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.

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.

 

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

medical insurance vs. dental “insurance”

“Dental insurance” isn’t even close to being actual insurance. Real insurance is about investing a small amount to help manage the risk of rare but potentially catastrophic events. From Wikipedia:

Insurance is the equitable transfer of the risk of a loss, from one entity to another in exchange for payment. It is a form of risk management primarily used to hedge against the risk of a contingent, uncertain loss.

You buy car insurance in case of a car accident or theft. These are relatively rare events, but they’re also undesirable events. You’re glad  you have insurance when you have a car accident, but rational people are more interested in avoiding them.

Even “health insurance” (which is probably better termed medical insurance) is mostly like real insurance. You (or your employer, or the taxpayers) pay a premium so that catastrophic and expensive medical treatment is available to you if you need it. Imagine someone having some kind of cancer and their medical insurance carrier explaining to them: “I’m sorry, but you’ve spent all of your insurance dollars this year on that broken wrist back in February so I’m afraid you’re going to have to wait until January for your chemotherapy unless you just want to pay out of pocket.” The ramifications of the ACA (a whole other topic) notwithstanding, the idea of health, or medical, insurance mostly lines up with what real insurance is about.

Dental “insurance” is a contract, usually between your employer and a 3rd party payor. If a patient breaks a tooth or needs a root canal their benefit should pay a certain amount each year for certain procedures specified by the contract. The insurance company isn’t interested in your dental health. They are interested in paying out as little as they can while still staying within the specified conditions of the contract. In almost all cases there is a maximum dollar amount that the insurance company will pay and no more. What you’re getting here is a crappy gift card that pays toward some dental treatment. This has been covered by myself and others ad nauseum and isn’t really the point of this rant.

Something that’s really important to realize is that the patient’s dental health and potential need of dental services is completely independent of what dental benefits they have. You can have a low caries nonsmoker with a premium dental benefit that only uses a small amount of the dental benefit for prevention or a chain smoking, pop drinking dude with ectodermal dysplasia and “Healthy Kids Dental.” The two things have no bearing on each other.

So, is it reasonable to ask the question: “what’s the right amount to spend on dentistry in a given year?” Not really. This is obviously going to depend a lot on the patient’s individual risk factors and habits. However, I promise you that insurance companies have given a lot of thought to that question. I would suggest that the dollar amount of a patient’s dental benefit has a huge bearing on what they perceive as being the right amount of treatment necessary.

For many, perhaps most of our patients, the right amount of treatment in a given year is how much their insurance will cover and no more. I think this comes from the experience we have as patients with medical insurance. When you go to the doctor’s office or hospital for something, there is an expectation that your insurance will cover any services there. It’s rare that there is a conversation about costs incurred by whatever services the patient receives. Whether it’s a $200 office visit or a $50,000 knee replacement, it’s a reasonable patient expectation that their medical insurance is going to cover it once their deductible (if they have one) has been met.

This is not so with dental benefits. If a patient needs a certain amount of dental treatment and it costs significantly more than any given year’s benefits, they’re less likely to pursue any treatment at all. I promise you that insurance companies are banking on this reaction.

I think this is where patient expectations get mixed up. Medical insurance covers what you need, no matter what the need is. If they apply this logic to their dental benefit, then whatever their dental benefit amount is must be the right amount to spend on dental care! So clearly if a dentist diagnoses a patient’s dental needs and it’s more than their insurance will cover, a patient might become suspicious of the diagnosis.

This is a complicated problem. To pretend that patients simply don’t value dental treatment enough is short sighted. It’s probably accurate for some people, but for others they just can’t or won’t spend any more than they need to on dental care. People react to incentives and if a patient has dental benefits, they’re going to want to use them. After all, they paid for them…either directly or indirectly. They shouldn’t be made to feel ignorant for wanting to use the benefits that they have. But I think it helps to illustrate the differences between medical insurance and dental benefits and how that plays into a patient’s expectations of how much treatment should cost.

