Why Are We Not Thorough?

When I was in dental school, it took three hours to do a new patient exam. It involved reviewing the medical history, the extraoral soft tissue exam, the TMJ exam, the intraoral soft tissue exam, forensic charting of the teeth (fillings, recession, furcations, mobility) and the 6-point perio charting (including bleeding on probing and suppuration), as well as review of the appropriate radiographic series (full mouth and/or pan plus bitewings plus selected PAs). We were taught to be thorough.

Then we got out of dental school and entered the “real world” of general practice dentistry. Suddenly, most of our colleagues were not charting the extraoral findings, not doing a TMJ examination, or not charting the periodontal status on every tooth (they may have looked but did not record anything, or they did the lesser PSR recordings, which look at a selected subgroup of teeth). For many, a new patient exam is a 5- to 10-minute greeting by the dentist. How does the patient benefit from this?

I recently had a new patient in my office. I always book a one-hour examination with me, not including dental hygiene services. We still do complete forensic charting as taught in dental school and add an intraoral series of photographs, as well. In this particular case, there was a deep pocket on the buccal of the upper right second premolar when all the other teeth were within normal healthy periodontal parameters. This tooth had been treated endodontically and had a post and core and crown. It all looked normal and was asymptomatic, but the deep pocket in one location (of 6) on that tooth was a strong suggestion of a vertical crack on the root.

We had two choices. We could wait until the tooth was symptomatic and act, or react. Or, we could assume the vertical crack was there, extract and preserve the bone for placement of a single tooth implant. We elected to do the latter. Upon examination after extraction, the tooth really did have that vertical crack. If we had not done a thorough 6-point probing on every tooth, we would have missed this finding. My patient was grateful we were thorough, and told us that no dentist had ever examined him this comprehensively in his past. We had earned his trust.

I do a lot of consulting for insurance companies, lawyers and disability management companies for orofacial and TMJ injuries from trauma, mostly motor vehicle accidents (MVAs). In these cases, I am asked to determine which injuries are due to the MVA and which are pre-existing problems. It’s a detective process for me and I enjoy sifting through records from my colleagues to attempt to figure out the source of the pain and dysfunction. Unfortunately, so many of the dental records I review have areas on the forensic chart for the extraoral and TMJ findings to be recorded that are completely blank. These critical structures are either not examined at all, or nobody takes the time to record their findings. This leaves me, and the patients, in a difficult quandary. It is sometimes to the patient’s detriment when I cannot demonstrate definitively that a problem is directly due to trauma and not a pre-existing problem.

I presume that we are taught to be thorough in dental school for a good reason. Why do we stop doing this? How do our patients benefit from us not being thorough? This is my plea to you to get back to basics and be more comprehensive. I think you will be surprised by how grateful, surprised and delighted your patients will be when you do this. I am now beginning to redo the complete examinations on patients who have been part of our practice for 10 years or more. So much has changed in that time that it is time to revisit their goals and their health.

And now for an update on my practice sale. I had it valuated in the Fall; within three weeks of listing it, I had two firm offers from two incredible dentists. I had the difficult decision of deciding between these two. I chose the dentist with 20 years of experience who possesses a skill set in general practice dentistry in treatment areas that I routinely refer out. This will likely lead to me reaching my goals of fewer hours and less stress faster. Did I make the right choice? Time will tell. I have such admiration and respect for the other dentist, and I hope I can find a way to work with her in the future.

I am now still in the final negotiation stage and hope to have the deal completed before the end of March. Onwards and upwards. And back to the grind…

Warm regards,

Larry Stanleigh, DDS