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In October, I attended the University of Maryland’s Innovations in the Prevention and Treatment of Early Childhood Caries Conference: an intensive and very interesting update on the status of caries, the disease, and its various treatments.
A few things became quite clear: measuring oral health is difficult. Treating dental disease is challenging, labor intensive and extremely expensive. The currently accepted surgical approach to caries fails often and regularly and has a questionable return on investment: for example, the relapse rate of 52 to 79% after 24 months for children treated in the OR. Sobering statistics.
At one point during the conference, my notes morphed into a mind map. I placed CARIES at the center and filled the bubbles to the left of CARIES with the inherent qualities of teeth and the disease that destroys them. On the right side of the map I focused on the embarrassing statistics related to this PREVENTABLE disease.
What are we missing?
For one thing, the prevention we do in our clinics is based on a teach and tell model that fails to honor the ability of our patients to manage themselves. At the conference I learned about promising research projects focusing on filling that gap with Motivational Interviewing to help people change, video games to help teens change their health behaviors, saliva tests being developed in Japan to identify pathogens, the promises of xylitol.
What remains is: our current approach with caries prevents us from seeing the bigger picture: an oral microbiome out of balance from a 21st century diet loaded with sugars and fermentable carbohydrates, (malnutrition?) and compounded by the lack of oral hygiene facilities everywhere.
What is a dentist’s work?
It is hard to be a dentist. It is physically demanding and the work seemingly never ending. But there is more to the stress of being a dentist. In my search for authenticity and integrity, I have struggled with reconciling my construct of a successful dentist with the statistics relating to caries. It seems to me that I worked very hard to make very little difference. I would imagine that you, like me, also struggle with this dilemma, especially if you have a decade or 2 of practice behind your belt. This tension ate away at me, especially when I heard remarks on the cost of care or comments on how financially rewarding it must be to be a dentist. Somehow, I was never completely satisfied with my replies to these comments highlighting the fact that dentists are highly qualified health professionals.
What can we do to fill those gray areas on the diagram?
This article, reprinted with the permission of the Ontario Dental Association and Ontario Dentist 2013, offers an introduction to Motivational Interviewing (MI) and its potential for improving the overall process of oral health care for patients and dental staff. Like any new skill, MI takes learning and practise. With training, you can take MI (an evidence-based, patient-centred communication method) and include it in the repertoire of your dental practices and skills so you can more effectively meet your patients’ oral health needs.￼
In January we had to fill out a Canadian Dental Association commissioned survey regarding the inclusion of infants in general dental practices, knowledge of Early Childhood Caries (ECC), risk assessment and risk management. I wonder what the results will be like. They should be pretty good given that we’ve all had more that 10 years to act upon recommendations from the Canadian Dental Association (CDA) and the Canadian Academy of Pediatric Dentistry (CAPD) regarding the above mentioned. Or perhaps the survey results will not be so good because too many of us assume that these recommendations do not apply to our type of practice or community. I expect the latter to be the case. Here is why.
For decades I prided myself for keeping up to date with all changes in dentistry, riding the leading edge of advancements in our profession. In dentistry, I fit the description of an early adopter, a little like those fans who line up at Apple stores for hours to be first to own a new iPhone. However, when it came to the CDA and CAPD recommendations for a dental home by age one, I am embarrassed to say that I only implemented these recommendations in January 2010 because I downloaded the information provided instead of inquiring. Let me explain.
Downloading is, in a nutshell, the process by which, as soon as we recognize a word, for instance “Prevention”, we stop paying attention and file the information into our mental pile labelled “Prevention”. Downloading is a time saving mechanism that gives us permission to not pay attention, to be blind to a new reality as we label it “Same Old, Same Old”. It also gives us the edge of superiority, especially when we attach to the downloading process the notions of already possessing the information provided and therefore not needing to heed the recommendations contained within it.
This is exactly what I did, me the early adopter, when I first heard of the recommendations for a dental home by age one. With 2 hygienists in my solo practice, oral hygiene and prevention were a daily routine and the incidence of tooth decay was low. I certainly did not feel it was necessary for my practice to include infants. Under that certitude hid a number of other issues: what would I do with a one year old in the chair?; How would I handle the screams that would surely come as soon as I would attempt to insert a mirror in their little mouth?; What would I look for in such a tiny mouth that barely has any teeth?; Clearly I would not find anything and therefore it would be a waste of time. Plus, being a woman did not endow me with natural abilities with babies, especially since I became a mother by procuration when I married a man whose 2 children were already 9 and 11. Personal experience with infants: 0. Level of comfort with infants: 0. So telling myself, and my team, and my patients, that we did not need to see children as young as one year of age was a convenient way to avoid facing my own shortcomings.
