It’s (almost) always about money

I want you to think about the worst patient problem in your practice. When you peel back the layers, it’s almost certainly about money.

If you think I’m wrong, let’s do a thought exercise. Think of the patient problem that’s been occupying your mind the most lately. It may be lack of case acceptance (the obvious one) or patient dissatisfaction (bad Yelp review anyone?). Hold that problem in your mind. Concentrate on it. Feel it.its-almost-always-about

Now…how does that problem become different if the treatment proposed to the patient was free? How might that problem resolve? What could you do in your practice to take away that objection?

I’m not offering any specific solutions here. Obviously there are a million ways to skin the financial arrangements cat. But it’s worth remembering that patients may love us, our office and our team. But no one is sitting at home hoping that they’ll be able to cut us a check using money that they’d rather spend on the new iPhone.

I know what you’re thinking. What about anxiety? That’s a big patient objection, too. I agree. But I’d say we’re talking 10% or less of patient objections are primarily due to anxiety. Also, how many anxious patients are in your office letting you know that they’re really freaked out about dental care, but clearly are happy to pay you whatever? If anxiety is their biggest hang up, money can (and probably will) still be an issue.

We’re not great at getting past this objection in my practice. The practices who can really identify and move past money as an objection definitely do better financially and probably are more satisfying to the dentist.

So next time you struggle with treatment acceptance it might be worth asking the patient, “is there anything besides the cost that would keep you from doing this treatment?” You’ll probably learn a lot.

 

 

 

Meet them or bring them?

I’ve been told ever since dental school that if I just use the right words I can get any patient to accept any treatment. At the very core of this narrative is that patients can afford the treatment that we propose, but they choose not to. They’d prefer to buy cell phones, new cars and cable. But if we’re good enough (and if we take their course) we can motivate them to forgo these luxuries for the glories of comprehensive dental care.

It never seems to occur to those folks that the value that we put on complete dental health is a value judgement that patient may not share. I’ll go even further and say that it’s O.K. if patients don’t value their teeth. Because I’d much rather work on a patient that already values having healthy teeth and gums than one I’ve convinced that they should value it. Perhaps the one I’ve talked into receiving my valued service is the one who’s more likely to have buyers remorse.

I have a friend that is really good at case presentation. He takes lots of photos, fully mounted study models and CT scans. Often he’ll have the photos digitally enhanced to let the patient know what his proposed treatment might look like. He does big cases. Lots of them. The kind of cases that much of dental continuing education explains that we should be aspiring to. He’s a very skilled and conscientious dentist.

Recently, he was sanctioned by his state board for supposed record keeping violations. How do you think the board found these “egregious” errors? Was the patient unhappy with the quality of the dentistry done? No. In fact, the patient had no complaints about the dentistry. It was just that she felt like she had paid enough for the work that was done and was “confused” about how much the treatment was going to cost.

Patient ValuesI’m positive that my friend had the patient’s best interests at heart. He knows how to deliver some amazing care. I think he persuaded her why she should value the kind of care he wanted to deliver to her without her actually valuing the care.

Our patients value all kinds of different things. It’s not our place to judge them for it. This is really hard for most dentists and dental team members. Everyone has heard a patient explain that they don’t want to spend the money on this tooth and soon after they talk about their upcoming trip to Mexico. This drives dentists crazy. “If they only valued their teeth the way they value their vacation” we think. We judge their priorities and what they value. It’s obvious to us that they should prefer more optimal dental treatment over a stupid trip to Mexico.

I have to admit that I’m guilty as charged.

But it drives us crazy when someone judges our values and priorities. If you’ve ever gotten annoyed with someone talking about “rich dentists” then you’ve been a victim of this. We valued going to school for a long time and taking the risk of starting a business and we feel like it’s fair that we reap the rewards. But from the standpoint of some, we’re just “rich dentists.”

Can we possibly admit that valuing a long anticipated vacation to Mexico over placing that implant is O.K.? Perhaps one person’s “optimal dental health” is quite a bit different than what we dentists think of as optimal and that’s alright.