 

Delta Dental, crystal balls and ridiculous incentives

I have a few patients with poor oral hygiene. The patients I’m thinking of right now are between the age of 17 and 24 and they’re male. I think of them as my “scuzzies.” Personal hygiene isn’t a priority. I make an effort to encourage them to step up their game. I strenuously suggest that they reduce their intake of sugary and acidy drinks. I even write blog posts about it. I suggest powered toothbrushes. I stop short of actually going to their house and brushing their teeth for them. That would be creepy. The bottom line, the scuzzies are high risk patients for tooth decay.

So let me tell you a little story. I did a two surface restoration on a scuzzy last year. It was radiographically evident (an MO on #14). The distal did not have any radiographic decay. When I was preparing the tooth for a MO restoration, I visually inspected (with a microscope, naturally) the distal marginal ridge. Nada. Nothing. Zilch. So, as an ethical and reasonable dentist…I didn’t prepare the distal.

Fast forward to a year later. The restoration I placed looks great! However, there is radiographically evident decay on the distal of #14. Anyone who participates with insurance knows exactly where this is going.

His insurance wouldn’t pay anything for restoration of #14. You see, I did a restoration on it last year, and they won’t pay for any other restorations on this tooth for a period of years. I think it was three in this case. So the patient will have to pay for this entire restoration out of pocket.

This is part of the contract. I get that. But the patient’s parents (you know, the ones who have money taken out of their paycheck for dental benefits who are going to have to pay for this entire restoration) are frustrated. I frankly don’t blame them. We explained that their child is a scuzzy and we’ve been all over him to reduce his risk factors (e.g.–stop guzzling pop, step a little closer to the toothbrush, figure out what that minty flavored string is all about). Their main question: why didn’t you fill it when you were placing last year’s filling?

Point of fact…this kid is creating cavities fast! He may be a world record holder. But, he’s not alone. This happens most often in the 55 and older crowd when they start taking medications for their blood pressure, their heart and maybe for depression. Combine medication induced dry mouth with the idea of high sugar comfort foods and you’ve got a recipe for some serious tooth decay, and seriously fast.

I cannot know when someone is going to form a cavity. There is no crystal ball technology available although I hear Sirona is working on it. I can help them understand their risk factors, but I can’t tell you when and where a cavity will show up. I’m not going to start second guessing, either. When a representative from a dental benefit company explains to the patient that I probably should have restored that surface when the original restoration was done, it makes my blood boil.

I ended up writing Delta Dental a narrative and sent some photos, but they turned the appeal down. Now the patient thinks I’m a jerk. Awesome!

A high caries risk is not incentive enough for me to overtreat. No matter how good our materials are, natural tooth structure is better. If I can’t see the evidence with a radiograph or my own (incredibly enhanced) eyes, then I’m not going to restore the tooth. Even if the “insurance” company thinks that I should.

Dr. Oz is wrong about amalgam fillings

MrWrong

Dr. Oz is wrong about amalgam fillings. He’s super wrong. He couldn’t be more wrong if his name was W. Wrong Wrongington. An episode of Dr. Oz recently aired where several “experts” weighed in on whether your amalgam fillings are poisoning you. That was the question that all the promos for the show asked: “are your mercury fillings poisoning you?” So I tuned in with bated breath to hear his answer.

His answer, of course, was that yes, they are poisoning you. Seriously, you knew that was the answer, right? If he’s said, “nope, they’re actually pretty safe” that would make the most boring television ever. And Dr. Oz is not about boring TV.

A couple of “experts” weighed in that the problem is the mercury vapor that comes off of silver fillings. According to the experts, any time you contact your teeth together, like chewing or heaven forbid grinding your teeth together, you’re emitting toxic gas into your mouth. That, my friends, is pretty scary stuff. But since you can’t see mercury vapor coming off of your teeth, Dr. Oz and another “expert” did a demonstration to measure how much mercury is released when you brush your teeth.