What I failed to acknowledge for many years is the fact that although the incidence of ECC in my practice was low, it was not zero. I also failed to recognize that my diagnosis methods for caries needed some serious upgrading. During examination processes, I looked for decay, cavities, the irreversible end result of a preventable disease called caries and therefore missing out on golden opportunities for effective prevention. You see, I had embraced prevention early on ( early adopter here too) but as I, along with my team, became proficient at it, we fell into the trap of downloading prevention information, not paying attention to, and missing out on, some important changes in examination procedures, disease classification and risk assessment / management. We developed a form of blindness that allowed us to continue to believe that we were still riding the leading edge of progress in dentistry.
Progress in dentistry has an intense focus on technology. And what more exciting for a dentist than a new high-tech instrument? I know. I used to say that the one who dies with the most toys wins. I was going to win this game. Early adopter across the board here! But is high-tech better? In some instances it surely is. When our patients come to the point of needing restorations, the technology that provides the best margins will benefit them for sure. But could there be better ways of benefitting our patients?
We invest much time and resources in perfecting our restorative capacities. The majority (by far) of Continuing Education offerings are on the topics of restoring and replacing teeth. Perhaps we are driven by the seldom openly acknowledged fact that, no matter how good our dentistry is, it never matches the engineering marvel a natural, unblemished, tooth is. But we should also remember the other seldom openly acknowledge fact that when we drill and fill a tooth we condemn it to an endless spiral of restoration and re-restoration. So who benefits most from the current restoration-focused state of dentistry? Our patients? or us?… What does it say about us and our profession when we are financially rewarded for fixing something we could have prevented in the first place? And how well does it serve us to blame our patients’ lack of compliance for our own short-comings? If we judge by the 2010 CDA commissioned survey results on Trust and Value, our patients are seeing right through us. Gaining Trust and demonstrating the inherent Value of our care will take a huge collective commitment.
The Chinese philosopher Lao-Tzu said: “A journey of a thousand miles begins with a single step”. What will this first step look like? Feel like? What can you do to positively impact the public’s trust in the care you offer?
Trust must be earned and Value needs to be demonstrated, our National Association tells us. What better value can we offer our patients than the possibility of a caries-free life? Examining babies before any irreversible enamel changes happen gives us the opportunity to make a big difference. It also offers the possibility of engaging in conversations about health and healthy habits with parents and care-givers, therefore influencing not only the oral health of a whole family and beyond, but also total health. We dentists seem to place a high value on providing high-tech procedures. But what if our true Value lied in placing our patients’ total health needs first? What then would happen to trust if we consistently placed our patients’ best interest ahead of our own?
Although I hold low expectations with regards to the 2013 survey results, I still have high hopes for my profession. Dentists are in an ideal position to influence health due to the simple fact that we see our patients more often than most other health professionals. The idea of ‘Dentists as Health Leaders’ is within reach. But first we must recognize the downloading patterns that keep us stuck. Then we can create a collective space and time for reflection on the true nature of our current work as dentists and from there, create a new model for dentistry that will better benefit our patients first without neglecting our needs as health professionals. What better first step than embracing the concept of seeing infants in our general dental practices? You might be surprised, as I was, to find meaning and fulfillment in choosing to do so too.
Dental offices are structured to provide safe care to as many patients as possible on any given day. Access to care and bottom lines are important. My question today is: what can we do to intentionally design into the current model time for dentistry to really listen to our patients. Please read Curing the Common Cold of Leadership, an excellent article by Daniel Goleman
The evidence connecting oral health to overall health continues to grow, and this is leading to changes in the way both dental and medical professional approach the care they provide to patients. When the root cause of health problems can be addressed, patients experience better outcomes and healthier lives. However, for this new approach to truly impact patients on a large scale, health care professionals need to take a new approach. In this article published on Dentalcompare, Editor Noah Levine interviews Dr. Charles Whitney, a physician who believes dental professionals are in the best position to lead this transformation of health care. Dr. Whitney is working to spread the message that by focusing on oral-systemic health and educating their medical colleagues, dentists and hygienists can lead the way to what he calls a Third Era approach to health care. Read the article