We need to educate patients about their condition separately from whatever treatment plan we might be proposing. That’s part of being a doctor. And part of getting true informed consent. The patient has autonomy and always should. Your superior skills of persuasion aside, the patient has a right to their own messed up teeth if that’s what they prefer.

I don’t want to come off like I’m not in favor of the concept of “comprehensive dentistry.” But I don’t think that paradigm is a good fit for everyone. In fact it’s probably not a great fit for a majority of people that might walk in your door. Some folks need a full mouth rehab but will only choose to have the painful tooth removed.

As a dentist you need to know a lot of things, but one very important skill is being able to meet the patient where they are. After all, patient values can change over time and being the one that helped them when they weren’t interested in much treatment can help you be the dentist they find when they are interested in more and potentially better treatment.

Letting people know what you’re seeing and explaining what you can do for them is our duty. Persuading people that the way they value dental care is wrong is a recipe for disaster and short circuits the patient’s autonomy.

Diagnosing surgeon

Dentistry is procedure based. Generally speaking, we do all kinds of procedures to fix problems with the teeth, gums and jaws. That’s what dental school trained us to do. With the exception of some newer “medical model” treatments, most dentists spend their days doing fillings, crowns, root canals, extractions, placing implants, making removable prostheses and doing periodontal therapy. These procedures typically have a starting point and end point (except dentures in dental school…those never really end) that is easily denoted.

That isn’t to say that dentists aren’t diagnosticians. We become expert at recognizing all kinds of pathologies of the teeth, gums, jaws and muscles. In order to treat our patients effectively (usually using procedures at which we become more and more proficient), we need to effectively diagnose their problems and communicate to them what we’ve found and their options to treat (or not treat) as the case dictates. Most dental offices are one stop shopping unless the dentist chooses to refer procedures out to specialists.

Broken armOur colleagues in the medical industry operate differently. In many cases the physician that diagnoses the problem doesn’t actually treat the problem. If I fall off a ladder and break my arm it’s likely that an ER doc is going to assign a differential diagnosis to the problem and order a radiograph that’s read by a radiologist, who diagnoses the fracture. At that point, it’s likely that I would be referred to an orthopedic surgeon to treat the broken arm.

What you don’t see very often in this multidisciplinary track of care is the patient being concerned that there is “overtreatment” going on. For one thing, it’s often very problem based. I wouldn’t have shown up in the ER if my arm wasn’t bent in a funny direction. For another thing, there are several clinicians that are coming to an agreement about the care you’re going to receive. That’s a big difference from what typically happens in dentistry. Not that we don’t refer to specialists, but it’s pretty rare that a patient’s diagnosis and treatment plan is put together with that many brains.

Some patients, especially ones that don’t know you very well, may believe that you are treating problems that they don’t have. A big cavity can remain painless until the pulp is involved. Sometimes even after the tooth is abscessed the patient doesn’t feel pain. Gum disease is almost always painless. Often the patients don’t realize they have a problem even though it’s obvious to you as a clinician. I find this to be one of the less fun parts of being a dentist. I’ve got to be the guy to deliver unexpected news in a way that doesn’t seem like I’m hoping to cover my boat payment. And it’s always a boat payment, right?

Spear Online education posted a video that I found helpful. It’s entitled “Managing Fear When Presenting Findings to Your Patients.” I related to a lot that he discussed. One thing I walked away with is that presenting findings is a lot different than presenting a treatment plan. That may seem obvious to you, but sometimes I get hung up in that. When I’ve got two hygiene checks per hour and I’m doing a bunch of time consuming restorative dentistry at the same time, I often don’t separate the two.

“A treatment plan scares people away.”

Dr. Frank Spear

I need to remember to share the findings of my exam. A few months ago I moved my microscopes from my treatment operatories to my hygiene operatories (I only have two scopes). Each one of the microscopes has an HD camera that’s connected to monitors in the operatory. I do all of my hygiene and new patient exams through the microscope. This has been the greatest tool I’ve ever used to explain conditions to patients without automatically moving to a treatment plan. Also, I get a lot less of the “boat payment” comments now, too. I’m still just beginning with this technique. I think my patients have a much better understanding of their condition than I’ve ever been able to offer. Another pleasant surprise…treatment acceptance is way up!

