I Tuned Up in Tennessee

Way back in June, I traveled to Nashville to attend my very first AGD Annual Meeting & Exhibits. I am relatively new to organized dentistry, but I have met some great AGD dentists. I decided I should check out the annual meeting and see what it was all about. I did not know too many people that would be attending, but I find this predicament just forces you to be more outgoing and meet new people, so that was okay.

My agenda was not very exciting. I have been eyeing that fellowship award for a couple of years now. I decided I needed to get myself to a meeting, take the review course and the exam right afterwards. I knew most of the meeting would be focused around this exam, as well as some last-minute cramming, dental school style. Several other bloggers have shared their exam experiences here, and I really appreciated that, since they encouraged me to take it. Here is mine.

This review course and exam took up the majority of my lecture time, so I did not get to attend many other courses. I did get to take a full-day esthetics lecture with Dr. Gerry Chiche, who is one of my favorite speakers, but more on that later. I arrived in Nashville around 1:00 a.m. on Wednesday, since my flight for Tuesday after work was delayed. The review course started bright and early at 7:30 a.m. Immediately, I was overcome with dental school flashbacks. The next 48 hours involved full days of PowerPoint slides filled with everything you always wanted to know about general dentistry. The lecturers were given by Region 17 of the AGD, aka military members, so believe me when I tell you they did not mess around. I returned to my hotel room that night, reluctantly bypassing the lobby bar where fellow colleagues were relaxing and enjoying a cocktail. I proceeded to sort through some sample questions and started feeling extremely depressed. I was not having fun like I had at meetings in the past, and I felt like I had regressed to being a dental student.

When I first signed up for this exam, I tried to set some time aside to review topics or, at the very least, review questions on the subway during my work commute. We all know how well that goes. I just did not have it in me to study for this thing in advance. Even though those two days that I was taking the review course and reviewing items in my room at night were not fun at all, I kept telling myself that this would be the last time I put myself through this.

The exam came and went. After a few hours of filling in that Scantron, I felt like my head was going to explode. Being a fairly recent graduate, I have a immense amount of respect seeing fellow dentists embark on this journey. So many of them have been out of school much longer than I have and have families and other greater responsibilities that I do not have early on in my career.

The rest of the conference involved some post-exam bloody marys, a little socializing, and some great lectures. I stayed late on Saturday to catch the full-day lecture with Dr. Chiche. I have seen him do a full-day course in the past, at local study club. At the time, I was not doing any cosmetic work so many things went over my head. I was excited to hear him speak for a second time, and I actually had questions. Another bonus was getting to chat with him in the security line at the airport right after the lecture ended!

Music City Center, where the conference was held, was a great choice. It was brand-new, and located within walking distance of many great Nashville restaurants and attractions. I am not into country music at all, but the level of talent that you can hear live from just walking into a random bar on Broadway was pretty impressive. I attended some social events and made some dentist friends. I even tried to let more members know about our little blog here; as most were not aware that it existed!

If you are an AGD member and would like to get that fellowship award one day, please do yourself a favor and sign up to take the review course and exam either in the fall or at the 2014 annual meeting next summer. Don’t worry if you do not have the required hours; I definitely don’t but I am hoping to complete them in the next few years. If you are feeling extremely confident in your study skills and want to skip the review course, all you have to do is apply for the exam and take it at a local testing center on a computer. How easy is that? You also get your results right away, which I am a little jealous about. I had to wait about 8 weeks for mine, but there was some charm mixed with excitement and anxiety when ripping open that envelope.

I hope everyone is enjoying their last summer weekend. I am looking forward to celebrating my two-year wedding anniversary in Lake Placid, New York.

Lilya Horowitz, DDS

My Biologic Width, My Self

A few years ago, I was a guest at a family wedding, along with many relatives I had not seen in years. As I made my way between the tables at the reception, I could hear the sounds of various aunts, uncles, and cousins whispering, commenting on everything from my choice of dress to which of my parents I bore a greater resemblance to. But I stopped in my tracks when I caught wind of the following conversation:

Cousin: “What’s her name again?”
Uncle: “Don’t be silly. You know Diana.”
Cousin: “Oh, right. I have to remember it this way: Diana is the one who looks like Misa, except Misa is thin.”
Aunt: “That’s how I remind myself which one she is, too!”

Ouch.