The demonstration consisted of a plastic model mouth with a bunch of silver fillings in the teeth. The model mouth was kept in a clear box that was ventilated. Dave Wentz, the guy doing the demonstration with Dr. Oz, let everyone know that they do the demonstration in a box so they don’t let any of the toxic mercury out. Which is interesting since it’s very likely that many people in the audience have silver fillings. If they’re that worried about the toxicity of silver filling, wouldn’t they screen the audience to not let folks with toxic fillings in the door? But I digress.

So, they do the demonstration. Dr. Oz puts his hands in the gloves in the clear box and scrubs these amalgam fillings like he’s cleaning the grout in the bathroom tiles. And, low and behold, they measure mercury gas coming off the fillings!

So Dr. Oz is scrubbing away at these silver fillings and asks:

“…at what point should I be concerned. At what [mercury vapor] level is it more than we’re supposed to have?”

Anything over zero is toxic. We’re at 61. 61 micrograms.”

Then Dr. Oz comes up with: “Now how can anyone dispute that there’s no mercury coming off of amalgams?”

And his guest expert Dave Wentz replies. “You can’t. You really can’t.”

If you aren’t careful or observant, this seems like a smoking gun. Amalgam fillings are dangerous and they are poisoning you. I ask you to step back.

The first thing that jumps out at me is the language that is used to frame the discussion. I typically refer to amalgam fillings as “silver fillings.” I never have thought of this as the element silver, but the color of the fillings, when polished is silvery. The Dr. Oz show refers to them as “mercury fillings.” Neither of these terms is probably adequate. Amalgam is a generic term for something that is mixed together. When the term is used in metallurgy it means: “an alloy made with Mercury.” So probably the most accurate term for these fillings would be “amalgam” and not “silver” or “mercury” fillings.

Language matters. When I use the term silver filling I’m indicating the color. When Dr. Oz uses the term mercury filling he’s pointing out the scary, toxic ingredient of the filling. That’s used to frame the discussion, so right away someone who isn’t thinking critically is thinking, “whoa, I didn’t know they placed mercury fillings!”

The next thing that jumps out at me is the way that they created and measured the mercury gas. It is assumed that the model that they offer (a plastic typodont with a ton of silver fillings in a plastic box) is an accurate representation of what’s going on in a human being’s mouth when they have silver fillings and they brush their teeth. I’m not sure it’s fair to assume that for the following reasons:

  • There was no moisture in this model mouth. A normal human being has saliva flow, which keeps the entire mouth moist and lubricated. Moisture on a surface could clearly affect the amount of vapor coming off the surface of a tooth.
  • We don’t know when these fillings were placed, if they were placed correctly, or if they were polished. All of those things can make a difference in the amount of vapor that might come off of these fillings. It wasn’t mentioned on Dr. Oz’s show.
  • We’ll also ignore the fact that the quadrant of fillings he scrubbed had anywhere between 4 and 7 surfaces of amalgam. I did my best to figure out how many surfaces the teeth had but they never showed the far side of the typodont. In any case, that’s quite a bit of amalgam…more than the average patient has for sure.
  • The model had no lips, tongue or cheeks and also wasn’t breathing. Wouldn’t a more accurate measure come from actual patients with actual fillings that were actually brushing their teeth?

They have measured the vapor that comes off of teeth in human models, and it is true that there is a measurable amount. In fact, there’s some question about the most accurate way to measure mercury vapor released from a silver filling. Is the vapor in someone’s breath the most important factor, or would absorbed levels of mercury in urine and blood be the most important measure? The Dr. Oz show wasn’t interested in an actual discussion. They went from “hey look, there’s mercury vapor in this model” to “your fillings are poisoning you.” No mention of actual outcomes based research. No mention of the millions and millions of teeth saved by the use of amalgam fillings with virtually no verifiable reports of bad health outcomes due to amalgam fillings. Clearly the most important message was that there is scary, poisonous vapor coming off of your silver fillings. Awesome.

The final thorn in my side was the statement made by the guest who was putting on the tooth brushing demonstration, Dave Wentz. He says, “anything over zero is toxic.”