I just need to remember that my exams are not just a way to create a treatment plan for a patient but a chance to explain the conditions that I’m seeing to the patient. It’s about diagnosis and education. The treatment plan will come from that discussion.

Questions or comments? Please leave them in the comments section below or email me at alan@meadfamilydental.com.  If you’re a dental peep you owe it to yourself to listen to my dental podcast. It’s called The DentalHacks Podcast and it’s made with 50% unicorn tears and 50% sweat from Chuck Norris’s brow.D

Human first

I had two patient interactions this week that got under my skin. I hesitate slightly to write about them because they may come across as petty to some. But I think they illustrate an interesting perception about dentists and maybe health care providers in general.

The first thing was a patient that came in with “an emergency.” In my office, the patient gets to decide what an emergency is. We go out of our way to see people with emergencies as soon as we can. Quite often we see emergencies the same day that they call. This patient had made an appointment to be seen by a hygienist the day before and didn’t show up. They also didn’t call. Honestly, that’s strike one. I feel like grown ups that schedule their own appointment should be able to show up and if they can’t, a phone call or some other acknowledgement is the least a patient can do unless there’s some kind of emergency that keeps them from contacting us (which of course, we understand). As you may have guessed, they patient has missed appointments before. Furthermore, the patient showed up 15 minutes late for their “emergency” appointment the day after. No apologies for being late. Nothing.

I saw the patient and was pleasant and professional, but purposefully aloof. We took care of the emergent problem and made a plan for a long term fix.  I probably was not my normal “bubbly” self. Frankly, I was annoyed. The patient didn’t show the day before, showed up late today and had an “emergency” that consisted of a broken tooth that has been treatment planned to fix for years. Literally years.

phone photo smallLater that day we received a phone call from this patient. They wanted to give us some customer service tips. They told us that because we didn’t seem all that busy that I should have spent more time explaining what I was going to do instead of chit chatting about things that didn’t have to do with the patient.

You can’t make this stuff up.

The second interaction happened later in the week. We got an “emergency” call from a patient that we hadn’t seen for a long time. They prefaced the call with “I don’t have any money…” Of course we saw the patient, did and exam and made a plan. Furthermore, we helped explain ways that we could help them afford dental treatment and even helped them find another provider that might take their government provided dental benefits.

I understand that some people aren’t in a position to pay for ideal dental care. I feel bad for them and we always go out of our way to try and help them. But I always wonder how that same phone call goes with the grocery store.

“Hello, this is Kroger. How can I direct your call?”

“I need some cantaloupe, but I don’t have any money.”

“Ummm. Well, we have cantaloupe, but we sell them for $2.15. I’m not sure what else to tell you…”

So now you’re either totally empathizing with me (which probably means you’re in the dental field or you’re some other kind of health care provider) or you think I’m an insensitive jerk. But there’s a little bit more to this.

How do people get to a point where they feel this is appropriate? I’m pretty sure it’s because we don’t think of health care providers as people. The fact that we think of them as “professionals” means that we hold them to a different standard. It’s almost like we don’t think of them as providing a service in the same way that other service providers do. Because we have specialized skills and a license granted by the state, health care professionals are different.

In fact, they are somehow less human. Doctors are not allowed to be irritated by my behavior because they’re doctors and I’m a sick person. A nurse in the ER has to be nice to me even when I’m acting unreasonably because I’m the patient and she’s the nurse. Dental offices cannot hold me accountable for appointments that I’ve made because they are health care professionals and I’m a patient.

Patients and providers alike, I’m going to let you in on a little secret. We’re all human beings first. No matter the skills we’ve accumulated and positions we hold, we’re still just relatively fragile and mostly squishy bags of emotion and meat. All the degrees and training in the world won’t change that.

Since that is undoubtedly the case, I want everyone on each side of the patient/health care provider to acknowledge this. There are always consequences to the way that you treat others. That doesn’t mean your surgeon won’t do their best for you even though you treated them like a jerk. However, they may be less likely to worry about your feelings in a post op exam. And dentists, if you’re paternalistic and not particularly kind to your patients, they may well decide to find an office that they feel like appreciates their presence more.

