developing habits

In 2009 I picked up a habit. It was a habit that I had all through dental school. When I was in dental school we were all positive that we’d quit, and probably most of us did. I mean, I dabbled in it between 1997 and 2009, but it didn’t really stick. Now, I’m finding that it’s a really tough habit to break.

No, I don’t smoke. I’m talking about the rubber dam. Actually, not the “rubber” dam, but the “nonlatex” dam. It’s just that the name I know it by is rubber dam. Old habits die hard. And new ones are kind of the opposite.

Ever since I started reading and posting on DentalTown I realized that the dentists that I aspired to be like used the dam. And they used it effectively. Most importantly, they took pictures. It was like rubber dam porn. They showed these amazingly clean endo accesses, bone dry restorative fields and perfect isolation for seating crowns and onlays. I wanted that. But it was my habit to isolate with cotton rolls and high volume evacuation. I could think of many reasons NOT to change my habit.

  • It would take too long
  • Patients don’t like it
  • Rubber dam retainers (clamps, for those that like to scare their patients) pinched the gingiva and hurt
  • My assistant wouldn’t like the change

But in 2009, I finally decided to suck it up and give it a try. I don’t exactly remember how it worked. I think we (my assistant and I) decided we’d try it on every composite case that came through the door for a month. If we didn’t love it, we could always go back. But we didn’t.

I couldn’t have developed this habit without Shelly’s help. I think at first she didn’t really like it. It was different and kind of uncomfortable. Patients didn’t know what to think about it, because it was different from what we used to do. But we kind of slogged through. At first, I felt defensive about changing up the routine. After awhile, we developed a team technique for placement. We can essentially place a dam relatively comfortably and  quickly within a minute or less. I have a pdl syringe in every set up and can use a dam painlessly. I give palatals routinely to allow for retainer placement on the upper.

How do patients react to it? Half the patients love it and ask for it. Most of the other half tolerates it without a lot of questions with a very small percentage of patients that can’t tolerate it. But dentistry is SO much more fun with the dam on and I work so much faster once it’s placed. Shelly and I often wonder out loud how we worked without it!

The rubber dam is a great habit that I’ve developed. Your mileage may vary, but if you’re wondering…you ought to try it.

What’s the next habit I’m looking to acquire? I’ve taken a few classes from David Clark and he advocates using Aluminum Trihydroxide powder blaster to remove all traces of biofilm once you isolate your field. I love the concept. But it’s another habit I’m going to have to work to acquire the habit. It’s messy as heck and to use it efficiently I’m going to have to add an air line to my operatory set up. I’m sure I’ll get there, but it’s a process.

What habits do you have? Are they habits that you’re proud of, or do you need to work to eliminate them? I’d be interested to hear!

Don’t just do something, sit there!

Last week we had an emergency patient. She left a message on the answering machine over the weekend because her tooth was “killing her.” The appointment went kind of like this:

patient: “The tooth really hurt all weekend long. I was ready to take it out myself with pliers!” (they always say this)

me: “Tell me more about ‘really hurt.’”

p: “Any time I drank anything cold it would give me these little zingers. Ice cream REALLY hurt. Also, I couldn’t really chew anything on it. All I really had to do was press on the tooth and it would get really sore. I look some ibuprofen but it didn’t really help.”

m: “Wow. That sounds really awful. How does the tooth feel now?”

p: “It feels better now. The gum is a little bit sore, but other than that it’s fine.”

So I did an exam and took a PA. The tooth had a small occlusal amalgam that was serviceable. The patient was a regular and never missed a preventive maintenance appointment. The radiograph was within normal limits. No widening of the pdl, no evidence of radiographic decay. I couldn’t elicit the patient’s chief complaint with hot, cold or a tooth sleuth. Percussion was negative. The palatal gingiva looked slightly irritated. So slightly that I may have been seeing things that weren’t there.

In short, I couldn’t find anything. The patient told me that she was in serious pain throughout the weekend, and I couldn’t find the source of her problem.

There’s something incredibly unsatisfying about that. Dentists are trained as diagnosticians and surgeons. We’re supposed to figure out what’s wrong and then fix it. The patient is looking me in the eye and telling me that she was really hurting and she wants me to a) tell her why it was hurting and b) make it so it doesn’t hurt again.

