has a population of almost 1.2 million people), and many arrive hours before it starts to get a prime spot to witness the parade. As a result, there is often more than one hour of pre-parade entertainment, resulting in over three and a half hours of grand western hospitality and entertainment that really puts one in a good mood.

The parade is the grand kickoff to the Calgary Stampede, 11 days of celebrating our local heritage. Calgary will have more than 1.5 million people visiting the Stampede over 11 days in early July, and I have to admit I do enjoy it.

The Stampede spirit takes hold of businesses all throughout the city. Banks, restaurants, and more decorate their businesses with western themes. In my office, for many years, we also decorate the office with a western theme, dress in comfortable, clean, western-style clothes for the week while treating patients, and bring the Stampede spirit of “yahoo” to our office every day.

I do love a parade. I wonder (tongue firmly planted in cheek) if AGD will have a parade to open its 2016 annual meeting in Boston?

Larry Stanleigh, BSc, MSc, DDS, FADI, FICD, FACD, FPFA

Boston or Bust

I am excited. I can’t wait. Believe it or not, I will be attending my first AGD annual meeting this year. This is surprising since I have been an AGD member since 2008 and have been blogging for The Daily Grind since 2013.

For the past several years, I have had intentions of attending. But, as I am sure you understand, sometimes, life gets in the way.

One year, my wife and I were in China meeting our baby daughter for the first time. I could not attend the AGD meeting that year.

Another year, our daughter was at Children’s Hospital with a serious disease. I could not attend that year. (She is doing great now.)

Yet another year, I was scheduled to attend the AGD annual meeting. Then, I was invited to my cousin’s wedding in Italy. I opted to attend his wedding and Pope Francis’ general audience instead.

But this year, I am saying, “Boston or bust.”

One reason Boston will be so special is that I’ll be able to visit fellow dentist Paul Revere’s house. Yes, he was a dentist. In fact, I understand that his dental instruments are still on display. I have been fortunate enough to also have visited Tombstone, Arizona, where Doc Holliday’s dental instruments also are on display. It is hard to think of two more famous dentists.

Being the classic rock fan that I am, I will listen to the band BOSTON during my entire flight into Boston.

One person that I am especially looking forward to meeting is The Daily Grind legend himself, Dr. John Gammichia. I understand that we have both been invited to the same get-together the Friday night of the meeting. I can’t wait.

Anyway, I am going “Boston or bust.” Please do me a favor: If you happen to run into me at the AGD annual meeting, please say hello. I would love to meet our Daily Grind readers!

Andy Alas, DDS

A Picture Is Worth a Thousand Words

Today, we find ourselves operating in a world with continuous transformation. As doctors of the oral cavity, we are faced with the daunting task of providing each and every patient with the utmost care. Our career is fraught with constant change, and it is incumbent upon us as dentists to approach the “latest and greatest” technology and materials with caution.

There is no question that various technologies, including the use of digital radiography and intraoral cameras, have enhanced the clinician’s diagnostic capabilities and simplified the process of patient education. Both of these technological tools have provided an accurate and tremendous record for future recall. Further, the combination of both digital X-rays and intraoral cameras can substantially reduce insurance company denials and/or delays in processing pre-authorizations for fractured teeth, the need for cuspal coverage when posterior alloys exceed one-third to half the intercuspal width, and more. It’s difficult to dispute color intraoral pictures that reveal vertical fractures, open cavosurface margins, caries, calculus, soft tissue pathology, etc.

I have found that when the clinician and dental team fully embrace and incorporate the use of intraoral cameras with high-definition large-screen monitors, case acceptance soars. The implementation and systematic use of intraoral cameras are one of the most beneficial and valuable pieces of technology available today, and regular use of it can serve as an educational adjunct to great verbal skills, resulting in increased case acceptance, and, in most instances, an irrefutable record for future inquiries.

Here’s an example: A patient presents with a fractured cusp, sensitive to percussion, and fails to remember your recommendation for full coverage months prior. If used regularly, the intraoral cameras and high-definition monitors can assist the patient in understanding the condition of his or her dentition and/or soft tissue and create a sense of accountability.

I have documented more than 40 uses for extra-oral and intraoral cameras, including before-and-after pictures that show the quality of your work. In 2008, we introduced this technology in our practice and experienced an increase in our production and collections of more than 40 percent.

Duke Aldridge, DDS, MBA