Alternative medicine advocates aren’t known for their nuance. Poisons are dose dependent. In other words, something that is harmless in small doses can become harmful in larger doses. That is the case for most things that are known to be toxic to humans. So, how do we know if we’re getting a toxic dose of mercury vapor? Well, the World Health Organization describes a “tolerable intake” of elemental mercury vapor to be 2 micrograms/kg of weight per day. So if we take an average male of 150 lbs, they can tolerate a daily intake of around 136 micrograms of mercury per day. So, are our amalgams delivering that much? The short answer is no. Dr. Oz was able to generate an impressive 61 micrograms by scrubbing on some silver fillings in a box. However, actual measured amounts in human beings are more like 1-3 micrograms per day, depending on how many surfaces of amalgam a patient has.

There are reasons to dislike silver fillings. However, there is no credible evidence that they will cause anyone harm. The outcry by many poorly informed people has led to the outright ban of this material in some countries and the sharp reduction of it’s use here in the United States. Amalgam fillings are durable, long lasting and safe. That’s what credible evidence states. Until credible evidence says otherwise, I think Dr. Oz is wrong. Really wrong. Super duper wrong. His name should be W. Wrong Wrongington.

That last part is just my opinion, though. The rest of it is the truth as we know it.

 

 

 

 

 

Meet the new guidelines. Same as the old guidelines.

Yesterday, the American Dental Association and the American Academy of Orthopedic Surgeons released new, evidence based guidelines regarding antibiotic prophylaxis before dental treatment in patients with joint replacements. The press release states that there is no evidence that dental procedures cause joint infections. Prior to this statement, we were to assume that a dental cleaning or placement of a filling had a special and dangerous power to seed the blood with frightening bacteria that somehow knew to go directly to the joint spaces of innocent artificial knees or hips with the malicious intent to infect.

For years I’ve been complaining to anyone who would listen about the joint replacement conundrum. Even though there was no evidence that premedicating patients was doing anyone any good, we did it. Because giving a patient a giant dose of antibiotics before having dental treatment is a much better option than having to treat or replace an infected joint, right? So just shut up and give them the antibiotics, Doc.

And that’s what we do. Each time I consult with a patient’s surgeon I get similarly frustrated. Some surgeons want premedication for the the rest of the patient’s life. Some surgeons want 6 months. Some want 2 years. Some think Amoxicillin is the way to go. Some say it’s Keflex or nothing. The one thing that all surgeons agree on is that they aren’t going to write the prescription for the antibiotics. That’s the job of the dentist. Which also means it’s the liability of the dentist. Let’s face it. Some patients can develop hypersensitivity to antibiotics and a huge dose of antibiotics could cause a reaction. Even a potentially severe reaction. And no one wants to be the one who wrote that script, right?

Let’s just get this out of the way. Most dentists don’t believe we’re doing a valuable service by premedicating our patients. Most of us know that eating a Dorito is at least as great of a risk as a dental cleaning for seeding the blood with oral bacteria. But we’re not rushing to premedicate patients prior to Dorito consumption. We’re doing it to cover our asses! We’ve been trained to cover our asses about this stuff since dental school. It has nothing to do with excellent patient care and everything to do with making sure we did everything right so that if some future joint infection or infective endocarditis event comes along we can prove that “it wasn’t us.” If it was really about excellent patient care, we’d have the ADA lobbying Frito Lay to bring out “Blazin’ Amoxicillin” Doritos.

I’m a dentist. My strength is treating dental disease. I’m a pretty smart guy, but frankly I’m not really up on the real risks of artificial joint infection or antibiotic allergies. How can I be expected to weigh the likelihood of two incredibly rare but very serious outcomes (joint infection vs. antibiotic reaction)? I don’t think it’s legitimate for the dentist to have their own policy. How about if the professional group that represents me, the American Dental Association, gives me some solid guidance so I don’t have to worry that I’ll be 1) harming my patients by not correctly weighing the risk factors and 2) you know…the lawyers.