Not, “Diana, the one who lives in New York City.” Not, “Diana, the one who wants to be a dentist.” Not even, “Diana, the one who spent her formative years cycling through a series of unflattering permutations of Jennifer Aniston-inspired haircuts and has never fully recovered from the psychological ramifications of those decisions.”

Nope. “Diana, the Fat One.”

I went back to my hotel room that night and took a good look at my naked body in the bathroom mirror for the first time since my mother sat me down in the fifth grade and explained that my pre-pubescent body was about to go through some changes. (I am still eagerly awaiting the arrival of my breasts, Mom. Seriously, where ARE they?)

When did I gain so much weight that it had become the defining characteristic that people most liked to attribute to me? How long had this been going on? How did I, a detail-oriented and esthetically-driven healthcare professional-in-training, let this happen?

Friends and family offered mixed reactions whenever the subject of my weight was broached. I heard, “WHAT?!? Who said you were fat?? SIZE EIGHT IS NOT FAT!!” I also heard, “Your butt got huuuuuuuge! NOBODY should be as big as you are right now!” One male classmate even said plainly that he didn’t think a girl should ever weigh more than 110 pounds, period. That a well-educated man of the 21st century could look an equally well-educated woman square in the face and say something that shallow and asinine was shocking and disgusting to me.

According to the National Institutes of Health’s guidelines for calculating body mass index (BMI), I was still firmly ensconced in the “normal” weight category. But even when the good folks at the NIH say you’re doing fine, it’s hard not to notice the looks being exchanged by those around you when you bite into a cupcake or pluck a sample from a box of chocolates.

It saddened me to know that so many people would rather focus on the circumference of my hips and ignore the achievements I had worked so hard to call my own. No matter what I accomplished as a student, doctor, or modern woman, the accolades were worth far less because everyone could see that my weight had strayed from our culture’s widely-distorted perception of ideal. Even though I had experienced success in ways that people two or three times my age never do, I was still partially a failure because I wasn’t doing it in a skinnier body.

At some point during my pursuit of a DDS, maintaining a healthy weight took a backseat to my academic and career aspirations. My metabolism, which had previously been functioning at near hummingbird-efficacy throughout my teenage years (despite an aversion to athletic activity that resulted in a relatively sedentary lifestyle), had gone into sharp decline.

Adding scrubs and sweatpants to my daily dental school wardrobe probably didn’t help, either. You don’t realize that your waistline is slowly expanding when you wake up every day and slip on billowing, shapeless drawstring pants that would make even a Brazilian bikini model look tired and sloppy.

I was not a person who liked to go to the gym to relieve stress before an exam because I felt that whatever time I spent working out would be far better devoted to locking myself in my room and devouring pan-Asian takeout while attempting to memorize information that my professors insisted would be absolutely critical to my success as a clinician. (Oh. For the record? “I trust you to take care of my teeth because of your readily apparent grasp of the Krebs cycle!” said no patient, ever.)

Some doctors say that their diplomas reek of blood, sweat, and tears. Mine probably smells of pad thai and fish sauce.

The ritual of grocery shopping became deeply depressing when I reached the checkout aisle, where cover after magazine cover glamorized borderline anorexic celebrities known for displaying atrocious behavior in the media that clearly indicated a lack of moral compass and intellect. With all my smarts and education, how was I being bested by airheads and bimbos in the weight loss game?

Why couldn’t all the brainpower and discipline I so artfully applied to mastering a foreign language or studying for the SATs be used to unlock the secret to fitting into size 0 pants? How is it that the same society that calls on highly intelligent women to meet the feminist directives of leaning in, fighting back, and moving up also chastises them for not slimming down to unhealthy proportions to meet unrealistic expectations?

It wasn’t until I finished my residency that I made a truly conscious decision to get in shape. It was important to me that I did it for all the right reasons: to embrace a healthier lifestyle overall; increase my strength and flexibility; and derive some actual enjoyment out of being active that would hopefully lead to a happier, more confident me. I resolved not to let the opinions of others be the driving force behind my quest for self-improvement.

In dentistry, the concept of biologic width is founded on the belief that any attempts to restore or improve health, function, and esthetics have to be done thoughtfully, deliberately, and in a manner that respects the existing anatomy and underlying substructure. The way I see it, this philosophy should also be used as a metaphor for the rehabilitation of the person as a whole. Before we start making aggressive changes to what everyone else can see, we first have to take stock of how those changes will affect what’s going on underneath. This will help ensure that our modifications will result in a healthy and sustainable outcome, rather than one that may lead to relapse and potentially destructive consequences.