For the people that treat everyone poorly, there’s probably nothing that can be said that would change your behavior. But if you ever wonder why people don’t like to be around you very much, you might take a look in the mirror. For everyone else, I’d like to make a suggestion.

If you’re a fearful patient, be honest with your dentist. Starting the appointment with “I hate dentists” goes over differently than “doctor, I just want you to understand that coming to the dentist makes me really anxious.” I’d much rather work on a patient who tells me the latter. Dentistry has lots of options available to anxious patients to make treatment easier. But if you just tell me that you hate dentists it doesn’t help me understand your fear and it makes me think you don’t like me. Who wants to work on a patient that doesn’t like them?

As an FYI…I hear that “I hate dentists” line at least weekly. Maybe more often. Every dentist will tell you the exact same thing.

For the patient who starts the conversation with “I have no money,” it’s kind of similar. I’d much rather you tell me, “doctor, I have concerns about how much treatment is going to cost. I don’t have much of a budget for dental care right now and I need to know my options before you get going.” I don’t know a dentist in the world that isn’t going to help with that. Seriously.

The point is that health care providers put their (scrub) pants on the same way everyone else does. It’s worth remembering that they are human and have feelings just like everyone else. They are likely to respond to the way you present yourself the same way everyone else does.

Health care professionals…this works the same way for you, too.

Questions or comments? Please leave them in the comments section below or email me at alan@meadfamilydental.com.  If you’re a dental peep you owe it to yourself to listen to my dental podcast. It’s called The DentalHacks Podcast and it’s made with 100% fresh squeezed awesome.

 

Sharing photos with the lab (or anyone else) using Dropbox

Dropbox-LogoIf you’re like me, you take lots of photos of your patients. If you’re also like me, you find sharing them with the lab to be a bit of a chore.

I won’t explain how to take photos. I’m clearly not qualified for that. I will tell you that smart people who know better than I do have told me not to bother printing digital photos and sending them to the lab. Dr. Mike DiTolla recently opined in episode 14 of the DentalHacks podcast (shameless plug) that if you aren’t springing for the right kind of printer paper and an expensive photo printer then your printed photos aren’t very helpful to a lab technician trying to match your shade.

But if you’ve ever tried to email photos to the lab you’ll find that the size of the photos that most digital cameras take is huge. Typically we’re talking several MB per photo when you’re taking high quality photos. So attaching them to email is a pain. Many email servers won’t allow you to send emails multiple files attached to them that are that large.

I’ve solved this problem using Dropbox. I’ve been a Dropbox Pro member for several years. I’ve paid $99/year for 100 GB of cloud storage that I can access on any device. It’s been handy. This year I started to approach 70% of my 100GB and was wondering what I would do once I got close. The folks at Dropbox fixed that problem before I ever really approached it by upgrading the Pro level to 1 TB of cloud storage. Same $99/year with 10x the storage. With that much storage, you can afford to be a little sloppy with it!

Anyhow, Dropbox allows you to share photos or folders with multiple photos with a simple link. Take a look at this short video tutorial for details. The video assumes that you’ve got a working Dropbox account and you have a photo somewhere on Dropbox that you’d like to send.

By uploading your photos to Dropbox you make it possible to share that photo with a simple link, rather than attaching it to an email. Even better you can put several photos in a folder and share the entire folder with a link. All the sudden you aren’t trying to figure out which photo or which angle is the best for the lab. Send them all and give the lab as much information as possible!

If you have any questions about how to use Dropbox to share photos or suggestions of other ways to use Dropbox to simplify your workflow leave them in the comments!

 

Doing reps

Let’s say you need a procedure. Perhaps a filling or a crown. You have a choice between two dentists to do the procedure for you. You can choose yourself at this moment or you can choose yourself 10 years ago. Or 5 years ago. Or 20 years ago. The point being you are choosing yourself at a time when you had significantly less experience than you do right this second.

Who would you choose? I’d wager that you would choose yourself at this moment. Why is that? It could be that you’ve started using a new instrument or learned a new technique. It could be because the technology has come a long way since you were the other you. But most likely it’s the reps you’ve put in.