But now, the evidence (or lack thereof) is in! We can stop worrying about the premedication for people with joint replacements because there’s no evidence of harm, right? 

Ummm. No.

What the joint ADA-AAOS actually gives us are 3 “guideline recommendations.”

But recommendations are good, right? After all, the American Heart Association passed down (many times!) their recommendations on stone tablets for all dentists to know and heed! And by following recommendations it means that the lawyers can’t get us! I mean, as long as we follow the recommendations!  

You’d think so. I mean, you’d think that having recommendations from the two big professional groups representing dentists and orthopedic surgeons would give us actual guidance on this issue. But it’s just not true.

The ADA-AAOS statement made me skeptical almost as soon as I started reading.

This summary of recommendations is not intended to stand alone. Treatment decisions should be made in light of all circumstances presented by the patient. Treatments and procedures applicable to the individual patient rely on mutual communication between patient, physician, dentist and other healthcare practitioners.

I read that and think, “these guidelines are perfectly fine, except you still have to evaluate patients on a case by case basis and if you get sued, we don’t have your back.”

I have to admit that I haven’t taken the time to read the full guideline, so my comments are based on the summary. The full guideline is somewhere around 100 pages and my own inability to concentrate for that length of time (thanks, internet!) has kept me from reading it. If someone does read it and find that I’m completely wrong, please let me know. I’d love to be wrong about this.

The recommendations strike me as incredibly watered down. They seem to be written as obliquely and indirectly as possible. Then each of them is given a “strength of recommendation” rating which means nothing to me. And they know this. So they give a definition about the strength of rating. Right after they give the strength of the rating. Honestly, it’s kind of bizarre.

The first recommendation addresses the use of prophylactic antibiotics:

The practitioner might consider discontinuing the practice of routinely prescribing prophylactic antibiotics for patients with hip and knee prosthetic joint implants undergoing dental procedures.

I might consider discontinuing antibiotics. Sure. I might. I might consider explaining my position to the patient, too. I mean they are the ones that are taking the very slight (but real!) risk here. But did I really need a recommendation from the ADA and the AAOS to tell me that I might think about it?

Further bolstering my opinion of this recommendation is the “strength of recommendation” score it’s given: “limited.”

A Limited recommendation means the quality of the supporting evidence that exists is unconvincing, or that well-conducted studies show little clear advantage to one approach versus another.

Practitioners should be cautious in deciding whether to follow a recommendation classified as Limited, and should exercise judgment and be alert to emerging publications that report evidence. Patient preference should have a substantial influencing role.

Recommendation 2 speaks to the use of preoperative topical oral antimicrobials:

We are unable to recommend for or against the use of topical oral antimicrobials in patients with prosthetic joint implants or other orthopaedic implants undergoing dental procedures.

So, they won’t say whether use of chlorhexidine prior to your filling is worth it or not. Great. Thanks for that. This strikes me as unnecessary because the risk profile of a swish of Peridex is a lot less than a megadose of Amoxicillin. In any case, they want us to know that we should feel “little contraint” in deciding whether to follow this recommendation. Gee, thanks.

Finally, the most bizarre recommendation.

In the absence of reliable evidence linking poor oral health to prosthetic joint infection, it is the opinion of the work group that patients with prosthetic joint implants or other orthopaedic implants maintain appropriate oral hygiene.

Really? Was there a time when I was supposed to be telling joint replacement patients that the risk of joint infection was so great that the shouldn’t floss? Or am I to assume that the ADA and AAOS feel that maintaining oral hygiene is vital to the health of an artificial joint? Honestly, I don’t even know what they’re trying to say. But at least they all agree on it. They give this recommendation a strength of: “consensus.”

A Consensus recommendation means that expert opinion supports the guideline recommendation even though there is no available empirical evidence that meets the inclusion criteria.

I had high hopes that the ADA would come through for us on this issue. I was hoping for an “AHA-like” guideline that would take the guessing out of this very common event for dental patients and dentists alike. It didn’t happen.