I began my physical transformation by experimenting with different workouts and fitness classes while making sensible adjustments to my diet and adopting a willingness to try new things. I soon learned that in weight loss, just like in dental care, any product or service that promises drastic, miraculous changes after just one use is almost always too good to be true. Truly lasting results require methodical application, excellent compliance, and remarkable patience.

Was it easy? No way! First off, I am not one of those girls who loves working up a sweat and feeling the burn. I am one of those people who nervously approach a machine at the gym, take far too long to figure out how it works, and manage to injure themselves just trying to adjust the seat.

There are likely a myriad of amateur videos of me falling off stationary bikes and treadmills floating around on the Internet, posted by onlookers who couldn’t resist whipping out their phones to capture footage of my awkward and unfortunate lack of coordination. Eventually, I learned to take these embarrassing moments in stride (but still told everyone that the scrapes and bruises were from a particularly tough kickboxing session).

Over time, these little changes in my routine started to have a big effect on my energy level and self image. Though the pounds were slowly melting away, the real weight that was lifted was the burden of thinking that I had no control over the shape of my body. It was a wonderful, liberating feeling.

My weight loss journey is far from over, but I have faith that I am headed in the right direction. I have accepted the fact that while there will always be people who will judge me for not being thin enough, the adjectives they use to describe my external appearance matter not.

Although the number staring back at me on the bathroom scale may go up and down, what’s important is that my commitment to making healthy choices, staying optimistic, and maintaining an active lifestyle remains unwavering. I strive for excellence, moderation, and balance in all areas of my life, on my own terms. I continue to surround myself with people who are loving, supportive, and see the good in me, at any size.

And that, my friends, is a beautiful thing.

Diana Nguyen, DDS

Greatest Dentist Ever?

I may just be the greatest dentist in the history of… well… dentistry. Should G.V. Black be so bold as to gaze upon my Class II cavity preparations, he had better be ready to take notes.

How do I know about my greatness? It’simple. I just received something in the mail that informed me of my prestige. Much like the Internet, if you receive something via the United States Postal Service, it must be true!

It all started when I received an envelope from an official sounding company (I won’t use their name here). Upon opening the envelope, I was informed that a research council is proud PROUD to name me one of America’s Top Dentists. Imagine, a Research Council! It took an entire group of people to evaluate me. Of course, no one visited my office or interviewed me or any of my patients. But, my greatness must have excluded me from such formalities.

Have you received such a mailing? Who am I kidding? Of course you haven’t. Is that a halo over my head?

Not since Who’s Who learned about my talents have I been so honored. Imagine how proud I was to be listed in their book for only a small fee. Before long, Who’s Who in Medicine came knocking. Then, Who’s Who in Business. Will the accolades never end?!

Upon further reading, I came across the Council’s criteria. They award points for education (apparently most dentists don’t have one), years in practice (take that, young graduates), and affiliations with professional organizations (those AGD dues are really paying off now). That’s it.

How can anyone ever deny my place in dental history? I’m already in talks with the folks over at Mt. Rushmore.

I thought there must be some way for patients to learn of such an accomplishment. When you win at the Olympic Games, they give you a very nice necklace. When you make the best film of the year, they hand you a paperweight named Oscar. Surely, being named as one of the nation’s top dentists deserves something. Just as I pondered this, I saw that I was in luck. The company that mailed me the envelope would be kind enough to send me a plaque or trophy with my name on it. Of course, I’d have to pay for it, but I’m sure that is just a minor detail.

Should I get the trophy or plaque? It’s not like you can just go out and have one made yourself.

Apparently greatness is contagious. I just happened to visit my optometrist and guess what? Right there on her wall is a plaque that states that she is one of the nation’s Top Optometrists! At my annual physical, I noticed that my physician was one of America’s Top Doctors! I am definitely a good influence on those around me. Imagine having all of the top docs in the world within two miles of my house. Who else could possibly make such a claim?

Well, if you’ll excuse me, I need to go find a spot for that trophy.