I look back on some of the work that I did 15+ years ago. Some of it I’m kind of proud of, but more often I cringe a little. I see underprepared crowns. I see overprepared direct restorations. Mostly I see things that were done to the very best of my abiity at that time. Which is good. But much of it I would do quite differently today.

When I was a newly licensed dentist I planned to take the world by storm. I thought I knew a lot. And let’s face it, I did. I knew how to pass tests. National boards, clinical boards, microbiology exams, operative practicals. I knew how to play within the rules that were set by others that proved I was qualified to be a part of the profession.

What I didn’t know a lot about was how to be a dentist. I had done a bare minimum of clinical work on patients. I sometimes complain about how little clinical training I had, but let’s be honest. How much would have been enough? If I had done 5 more crowns in a setting where I had to check in with an instructor at every step would that have made me “experienced?” Probably not.

I’ve become the clinican that I am through reps. I’ve diagnosed real disease on real patients and then treated them. And make no mistake, I’ve learned how to treat patients by treating patients. It isn’t that I’m asking patients to be guinea pigs. But to some extent I ask them to believe in my abilities and experience up to that day.

Your patients trust your judgement and ability even though they really can’t know much about either. A poorly done restoration can be done painlessly. I’m not trying to make newcomers to the profession feel bad. You can’t get experience without doing the reps. But understand that most of us learn best by doing. I was never any good at reading the directions and then doing exactly as the directions said and having success. Those directions were written by someone with experience but were being read by me: someone with much less or different experience. For me, dentistry is a “learn by doing” profession. The only way I learn is by being open minded enough to see that there are different ways to get the job done and being patient enough to try something new.

The profession continues to evolve and as clinicians we evolve as well. I believe that most of us really do the best that we can at any given moment. But make no mistake, we get better by doing reps. This isn’t an excuse to be cavalier about treatment but a call to humility. Do your best, but be committed to being better next time.

Delivering bad news

Most dentists have gotten really good at the delivery of bad news. Most of us are pretty good at explaining our findings in a dispassionate way. We’re supposed to explain what we’re seeing, recommend different treatment options, explain the pros and cons of each option and then let the patient ask questions and make a choice. The trick is that you can’t own the patient’s problem. It’s really important that you don’t care more than the patient does.

Straightforward stuff, really. I mean, it’s not like we’re oncologists or something. The great majority of dental problems are not life and death.

I’m here to tell you…I still struggle. I’m not as good at delivering the bad news. I sometimes struggle because I do care more about the problem than the patient does. I think that’s because I understand the problem better.

Tooth decay doesn’t hurt until the tooth is in real trouble. Gum disease is painless right up until the teeth get wiggly. I see what’s going on in their mouth in HD. I use high powered loupes or even a microscope to see what’s going on and sometimes it’s hard for the patient to get as concerned about it as I do.

Some days I get really discouraged about it. I’ve got to let people know what I’m seeing. Modern dentistry can do some amazing things, but getting people to choose that is the difficult part, in my opinion. Some days I get burned out. Sometimes I have patients with multiple and serious problems that have no clue. That is so hard for me. It’s times like those where I don’t even know where to start.

But I’m a doctor. I owe my patients the truth. I don’t have to be mean about it, but I have to be truthful to the best of my ability. Patients need to understand that I don’t enjoy giving bad news any more than they enjoy hearing it. But we’re in this together. They always have the choice to do nothing, but my duty as a doctor is to let them know what’s going on and give them ideas on ways to treat it. We’ll get through this together.

I started a podcast

Mead podcastingI don’t know if I ever had “regular” readers of The Blogging Dentist. But if I did, I probably made them think that I’m not writing any more. I’ve fallen down on the job. I’ve published inconsistently. I’ve been lame. What can I say?

Well…I started a podcast. I used to think that writing a blog took a lot of time. And it does. Kind of. But podcasting takes even more time. So the time I might have spent writing here has been spent getting a podcast up and running.

I’ve been listening to podcasts for a long time. For those who’ve never listened, a podcast is a radio show that can be downloaded from the internet. They’re usually free downloads and the best place to find them would probably be the iTunes store.