The most hopeful statement I got from the new guidelines is this:

Patient preference should have a substantial influencing role.

Although this statement was made specifically in reference to recommendation 2, I think it’s worth contemplating for the whole thing. Taking a large dose of antibiotics prior to dental appointments is not a risk-free event. I honestly don’t know if the data exists to weight the risk of taking antibiotics against the risk of joint infection at the dental office. I think patients can and should be part of the decision here.

The whole inconclusive data issue cuts both ways. Sure, there is no data to conclude that dental treatment causes joint infections. However, outside interests can just as easily claim that there isn’t data that dental treatment doesn’t cause infection in artificial joints. As a profession, we’re in the exact same spot that we were before these so called recommendations came out. We’re still going to cover our asses for the wrong reasons. It wasn’t good medicine before and it still isn’t.

What do I think should happen? I think the ADA and AAOS should sound off like they’ve got a pair. I think they should put a statement out that they’re going to help fund research on this topic to really answer the question and in the mean time they need to make a statement to dentists that “this is the recommendation and we’ve got your back if there’s a problem.” I think that the ADA should set aside a fund for the inevitable legal challenges that will come along to such a definitive statement and let member dentist’s know that they will be represented. It’s time to do the right thing for the right reason.

Am I right on the money? Am I completely dead wrong? I’d like to hear what you think. Feel free to leave a comment here or email me at alan@meadfamilydental.com.

 

 

 

 

 

Why dental presentations and dental presenters usually suck

Public speaking is my bag. No, seriously. I like speaking about topics I’m passionate about in front of a group. And I’ve been told that I’m pretty good at it. I keep getting asked back, so I must not be too bad.

I would like it even more if it were really easy to put together a good presentation. It’s not at all. And worse than that, I’m a terrible procrastinator. If I could just fast forward past the idea generation, slide design and rehearsal I’d be in heaven. The actual getting in front of a group and doing it is a blast. There have only been a couple times when I didn’t do well in front of a group. Very occasionally I just don’t connect with an audience or they just aren’t into the subject matter. Sometimes I don’t think I’m connecting and I’m doing O.K. But usually you can tell by the energy of the audience.

One reason why presenting to dental audiences is hard is the amount of time we’re supposed to present. The classic dental meeting time frames are 3 hours (“half day”) or 6 hours (“full day”). John Medina, author of “Brain Rules” suggests that 50 minutes is the maximum amount of time an audience can stay involved with a presentation. Further, the presenter has to do something different to grab their attention every 10 minutes or they’re toast. My experience tends to agree with this.

So why do we have 3 hour and 6 hour classes? I don’t know. The courses I took at the Chicago Midwinter this year were varied. One was really bad, a couple were pretty good. All were 3 hours. And every last one of them should have been no longer than an hour and a half. That would have required the speakers to boil it down and would not have required the audience to have such endurance.

The other problem is the speakers. As speakers, we need to remember that we’re there for the audience, not vice versa. In other words, it’s not about the speaker. It’s about the audience. It’s not lecturing, or at least it shouldn’t be. It’s closer to a performance or, as Garr Reynolds describes, a conversation.

A couple pet peeves of mine when I’m watching a speaker:

  • The speaker reads their slides…usually bullet point by bullet point. No offense, but you could have emailed me that and saved me the trip.
  • The speaker prepared the slides up to the morning of the presentation and never did any rehearsal. I’ve been guilty of this in the past. I’m trying to get better. Just try not to be baffled by your own slide deck, mmmkay?
  • The speaker isn’t sure how long their stuff is going to take. So, they go way over. Usually into lunch. Don’t do this. Ever. Go short as much as you want. Don’t go long. It’s rude and disrespectful of your audience. Remember, going “short” means there’s plenty of time for questions.

Dentists and dental teams are above average audiences. They forgive a lot. Trust me, I know. They can stay with you on the wildest tangent and they’ll overlook your awful tie if you treat them with respect. They’re colleagues and they want you to do well. Just do your part as a speaker and they’ll keep asking you back. Or at least that’s my experience.