Andy Alas, DDS

Say it Loud and Proud

I was speaking last week to a group of new dentists about private practice and trends in dentistry. One of my co-lecturers was the regional manager of a large dental supply company. He first spoke about trends that he is seeing around the country: technologies, the insurance industry, and the impact of corporate dentistry. Essentially, he tied together the three concepts by pointing out how the proliferation of insurance-reimbursement dependent corporate dental clinics requires us to utilize technology to be more and more efficient. He stressed that the profession is evolving and, with today’s economy and patient’s greater reliance on dental insurance, we have to adapt and produce more dentistry in a shorter amount of time. We have to compete with the special offers of free or discounted exams and x-rays that are constantly advertised by these corporate entities, or risk becoming dinosaurs. He asked, “How would you like one of these corporate entities to open next door to you?”

I then got up and said “I’m going to teach you how to be a dinosaur. I proceeded to discuss some ways to maintain a fee-for-service practice. The key is to build value for our services in the patients’ minds. Develop an experience for patients that they have never before received. One tip I had was not only to perform an extra-oral exam, TMJ exam and cancer screen, but also verbalize those results, loud and proud. Nothing is more powerful and surprising to a patient than to hear you dictate to your assistant, “Negative cancer screen.” This lets the patient know what you’ve done for them and sets your practice apart.

I then picked up on the regional manager’s comments about competing with the corporate entities. In response to his question about one of these corporate entities to move in next door, I answered a resounding “Heck yes.” It is amazing how many patients come to our office because they have heard that we offer a different experience. They are disenchanted by their visits to these corporate chains; often not seeing the same doctor or staff members, and feeling pressured or rushed. This is not to say that these clinics or dentists are in and of themselves, inferior. Rather, by their nature, they have high turnover due to burnout, and need to be super-efficient due to the pressures of production goals with inadequate insurance reimbursement.

I actually go to great lengths to advertise in direct contrast to these clinics. One of my radio advertisements says that we are not offering patients a $17.99 exam and x-rays, but rather the most thorough dental care available with a team that has been together for over a decade. It further assures people that they will see the same dentist (me) at every visit. It is amazing how many patients are thirsting for that approach. They want a dental home where they know there is consistency amongst the staff and a dentist who will truly know and appreciate their dental history.

Say it loud and proud. Let patients know what they can expect from you and be proud to let them know what you have done for them by verbalizing your findings. Let’s not diminish the most important thing we do for patients—examination and diagnosis—by offering free or discounted exams. We are true physicians of the head and neck; let’s make sure patients know it. They will thank us for it.

Christopher J. Perry MS, DMD, FAGD

Being a General Dentist

I had a ‘light bulb’ moment recently. Thoughts, ideas and facts came together and formed the bigger, clearer picture. And it came when I was reading an article in the August 2013 issue of AGD’s peer-reviewed clinical journal, General Dentistry.

Mark Malterud, DDS, MAGD, presents a case of an anomalous cusp projecting off of tooth #2 in a 17-year-old female patient. Malterud discusses the treatment options that would need to be considered in this unique case to correct and maintain the molar for this patient. In his treatment considerations are a variety of specialists that the patient could be referred to: an endodontist for the treatment of the shared innervations; a periodontist for the lack of bone; even an oral surgeon if extraction and implant are required. But each of these specialists alone could not provide the comprehensive treatment that would be needed to restore the tooth. Malterud concludes that, “a well-trained general dentist who has studied widely, such as an AGD Master, was probably this patient’s best chance at getting a successful outcome.”

This statement resonated with me. I had heard the terminology that a general dentist is the “gatekeeper” of patient care. But I naively thought of that meaning they are the ones that come in contact with the patients first. Then, if the patients need specialty care, are responsible for referring them (triage, basically). What I can see now is that the general dentist is the mastermind behind the necessary total treatment. We are the ones to diagnose, break down the issue, find a way to fix it and make it happen. We get to decide what treatment to take on in our offices and we can fall back on specialists to take on those harder cases. Patients rely on us for their own “big picture,” comprehensive care. And that’s pretty cool!

A high school friend of mine is completing a family medicine residency right now. He posted a Facebook status update that read, “Delivered two babies, guy with pulmonary embolism, code blue, sutured a hand laceration. Today was cool. Love FM.” General dentistry can relate in some ways. Anything can happen during a day. We need to be ready to handle whatever walks through our doors. That requires an extensive knowledge base of all divisions of dentistry and the clinical skills to back it up.

In dental school I was asked if I was going to specialize or just be a general dentist. It sounded like becoming just a general dentist was settling. What this light bulb moment and Dr. Malterud’s article made clear to me is that general dentistry is far from settling. General dentistry is quite a responsibility, and it requires continual education and drive to provide such comprehensive patient care.