I like podcasts because they’re often done by regular folks in their spare time and this gives them a really nice authenticity. The typical podcaster is someone who’s an enthusiast on a subject (think Harry Potter, triathlons or Thai food. Or at least they used to be. A lot of radio stations and professional entertainers have come to realize the power of being able to syndicate your own show for next to nothing and have begun to use the format as well.

It’s actually a blast. I’m enjoying the interviews and discussions with my friends and colleagues. I’m enjoying the fact that I’m spreading ideas. In fact, that’s the same reason I like to write a blog here and at meadfamilydental.com.

There are a lot of similarities between blogging and podcasting. The similarities are all about being a “content creator.” So much of what dentists post on the canned “our blog” part of their websites is written by whoever it is that manages their office’s social media. When I read those blog posts they usually don’t seem authentic. I’d much rather read something a little less polished that I can tell was written by the dentist who is connected to that website.

That’s the spirit we’ve tried to bring to the podcast. The format is half interview and half group discussion. We’re interviewing people that my co-host (Jason Lipscomb) and I find interesting on topics that we find interesting. We call the group discussion “the Brain Trust.” It’s informal. Kind of like the discussion you’d have with colleagues at dinner when you’re taking some CE.

The DentalHacks PodcastThere are a lot of laughs and we don’t take ourselves too seriously. Which some may consider a fault. I think it’s our biggest strength.

So, go check out our podcast. I think you’ll enjoy it.

And I’ll try to start posting more here, too.

 

Emails about fluoride

I recently received an email from a student at one of our local community colleges. The student was taking a journalism course and was writing a story about the “controversy over fluoride.

“Hi my name is **** and I’m a Journalism and Emerging Media student at ***** I’m contacting you in regards to an article I’m doing for my newspaper class on the controversy over fluoride. I was just hoping to ask you a couple questions on the subject of fluoride and I’ll leave them below in this email. The basis of my article is to have a fair and balanced debate between those in the Dental community who support the use of fluoride in our hygiene products/water supplies and arguments made by the anti-fluoridation movement that fluoride causes harm to the body (one website I’ve looked at before is www.fluoridealert.org). I haven’t had much luck contacting anyone else who would speak with me about this. 

Questions:

1. Have you heard of the arguments made by anti-fluoridation movement? If so, do you feel they have any merit? If Yes, Why? If No, Why not?

2. Do you have any personal hygiene suggestions for those who would rather not use fluoride based products?

3. As a Dentist do you have patient refusal of fluoride often? If you do, does it change how you approach cleaning their teeth? Or change what products to recommend to them?

4. What advice would you give parents who are worried about their child’s fluoride exposure (regarding hygiene product usage, etc)?

5. Anything else you would like to add?”

Right away my skeptical alert system went off. Lots of peer reviewed research has determined that the use of optimal fluoride concentrations in drinking water is safe and incredibly effective. The CDC called public water fluoridation one of the top 10 public health achievements of the 20th century. By any reasonable standard, there is no scientific controversy about fluoride. I felt it was important that I let this journalism student know what I felt about science journalism and “teaching the controversy” when there isn’t really a controversy.

“Hi *****,

I’m curious about where your research has taken you. I’m wondering what you personally think about fluoride, both systemic and topical. It won’t change how I answer, but it might help me frame where I’m coming from.

A story like this is interesting. Health and science reporting is kind of special. I understand that you want to have a fair and balanced debate. But when you frame it like that, it assumes that both sides of the debate have equal merit. That might work for political stories, or stories about art. It’s not the same for science. Science journalism is special. Often, there aren’t two sides to a story. There’s the side which the science supports and the side of people who don’t like what that science says. These are not viewpoints with equivalent standing. The evidence weight heavily on one side. Unfortunately, people unfamiliar with the scientific process don’t necessarily understand this.

