Stephen G. Blank, DDS
I was shocked to read the Viewpoint by Joe Steven Jr., DDS, in the August issue! (Dental Economics, page 16.) He made the philosophy of offering "quality dentistry to each and every one of our patients" seem like a negative thing to do. I believe every patient should have ideal care offered. Care should be related to the patient's oral health level, and presented accordingly. For example, to present full-mouth rehab to a severely periodontal-involved new patient that is negligent in home care and overdue for dental care is not appropriate. To say nothing is worse. It should sound something like this: "Mrs. Jones, you are right, you need a lot of dentistry to fix things up, but I can't even think about that yet. You need a healthy foundation first (periodontal and occlusion). When you get there, then we will talk about long-term planning. In the interim, we will place fillings that are long-term temporaries (composite core build-ups, for example). [Sometimes temporary crowns are needed to remove iatrodontic pathology.] This material will hold up until you finish your periodontal therapy. Does that make sense to you, Mrs. Jones?" We may even mention the need to restore teeth if they can become stable. "Mrs. Jones, I hope to be able to restore your teeth and smile by placing restorations on the damaged teeth when they are more healthy." To simply revert to single-tooth dentistry is doing no one a service. When she is healthy, a $20,000 treatment plan may seem more appropriate. I wouldn't feel good adding on to my house over quicksand. To discuss crown details at the beginning, in the face of disease, is both overwhelming and premature. Personality types also dictate the level of information and detail to provide at the first visit. She is not a candidate for full-mouth rehab yet.
There is no need to be deceptive. Too often, I see patients who had endodontic treatment, and never had a crown placed or even discussed. The tooth is now non-restorable. The previous dentist was too "chicken" to tell the patient all the fees and that a crown and core are needed at the beginning, because the patient might decide to have the tooth pulled instead. Honesty works. Phasing ideal care is very acceptable. This is our professional obligation to discuss what they really need, not what the dentist wants. This is not the same as offering alternate treatment plans. It would be wrong in my opinion to say, "Mrs. Jones, your mouth is a wreck, so [I have decided] we are just going to see you every three months for cleanings, and we will just keep patching you up, and watch some things. You will probably lose some teeth this way, but I will be here for you." It is a form of malpractice to not tell patients what could be done! We see it all the time! Patients present with severely worn occlusion and a dental history of prophys every six months for years. No one ever thought they would accept complete care, so it was never mentioned. Possibly the dentist did not recognize the wear as it was occurring as a problem. Patients have to be given information to consent. A patient cannot consent to malpractice, even if it is commonplace. For a dentist to volunteer to patch people up is not helping anyone. We do no one a favor by not giving them the option of complete care. Of course, we all place large fillings — if we are honest with the patients, we will tell them it is a core, or that it is an interim measure until they are ready for crown protection, not that we prevented them from needing a crown.
Dr. Steven raised the issue of the level of dentists' mouths — his course attendees — and what they would spend on themselves. I question whom he attracts! At the courses I have attended, many of the dentists have been equilibrated and restored! I would suspect that many of the course respondents that he speaks of may be like many of his patients. A mentor once told me to be careful when complaining about your patients — you attracted them, Doctor! If your patients just want you to watch teeth with cracks or questionable decay, it may be due to your reputation: "Dr. So-and-So lets everything go; he doesn't try to fix all your teeth. Just call him if one breaks." Or maybe, "Dr. So-and-So is great, he doesn't try to cap all your teeth." Whom does this serve? These patients will require more endo and more difficult restorative treatment later. More teeth will be lost! Patients who want complete care will ask the patients who look good, "Who is your dentist?" They will find dentists who help people look good or feel healthy. Those patients are everywhere, but they do avoid certain offices. If your office reflects high volume, double booking, or chair-hopping dentistry, don't expect the patients to raise the dentist's level of care by requesting complete care. The doctor has to be the leader. The patients will allow you to just patch them as long as that is what you do best.
Dr. Steven goes on to say, "Too many dentists are headed in the wrong direction simply because we can't all have 'Rolls Royce' dental offices." Wow! I believe that to be false. That statement comes from a "scarcity mentality" — that there's not enough good patients to go around, and not enough dentists willing to learn. We all can have good patients! If all dentists offered only good care, dentistry would be very good; patients would be better. Dentistry has helped to create the patient base we have today, for better or worse. Imagine if banks thought the same way about accounting: "Mistakes happen, Doctor, maybe we will find your deposit today, maybe not. We did pretty well last week; not the best, but average."
If dentists did complete dentistry, then all patients would expect that. It is what we were taught in dental school. Dentists have trained their patients to behave in congruence with the way they practice. Dentists may not like what they have when they go to work, but the dentist created it (I know; I used to be one of them!). Dentists do it when they sign up for an HMO or PPO, then complain they are seeing too many people and few patients are healthy (or more often, they complain that cash flow is poor or overhead is high). In the long term, less dentistry would be needed if the goal was ideal "Rolls Royce" dentistry and good health the first time. Imagine if the physicians said, "We can't afford blood tests on healthy people, wait until you look sick. We can let the hospital look a little run down, we can't afford to paint the place or buy an MRI; X-rays will do fine." You wouldn't accept it there. You would get up and leave, I hope. Why should dentistry be a lower level of care? Why are dentists willing to buy $25,000 computer systems to bill insurance for the maximum amount of patch work we can do each year, but most dentists will never take a course that costs $5,000 to learn how to restore a mouth the right way? Is it the computer system or the dentist (and the CE courses taken) that makes a "Rolls Royce" practice?