Katie Divine, DDS

TMJ

I’m writing this post as on a flight back home from a weekend course on advanced occlusion. Eversince I graduated from dental school, I’ve been searching around amongst books, courses, lectures, and articles, trying to understand what the role of TMJ is in my day-to-day practice. The more I learn, the more I realize how important it is to understand some of the basics about this joint and how it relates to even the simplest dentistry we do.

I’m shocked at how little knowledge we gain about the TMJ during our dental education. After hours and hours of CE courses, I’ve realized how even the simplest filling we do can have a negative impact on the health of this joint. How many fillings and restorations have I placed in the past years without any attention to this concept? I am only one of hundreds of students who graduate every year. Only a handful of us spend the time and energy to investigate this subject further. It scares me to even think about the magnitude of damages we have potentially caused. But, at the same time, it does relieve me to know that the human body is so sophisticated and self-healing that about 70 percent of it usually adapts to whatever is thrown at it. Thinking about the other 30 or so percent still leaves room for questioning the structure of our education system.

Why is a concept as important as the health of the jaw joint, which is known to be the most complicated joint in the body, touched on so lightly in dental schools? Perhaps it is because of its complicated nature and the amount of controversy that exists in different philosophies. But I would much rather have had this concept dissected for me even with all its uncertainties and left open for me to reach my own conclusions than have it be taken off the shelves and hidden because no one has a solid answer to the questions.

I love the school I graduated from and cherish the education I received. I’m proud of it and would go back in a heartbeat if I ever had to repeat it. But if I had one request to make things better, it would be to add a serious discussion about the TMJ and at least drive home the importance of it in everyday dentistry. We should all continue to pay attention to it as the studies evolve and methods emerge. I know this issue is universal amongst most dental schools, and I wish it could change.

Mona Goodarzi, DDS

I Am a Dentist... But Not a Plumber

Am I the only dentist that relates most everyday activities to the practice of dentistry?

Recently, I had the displeasure of changing a bathtub faucet cartridge, and I had several flashbacks to extractions gone wrong. I would much rather perform restorative dentistry, and am fortunate that my practice allows me to do just that. But, from time to time, we are faced with a surgical challenge that must be handled accordingly. So I looked at this challenge and said, "Let’s get this done."

Got a leaky faucet? No problem There are hundreds of videos on YouTube on how to rectify the problem. I watched, took notes, and figured it would be an easy fix. What was not immediately apparent (or mentioned in the first set of videos) was the calcium deposits on the cartridge, which had basically fused it to the brass piping. I bought the part, followed the instructions, and lo and behold, it snapped! The plastic end on the old cartridge broke, just like the crown on a difficult molar. My plumbing cartridge looked like an ankylosed tooth.

Plan B. More YouTube videos shed light on how to get out of the mess: make a purchase point, and pull. Sound familiar? To no avail. I bore out a hole, but that was a no-go. Frustration set in, with sweat on my brow beading up and dropping like buckets. I'd been here before and this is a place I don't enjoy. I took a deep breath, and went at it again. And again. And again.

Fortunately, I am a dentist and not a plumber. And, in my practice, I wouldn't rely solely on YouTube to do a procedure (although some reinforcement and education isn't a bad thing). Much like ankylosed molars should be handled (by an expert deal, if you are not comfortable with it), I called the plumber. After some effort, the old cartridge is out and the new one is in.

This is one anecdote that backs up my claim. But I guess when you spend most of your time doing something, like dentistry, everything else you see relates to it. Either that, or I just need to get out of my office more often.

Jason Petkevis, DMD

Do Probiotics Help With Dental Issues?

Do probiotics help with dental issues, and should we be recommending them?

Yes, they are probably helpful. A new study released in the American Journal of Orthodontics showed a toothpaste reduced the levels of S mutans in plaque around the brackets of individuals with braces. Other studies have shown positive results for lozenges, probiotic cheese and yogurt, even ICE CREAM!

Probiotics have been proven to reduce gingivitis, likely by reducing inflammation at a biochemical level, and even reverse decay in adults. Pretty impressive results for something that I think could be easily implemented into almost anyone's daily routine.

Knowing that, has anyone tried these probiotics for dental care? Is anyone recommending them?