I did have a differential diagnosis list forming in my mind and I laid that out for her. She may have gotten some food impacted between a few teeth (e.g. “Did you eat any popcorn this weekend?).  That can be very painful, but it almost always resolves itself with some effort at hygiene or by just working its way out. Or maybe the patient accidentally bit on something hard (think olive pit, chicken bone) and didn’t really remember doing it.

Who hasn’t had some kind of transient tooth pain at one time or another? If the patient has a low pain tolerance, this kind of thing could account for it as easily as anything else.

The bottom line was that the patient wanted an answer. And I wanted to give it to her. But I had nothing. Zip. Nada. My training as a diagnostician gave me nothing to go on.

My training as a surgeon said “let’s do something!” Hey look, when patients present with a problem, I gotta fix it, right? And if I don’t, I look ineffectual.

Put that drill down, cowboy.

Everyone remembers the radiograph of the patient that had endo in every tooth on the upper. The patient kept having pain and the doc kept doing root canals. The moral of the story was that the patient suffered from severe, chronic sinusitis and ended up needing surgery for her sinuses, not her teeth. How do you think that dentist looked after a mouthful of root canals placed without solving the problem?

I’m here to tell you that there’s nothing wrong with a good, old fashioned “let’s wait and see.” So long as the patient is comfortable, what’s the rush? Let the patient know that you have some ideas about what may have been happening but you’re not sure. Let the patient know that you’re there for them and if it happens again, you want to see them right away.

John Kois says “the best dentistry is no dentistry.” Especially when working from a lame differential diagnosis.


The “loving headlock”

I’ve got dentist friends who have chuckled about having to do fillings on their kids. They’re proud of how well their little cherub handled anesthesia and glad to know they can get the job done. Good for them, I guess.

I live in fear of the day I might have to restore one of my kids teeth. I have two active, healthy boys. Sean, my oldest is somewhere on the autism spectrum, which actually doesn’t mean much to me. I just know him as Sean. He has little quirks, but in all he’s a pretty regular kid. Jake is a solidly built 2 year old who wants to do everything by himself, including brushing his teeth. The upside is that he wants to brush. All. The. Time.

Not kidding. I got up with him at about five minutes after 6am this morning. His first request was to brush his teeth. Which is fine, but he’s not much on spitting, so I mostly skip the fluoride toothpaste. He’s got an obsessing brushing habit, but he’s not really reaping the benefits of it yet.

Here’s the deal. I don’t want to do fillings on my kids. I LOVE children, but not as dental patients. I handle the really easy pediatric patients, but I can’t hold it together for most of them. I have great specialists that I can refer to. Mostly I do. My pediatric dental goal: “don’t be the experience that this person is telling his/her dentist about in 30 years.” It’s a simple goal. Usually achieved with a referral pad and a smile.

But what about my own kids? Would I actually pay someone else to take care of their teeth? Hell yes. In a second.  Don’t even kid yourself. I’m sure I’ve already given my children years worth of therapy topics and I’m not willing to give them any more when I can avoid it.

My plan to keep them out of the dentist’s chair? I call it “the loving headlock.” I brush their teeth first. Then, if they want to brush their own teeth, I let them. But I get the brush on each surface so I can see it with my own eyes. Buccal, lingual. All of it. How do you do this on two vital, healthy and squirming boys you ask? Let me explain…

I stand behind them and to their right (I’m right handed). I have them stand on a step stool. I take my left arm and wrap it VERY firmly around their chin. I take my left index finger and middle finger (recently washed) and prop their little jaws open. Then I brush. I brush so I can see the toothbrush clean each surface. If I can’t see it, I’m not sure I’ve cleaned it. So I make sure I can see it. It probably takes me about 45 seconds to do all of it. I know you’re supposed to do it for two minutes. But that’s voluntary brushing.

Sean handles this exercise like a champ. I’ve been doing it with him for the better part of three years, so he’s used to it. I give him props, because he’s really strong and could probably wiggle away more than he tries. Jake is still learning. But he’ll get there.

“How long are you going to do this?” you may ask.

I figure I’ll do it until they’re big enough to push me off. Maybe college?

So far, the results are excellent. We’re O.K about avoiding sweets. We avoid sugary snacks as much as possible and we try to eat at meal times and only designated snack times. The kids drink no pop, but they’re fond of juice which is just as bad. But so far, so good.