Imagine if all dentists refused to let patients "just have a cleaning" without an examination. Is there a downside of doing it right (like you were taught in dental school)? Perhaps we would have a healthier America! The dental profession is beginning to accept mediocrity as a standard. We all know it. Check your new patients who have been to another dentist regularly and see what is in their mouths. Would you want your mouth to look like that? Many dentists do treatment in a manner that would not be acceptable by their own dental school: Crowns before periodontal health; having only bitewing X-rays on adults; setting three-month maintenance on patients without ever doing a full-mouth periodontal re-evaluation; starting patients with a "cleaning" without a diagnosis by the dentist; skipping examinations or doing the five-minute version for a new patient; skipping full-mouth periodontal measurements on new patients; allowing patients to return for emergency care without ever doing an examination.
Some dentists "don't do TMJ," yet they do crowns on people daily, changing their occlusion. They know they skip steps, yet they do it, saying, "I just don't have the time to become a 'Rolls Royce' practice." They have too many people to patch to have time to prepare for a full-mouth case. They say, "Not everyone can have a 'Rolls Royce' practice!" Why not? Who decides how we spend our time? Who decided that courses on insurance-claim filing should be done before comprehensive oral-examination courses? Accepting that we cannot all have a "Rolls Royce" practice is an excuse for not trying! I hope all other professions still strive to be the best. Every profession has a few that fall below the curve; let's not lower the curve. Some dentists try to raise fees and cut out insurance before they raise their own skill level. As Dr. Steven points out, these dentists do fail in that model of a dental practice. Dental skills, management skills, and verbal skills are all part of the "Rolls Royce" practice. You cannot choose to do part of the program and have success. Learning does not end at graduation.
Dr. Steven says, "I take great pride and satisfaction telling a patient I did not find a thing!" Me too! We agree on that. Then the foot goes back in the mouth: "I break the golden gurus' rule and will actually watch suspicious areas." That is not some guru thing; it is a diagnosis issue. He calls that a conservative approach. That is a risky approach! What are you watching? Don't watch my tooth, please! Patients are the ones who say, "Doc, if it ain't broke, don't fix it." The dentist is supposed to decide if it is "broke," and inform the patient, not wait for disaster. We don't wait for decay to hurt before we fix it. Why do we wait for the occlusion to get so bad that the entire mouth needs rehab before we notice? And then, we often don't recognize the signs, and we still don't fix it — we remove teeth.
Another misconceived idea by Dr. Steven is, "There's nothing wrong with part of our profession catering to the very affluent sector of society who demands the best dentistry money can buy." I see a few flaws with this thinking. First, the most wealthy citizens often have mouths that could use care, but they don't value it enough or have fear, which keeps them from getting it. Money has nothing to do with valuing good health. Second, everyone wants the best care. Rare is it that a patient will request I skip a step or do secondary care. I just don't hear, "Doctor, can you place a cheap crown?" Patients may be concerned with a fee, but they don't want less than the best care. The best patients I have are average folks who save for their treatment or use a financial plan such as Dental Fee Plan or Care Credit. They appreciate good care, because paying for it is not so easy. The more third-party coverage, the less patient ownership of the problem. If all insurance went away, patients would have to take responsibility. Dentists would have to talk to patients about long-term planning, including full-mouth rehab. After all, the patient would be the consumer again, making their own EOB determination.
Dr. Steven goes on to talk about the "big case" trend. You don't get big cases if you don't watch problems grow! TMJ cases never start in a severe stage. The easiest cases are resolved by equilibration, and no restorative treatment. If patients are given a choice, they will wait until something hurts (teeth worn down to the pulp). Patients are just ignored by dentists who don't take the time to learn or care. Then the patient finds a better dentist or one who takes the time to diagnose. I have seen the following scenario too often. My new dental assistant's sister saw her previous dentist faithfully for 15 years, twice annually. In that time, her jaws clicked and popped; she had headaches, migraines, and pain. She never missed a recall visit. She saw a neurologist and an ENT doctor. She even had a CAT scan! It was not a medical problem. When I did a "Rolls Royce" examination with mounted study models, we found an easily treated occlusal discrepancy! After one long visit for equilibration and adding composite to the cuspid tips as an interim measure, her headaches were gone the next day! No more pain, no more medications, no need for appliances! The tragedy is that, at age 36, she now needs six upper teeth and two lower cuspids restored in a virgin mouth. Her last dentist just watched her wear the enamel off her upper anterior teeth until the dentin was exposed and her teeth became as wide as they are tall. Her last dentist did not offer her a "Rolls Royce." He didn't have one to sell. He was a "Chevy" dealer, or worse, he was out of inventory and sold her nothing. We owe it to our patients to offer them Rolls Royce care, but we first have to raise ourselves to a level that allows us to provide that care. Average is not good enough. Some dentists balk at the requirement for continuing education; they say they don't have time to take the 40 hours in two years that Florida requires! Some say they cannot afford to take time off work for courses. Some dentists say their staff is the problem. And then comes the finalblow — "My patients won't do all that fancy care, so why bother taking the courses?" I think we should all aspire to the "Rolls Royce" level of care, and raise patients' expectations of dentistry. We should all hear more patients saying, "My dentist is the best. He took good care of me once, and I don't have to go back all the time for the next disaster. My mouth is healthy. I can eat and I can smile. Thank you, Doctor, for telling me how you could give me the best care so I don't have to worry about my teeth always being a problem!"
Dr. Blank is a private-care practitioner in Port Saint Lucie, Fla. Dr. Blank can be reached at email@example.com.