A great example is the “theory of evolution.” The scientific use of “theory” is unfortunate. To lay people, the term “theory” implies that it’s just someone’s best guess of how something happened. That’s not what a scientific theory is. An excellent definition of “scientific theory” is from Wikipedia: ‘A scientific theory is a well-substantiated explanation of some aspect of the natural world that is acquired through the scientific method, and repeatedly confirmed through observationand experimentation.’ In other words, when scientists use the word theory they mean something that is essentially an explanation of something in the natural world that has been tested and confirmed over and over again. Not just some guy’s idea of how something works.

So I guess what I’m saying is that the fluoride “controversy” isn’t really a controversy. There isn’t credible scientific research that suggests systemic (fluoride in the water) fluoride is dangerous and/or toxic. There is lots of evidence suggesting that systemic fluoride is helpful in preventing tooth decay as well as very cost effective. There’s also lots of evidence suggesting that topical fluoride can help with prevention in tooth decay as well as reversing early “precavitated” lesions.

The problem for a journalist is that doesn’t make for much of a story. The recognized science that includes well designed research says fluoride, when used as directed is safe and effective. If those who believe otherwise have properly designed research published in well peer reviewed journals, the scientific consensus will start to change. Up to now, that’s not been the case.

I’m happy to help, but I want to think a little bit about my answers so I’ll get them to you in a day or so.”

I went ahead and answered her original questions. I answered them in the the way that the current science would indicate. I had done my part by standing on my soapbox and yelling about “teaching the controversy” when there really wasn’t a controversy. This was a college student who didn’t realize they had stumbled upon a dyed-in-the-wool skeptic with a tendency toward rambling emails. Then I received a reply about where this student was coming from.

“My main goal for this article is to basically weigh both sides of the issue and let the audience decide what is best for them and their health. I’m just trying to give each side to the debate a chance to voice their opinion on it. As a journalist I am doing my best to be unbiased while reporting. (As far as me personally),I choose not to use fluoride based toothpaste or mouthwash, and I also have a water bottle that filters fluoride among other things out of my water such as: heavy metals like lead, mercury, radiation etc. I have gone on other websites besides the one I mentioned to research the fluoride debate more. I have contacted the media director for the Fluoride Action Network to get their take on why they believe fluoride is toxic and I was able to get in contact with two Dental Hygienists on what they think. At this point in my life I feel I’ve made the best decision (for me) on fluoride. I understand ‘too much’ fluoride can be toxic, but I’m also told a ‘little bit’ helps our teeth. I just want to make sure all those ‘little bits’ don’t turn into something bigger in the future (If that makes any sense). A main concern to me would be fluorosis of the teeth, and to avoid things like using way more than a pea-size amount. I would just like the opportunity through further exploration finding other ‘all natural’ ways of caring for my mouth.”

So there you have it. As much as I want to believe that this is just a mistake of a somewhat naive college student, I think it’s a bit more than that. In many cases, journalism is about generating a story. The “facts” in this case aren’t hard to find with a little looking. I actually have to give credit to our journalism student for being honest about their biases. Most don’t believe that they have biases. Having biases isn’t a problem. It’s actually part of being human. Recognizing them and overcoming them is really difficult, though. I admit that I struggle with this often. Our aspiring journalist admits that they feel that fluoride isn’t for them. Further, they worry about fluorosis and would prefer a more “all natural” way of caring for their mouth.

Our journalism student commits an “appeal to nature” fallacy here, which is so common that it’s probably not worth dissection. Let’s just say that fluoride is natural, as it is naturally found in most water sources and leave it at that. A bigger problem is our journalist’s concern about fluorosis. Dental fluorosis is a developmental problem. Enamel defects can form in developing teeth if a person is exposed to a high level of fluoride during the time that their teeth are developing. However, it doesn’t effect teeth that have already developed (e.g.–in an adult). This is a fact that can be verified on Wikipedia or any other medical website. Yet our journalist who wants to tell both sides of the story didn’t know that and was, in fact, concerned about it for themselves. A science journalist with clear biases that hasn’t done the basic research can do a lot of damage by simply not knowing the truth about their subject.

On the other hand, the “controversy” is much easier to find. Anti-fluoridation groups make up as much of the first page of a Google search for”water fluoridation” as straight up information sources. The movement against water fluoridation is getting its story out very well, while the boring and decades old success story of public water fluoridation doesn’t have that many blogs and websites dedicated to its advancement. The internet has allowed anyone with an idea and a way to get online the chance to disseminate whatever information they like, whether it is accurate or not.