Based on the research, they seem helpful. But is it really to the point of being worth mentioning this as an adjunct treatment? I did buy and use an oral probiotic once. I had the whole staff try it, mostly just to see what it tasted like. It tasted fine, but I really wasn’t that interested in it and we never spoke of it again. It kind of just got forgotten. Reading the AJO-DO article re-piqued my interest and I am curious as to what others think.

Bryan Bauer, DDS, FAGD

Tongue-Tied

I have given multiple presentations and had training in prepared and impromptu speeches. I’ve had every “Ah,” “Um,” and “You know” counted. But that did not prevent me from struggling under the pressure of the elevator pitch. I recently suffered from podium amnesia when I stood up to speak in front of more than 200 colleagues for a couple of minutes.

This year, I took over the position of CE chairperson for my local AGD constituent. At the first CE event that I lead, I had to speak to the audience at the end of the day. Keep in mind that you can squeeze many words into a couple minutes. I wanted to promote different aspects of the AGD, including continuing education, professional growth, and advocacy. I wanted AGD members to consider becoming more active and non-member attendees to consider joining. I did not just want to report facts that anyone can read online. I meant to inspire and influence.

I carefully prepared my speech the night before, hoping that I would ignite the spark hidden within each dentist. I planned to have an inviting tone of voice and welcoming gestures. I also did not want to read from a paper; you can easily lose eye contact with your audience and become too monotonous. There is also this perception that if you read from a paper, you are not as proficient.

But, I think I was mistaken or too ambitious. It was Friday at 4 p.m., after a long day at the first CE event that I personally felt responsible for. When I went up to the stage, I seemed to suffer from instant amnesia. The good news is that nobody in the audience knew what I had originally planned to say next, so I just kept talking. I learned that trick when I was a member of Toastmasters International. The key is to stay calm and at least seem in full control. I talked slowly as I looked right and left to maintain eye contact with the audience and buy myself some time. I regrouped my thoughts and went on. I may have delivered a complete message, but it was not as powerful as I had planned. Although my other constituent leaders were very supportive and felt that I did great, I still gave myself only a fair grade.

My attempt to convey myself as well-suited and prepared for this role ended up with me almost losing control. I probably should have planned to keep it simple. Next time, I will at least walk to the podium with some headlines in big fonts to remind me of the important points I should cover. Maybe I’ll even use an iPad instead of a piece paper!

Have a great weekend.

Samer S. Alaassad, DDS

Second Careers

In my March 13, 2013, blog, "Trying to Find Balance," I discussed how a consulting business has turned into a second full-time job for me, making it hard for me to find balance. In the comments section, our colleague Andy Alas asked to learn more about that second career. I hope to expand upon that here.

I am also an executive producer for the USNA project, a would-be writer of a children’s book series, a voice actor, and a serial entrepreneur. It really all started many years ago…

I had taken some courses in neuromuscular dentistry and learned that, when optimizing the position of the lower jaw, we could reduce a person’s incidence of headache pain, ear pain, dizziness, ringing in the ears, neck pain and more. I found that fascinating. I was intrigued and thrilled. Upon further reflection, I am not that surprised to learn that the lower face can influence the rest of the body, and the rest of the body can influence how the lower face responds. It fits with the oral-systemic connections we are discovering in periodontics, endocrinology, immunology and more.

Armed with this new information, I had lunch with an ENT friend of mine. I asked him if he had patients referred to him with headache problems that he determined were not an ear, nose or throat issues.

“Every day.”

When I asked him what he does with these patients, he told me he tells they have a TMJ problem and they need to see their dentist. Then I asked him what he does when the dentist isn’t sure what to do.

“I don’t know.”

I asked if he would consider referring that kind of person to me to see if I could help them conservatively, and non-invasively. Three days later, Linda was in my office. She had gone to my ENT friend for a third opinion. She had seen doctors, specialists, dentists, and more. She was on a cocktail of drugs to (unsuccessfully) manage her pain. Now, five years after her problems started, she had to stop working, as she was disabled at home with her headache issues. She could not care for her family (with young teenage kids) and was scheduled for surgery to sever a cranial nerve.

My friend agreed that her problems were not an ENT issue, and suggested she see me because she had nothing to lose. She had a deep, over-closed Class II malocclusion, and signs and symptoms of severe muscle spasm, TM joint compression and more. We decided to try a team approach to wellness with reversible therapies that included an intraoral orthotic (I don’t like the term splint, because we are not holding the mandible rigid; rather, we are orthopedically repositioning the mandible), physiotherapy, massage therapy and a home exercise regimen that also included heat and ice.

