Tony Ratliff, DDS
"Mrs. Jones, it looks like this tooth has a lot of stain in the occlusal grooves, and I think you are starting to get a cavity in it. I`m going to put a `watch` on this tooth, and we`ll check it at your next recall appointment."
"Bob, everything looks good; however, you may be starting to get a small cavity here between your back two molars. We`ll just keep an eye on it and watch it until next time."
Recently, one of my young dental associates (five months in private practice) and I were discussing a particular case he had been treating. He was explaining to me that he had told his patient he would just watch the tooth. He immediately turned to me with a puzzled expression and said, "Why do we `watch` teeth?" How many other dentists have this word watch in their vocabulary? How many of you have used a similar sentence in the last week? Is this something that was invented after graduating from dental school, or is this word some secret password that has been passed down through dental generations.
It took my partner and I at least three years of practicing dentistry to finally eliminate this word from our vocabulary. For our first three years, this word, "watch," somehow entered into our treatment plans and case presentations. It became as common as any of our other learned dental terms. Who had taught us this bad word or how did we discover it? What were we "watching" anyway? How long did we plan to watch those particular teeth? Were we waiting and hoping for a magical improvement?
Why are dentists, who have graduated from accredited dental schools and passed national and state dental-board exams, and their hygienists watching teeth decay? How many older, more experienced dentists, still have this word in their vocabulary? Dentists, both young and old, use this word for three simple reasons. Which category do you fall into? What`s your reason?
Let`s face it. Rejection is not fun, and many of us feel uncomfortable about confrontation. This is especially true for younger dentists who have recently graduated from dental school and who may not have overcome the mental trauma and low self-esteem many develop while in school. So, we tell the patient, "We will just watch this cavity until next time," to avoid dealing with it now. Somehow, in our conscious minds, we hope that the cavity will just go away or get better on its own before the next recall appointment.
It doesn`t take a person skilled in communications to pick up on the nonverbal clues a patient gives off after hearing he or she has a cavity. The patient usually becomes defensive or resistant in some way. I even have had some patients come right out and say, "I`m having a good day, Doc, so you better not find any cavities!"
I think it takes a few years to become callused to the repeated rejections and ugly faces. But, it`s a wonderful day in your dental career when you finally reach the point of understanding that your job is only to give patients the facts and make treatment recommendations. With this knowledge comes the understanding that you cannot please everyone, and you can`t be everyone`s dentist. Let the patients make their own decisions, and learn not to take their decisions personally.
Inexperience another factor
This is another reason many young dentists quickly get into the routine of watching things. When I first started practicing dentistry, being inexperienced, I developed a bad habit that would take about three years to change. Not wanting to scare off any of our new patients and having a fear that they would not like my practice or me, I often would underdiagnose the condition of their mouths.
Maybe the patient would have three or four obvious problem areas. I would choose the worst areas and say something like, "Well, John, you have two cavities here on your upper left teeth, and a couple of other questionable spots on the lower right. But, let`s do these two, and I will check the others at your next appointment."
I did this because I was afraid they would think I was some "young-gun dentist" who only wanted their money. This was the mechanism I used to avoid their rejection. Now I just say, "Mr. New Patient, you have four cavities, and we need to get them fixed as soon as possible." With experience comes knowledge. If I feel resistance or get a questionable look, I`ll reach for the mirror, radiograph, or, better yet, the intraoral camera.
Because of the high magnification when using the intraoral camera, both the patient and the doctor can see the deep, dark occlusal stains or marginal breakdowns. The teeth look incredibly different on a 20-inch television monitor, and you don`t have to be a dentist to notice the abnormal tooth anatomy or deteriorating fillings. An intraoral camera can be a good tool to improve your ability to diagnose correctly. My partner`s advice on diagnosis to the younger doctors in our practice always has been, "Just do what they taught you in dental school." When following this advice, you eliminate thoughts like:
- Will the patient believe me?
- Does the patient have insurance to help cover the fee?
- Will the patient come back and get all the work done or go get a second opinion?
Not wanting to do the dentistry
Hopefully, not many of you fall into this category. I know of several older dentists who just got tired of doing the dentistry and, for that reason, began to underdiagnose as they started slowing down in their later years. But, those of you who put watches on teeth because there is no financial reward are the greatest offenders of this word. The worst use of the word watch is when the dentist does not want to do the needed service.
Although I do not have a lot of experience in dealing with capitation and managed care, I know of many dentists who accept it or have accepted it in the past. After many conversations on what must be done to have a profitable capitation practice, I`ve learned that there is a negative financial incentive to doing the dentistry. In this case, sometimes the dentists watch teeth because they have used up all of their capitation money for the month, and hopefully there will be some available when the patient returns. But, many of these dentists would rather the patient not return, or they wish the patient would either switch insurance plans or go to a different dentist in the plan.
My wish is for all dentists to strike the word watch from their vocabulary. I hope that my own dentist never tells me that we`ll watch my teeth decay until they get worse. In my short dental career, I have yet to see a watch improve. As our diagnostic skills improve and the number of watches decreases, we will begin to provide a greater service to patients and the community.
Dr. Tony Ratliff is a 1994 graduate of Indiana University and lectures senior dental students on "Life After Dental School." He enjoys the business side of dentistry and is enrolled in an MBA program at Anderson University. He and his partner, Dr. Derrick Johnston, practice general dentistry and own Family Dental Inc., which currently owns and manages five dental offices in central Indiana. He can be contacted at (317) 773-1302.