To their credit our hopeful journalist was seeking out a dentist’s input on fluoride. When asked, “have you heard of the arguments made by the anti-fluoridation movement and do you think they have any merit” I answered like this:

“Yes, I have read about some of the arguments made by the anti-fluoride movement. I think it is legitimate to be concerned about ingesting too much fluoride. But I find most of their arguments to be based in emotion and lacking scientific credibility. Fluoride is present in all water sources. ‘Fluoridation’ is actually more ‘fluoride optimization.’ Some communities with public water supplies have optimized the levels of fluoride in the water supply for dental health. In some cases that means removing fluoride and in some cases that means adding it. Much of the concern of those opposed to fluoride in the water is based upon the idea that it is poisonous and damaging. Fluoride is toxic in chronic high doses. It can cause problems in brain development, problems in bone and tooth development, kidney injury and in certain cases thyroid problems. These injuries happen at high doses over a long period of time. Optimal fluoride (1ppm) is well below a dose that could cause these kinds of problems. Much of what the anti-fluoride groups claim is an extrapolation: since fluoride can cause these problems, it is toxic and poisonous at any level. Toxic effects from anything are dose dependent, and thus optimal fluoridation is safe.

There is overwhelming evidence that optimal fluoride reduces dental disease in a population. Occasionally the anti-fluoride movement will point to research that questions this, but the studies that they tout are usually questionable in their design or interpretation. There is overwhelming scientific support for the use of fluoride in the water supply as safe and effective as well as cost effective on a community wide basis.”

You cannot give “both sides” of a story like this without at least a cursory review of the scientific literature. The water fluoridation issue reminds me a lot of the vaccination issue. For some, the public health gains we’ve achieved with vaccinations are only now being appreciated by people for the fact that many vaccine preventable illnesses are coming back with a vengeance. I only hope that’s not how it goes with public water fluoridation.

letter from a grumpy dentist

Dear Patient that Didn’t Show Up for their 7am Hour and a Half Appointment,

I hope this letter finds you well. I wanted to take a moment to fill you in on how you affected my life today.

To you I’m probably just a service provider. Like the drive through at the bank or the guy who cuts your hair. Someone you see on occasion to take care of a small part of your life. And I’m fine with that.

On top of being a service provider I’m also a business owner. Which is to say that it costs me money to keep my doors open. As soon as I have employees on the clock, my overhead is growing. I pay employees, my rent, utilities and the rest from the proceeds that I’m paid to be that service provider. I understand that dental care is more expensive than a trip to the barber. I understand that paying for the services I provide can put a person out. I take my appointments with you seriously. I set aside appointment times for you and only you. My team and I are ready and waiting at the appointed time to take care of your needs. In this particular case, that meant getting up really early in the morning. So when you didn’t show up, my overhead didn’t get paid by the procedures we had planned and my business loses money.

More importantly than my role as service provider and business owner, I’m also a human and a dad. I don’t mind getting up early and I do it quite often. But given a choice, I might sleep another hour. I might delay the time that my office opens knowing that I’m not going to be seeing patients until later. I definitely would have preferred to see my children when they woke up and put my oldest on the bus than to drink coffee in my office.

So, what’s the solution? I could be a jerk and charge you a no-show fee. But that’s guaranteed to make me look like a bad guy. Furthermore, any reasonable fee couldn’t make up for the overhead that’s been burned. I could ask you to pre-pay for your appointments, but that’s never been part of the culture of our office. That would just make you feel singled out and resentful. Kind of how I’m feeling right now. I could just always double book appointments so that in case if one patient doesn’t show up I’ve always got another one in the next room. But that makes it so I’m not giving each patient my undivided attention and that’s something I pride myself on.

The solution is to make you another appointment. Because I want you to be my patient and I want to take care of your dental health. We’ll probably give you extra reminders to make sure that you remember.

And to write this letter. Because it does make me feel better. Slightly.

Respectfully,

 

A Grumpy Dentist