Within two weeks, her pain was subsiding. Within two months, she was off her drugs. Within four months, she was back at work and had cancelled the surgery. She had her life back.

The success of that case almost nine years ago parlayed into a steady stream of referrals from this specialist to me. Many of these people were car accident victims, and my success caused their lawyers to contact me for reports. I like to write and am reasonably good at it, so I became a little bit popular. Then the insurance companies started asking me to examine and report on these cases, and a niche career started.

Just like a lawyer with a specialty in one particular area, I decided to charge fees commensurate with that level of expertise (but do note, there is no recognized specialty in the diagnosis and treatment of TM disorders). Over time, I became well known in my area as a local “expert.”

This niche practice has become nearly full-time, and will bring in a net income of six figures this year. There is an art and science to completing independent dental examinations and writing the reports. There is a difference between resolving problems, determining the problems are directly due to an accident, and deciding which are pre-existing problems.

It has become quite a nice business for me, and I enjoy it. I am making a difference for many people, changing their lives compassionately, conservatively. I am working with teams of like-minded health care professionals. Because of this success, I have been asked to lecture on the subject of “Independent Dental Examinations” at the Occlusion Connections 5th Anniversary Symposium. In this lecture (the entire summit has been AGD PACE approved), I will teach those attending what an independent dental examination is and how to perform one, provide the templates I use in my office, offer instructions on how to write a report (for insurance, for lawyers and more), explain what happens if you are called to court as an expert witness, and describe how to set your fees.

As my mentor, general dentist Dr. Clayton Chan, states, “I remain a general dentist purposely, not specializing in any particular area of dentistry, which would limit my scope of care and ability to treat my patients comprehensively.”

It is in that spirit that I am proud to be a member of the AGD, and use this broad knowledge to help my patients lead healthier lives.

In future posts, one day, I’ll write about my ‘other’ careers. Now what was I saying about balance?...

Larry Stanleigh, DDS

Keeping Your Cool When You're Getting Hot

I am writing this just moments after a patient encounter that set me back. Admittedly, it takes a fair amount to raise my blood pressure. I’d appreciate your feedback on how you would have handled this situation differently, if at all.

A bit of history:

In the morning huddle, I saw a patient on my schedule for a toothache. He had never been seen for treatment in our office. It was brought to my attention that this patient was “the guy that scheduled two weeks ago, then, once seated in the operatory, stated he didn’t have any money for this appointment.” (Yes, he was given fees during the initial phone contact.)He had brought in a bag full of meds and wanted “the doctor to tell him what he could take.”

For the record, the meds were a plethora of friends’ and family’s pain meds and Abx. It was explained to the patient that Dr. DeLacy would have to examine the area and review an x-ray (including what said fees would be) before she could discuss the use of any type of prescription medication. Mr. Patient responded that he didn’t have the any money to do that and asked if she could “just look.”

The patient was dismissed that day, having refused an exam or review.

Flash forward to today. A team member reminded me of the patient and assured me that he had been informed of the fees and he understood his financial responsibilities. “Oh, and by the way, Doc, he needs meds for his dental anxiety too.” As you can imagine, I had to mentally prepare for the patient.

Fortunately, his clinical need was a straight-forward diagnosis. Tooth #29 fx’d approximately 10 months prior. Three weeks ago, it began to ache. The patient had visited the ER and received Abx and T#3. He took “some” of the Abx and now stated that now “it doesn’t hurt that much.” The tooth is restorable with a favorable prognosis. I discussed with the patient the clinical options: clean out as temp fix, RCT/CORE/PMC, or an extraction. I also informed Mr. Patient of the pros and cons of each.

Let me point out that this patient is the type of patient that has a tendency to tell you how his bite is off and that this situation is what is causing the dental decay, etc. Mr. Patient is clearly a clinical expert in dental occlusion, load, and endodontics. He proceeded to explain to me that when it was really “hurting,” he could “suck hard enough to drain blood out of it,” and he didn’t think the root canal was needed. Now knowing the personality type I was dealing with, the next portion of our conversation will likely be familiar.

As I turned to the computer to enter the treatment plan services, the conversation slowed. I assume he is uncomfortable with silences. He began to ramble. It started off generic enough, but quickly turned to a personal attack on myself and the profession that I have committed a significant amount of time and finances to be proudly associated with.

“Doc, this dentistry is a racket. Don’t you do any pro bono work? I mean, there isn’t anything for the poor. I’ve never heard such a situation where you don’t have to do pro bono work to keep your license.”

As hard as I tried not to engage in this line of conversation, I did politely respond that my partner and I do, in fact, selectively choose when we donate our services. I also explained we participate in the tax payer’s state-funded children’s Medicaid program, which means we accept significantly reduced fees for children under age 21. AND, in order to keep our licenses in good standing, we have to continue to take courses and schooling.

“KIDS?!?! Why would they need dental care? They have brand new teeth.”

I took a deep breath and focused on my computer. In that moment, I realized that I could refute and debate for hours, but the beliefs of this patient was that he felt that I shouldn’t charge him anything. He had so kindly informed me earlier that, “The hospitals HAVE to see you, even if you don’t have money. Dentists? Well, they all want your cash UP FRONT!”

I proceeded to, as nicely as I could without screaming or becoming physically violent, inform him of two known clinics that do, in fact, see patients that qualify financially for either no cost or reduced fees. At this point, I had resigned myself that I wasn’t going to gain any ground and it was best to excuse myself. I politely explained that we would give him the fees for dental treatment in our office, if he chooses to have the dental treatment completed in our office.

Maybe I should have attempted to educate him further. Maybe I should have offered to reduce my fee on the exam and the x-ray? Or, maybe I handled it correctly. The problem wasn’t only that he was ignorant on the topics or that he so infuriated me that I wanted to scream, but that I allowed myself to get drawn into a conversation that made me feel I needed to defend myself and my profession. Fortunately now, I have this blog as my outlet and have an acceptable place to “get it all off my chest.” I’m feeling much cooler now; the AC is working again.

Colleen B. DeLacy, DDS

Where Do You Send Your Patients?

My 45-year-old patient presented to the School of Dentistry walk-in clinic on a recent Friday afternoon to be seen by a dental student. She had driven two hours across the state from her hometown of Grand Rapids. The front page of her medical history included “tumor on C1 Bone,” “tumors in bones,” and “carcinoid tumors in liver and pancreas.” Before I even turned the page to see “carcinoid tumors in abdomen including spleen,” I knew this was not going to be a simple one-hour emergency extraction appointment. On page three, she indicated that the reason for today’s dental visit was “oral cancer, toothache.”

Her general dentist provided us with a well-written and detailed referral. “#18 is grossly decayed, with furcation involvement and associated infection. She is unable to have this extraction in our office because of her current/past medical history and is Metastatic Carcinoid post radiation to the mandible in the area of dental infection.”

I spent the next two hours contacting her primary physician and oncologist to obtain information about her radiation therapy (no easy task on a Friday!). It so happens that she had a 30 Gray course of palliative radiation for her Stage 4 cancer, which was completed roughly a month before.

Once the information was finally assembled, I had a long conversation with the two faculty members supervising the clinic. We all agreed there was no alternative but to extract the tooth because she was in extreme pain and there was no chance for endodontic and restorative success. We had a long discussion with the patient and explained the risk of osteoradionecrosis. She clearly appreciated our diligence and, upon answering her questions, she agreed to the extraction.

A week into my fourth year of dental school, I extracted the tooth. She had driven across the state to have her tooth extracted by a dental student because “she was unable to have this extraction in their office.” It is certainly in our patients’ best interests to refer procedures we are uncomfortable performing, but there is no reason a local specialist could not have seen her.

Sadly, it is common that procedures are referred to the School of Dentistry that can and should be performed elsewhere. We frequently see patients for extractions because the dentist office (which happens to be a dental chain office) “does not have the necessary equipment.” I realize dental equipment is expensive, but a set of elevators, forceps, and a surgical handpiece should be stocked in every office. I have also been told that area dentists have also set up voicemail messages that refer after-hours emergencies to the School of Dentistry.

My not-so-succinctly argued point is that, although it takes a team to properly care for our patients, it is vital that we only refer when it is in our patients’ best interests. Further, we should only refer them to an appropriate provider. When a patient of record shows up in pain, you should be prepared to help him or her. If a case is too complex for your office, it probably should not be sent to a dental student!

Here’s a copy of her pano. What do you think? How would you have managed this case? Do you know a local oral surgeon who would have seen her? Would you have extracted this tooth yourself? Would you have sent her for hyperbaric oxygen? What other precautions would you have taken?

David Coviak