Bite Point

Maintaining Oral Health While Limiting Pandemic Anxiety

Our 30th President, Calvin Coolidge, was a man of few words and an extremely pragmatic, practical, skeptical New Englander.

On a brief vacation, President Coolidge and an old friend were riding horses in Vermont.

His friend said to Coolidge as they rode through the rugged Vermont farmland, "See how closely they have shorn those sheep."

"On this side," said the President.

We only really know what we can verify by direct observation. And sometimes, the culture overlooks an important observation for a very long time, as we shall explore here.

Our situation is sobering: I wish all of our practice family well as we enter into a dangerous surge in Covid-19 cases across the nation. Noting this alarming increase in cases, I  wonder how many people have been harmed by other diseases because they did not seek medical care. Broad reporting indicates these numbers are turning out to be nearly as large as the Covid-19 statistics. Thus, we are all strongly advised even at this time to continue our normal health care, including any specialists we normally see and, of course, that includes dentistry.

Most Covid-19 deaths involve the virus itself and also a bacterial superinfection; the host gets weakened, and then other bad actors move in to take advantage. In some cases, perhaps in many cases, the bacteria that cause these dangerous superinfections in the lungs are traceable to periodontitis—gum disease. The germs that cause periodontitis thrive in a small band of gum tissue around our teeth and are particularly vicious. Many are extremely effective at evading the human immune system. Further, current science informs us that when present, these bacteria invade the bloodstream, and also travel directly to the lungs, day after day, hour after hour.

This scenario makes sense if we think about it carefully. One of the most powerful defenses we have against infections of all kinds is shedding. The outer layer of our skin completely renews itself from the base up every 28 days or so. Our intestinal lining regenerates even faster, with a turnover time of an astonishing 4–5 days. Our corneas, nasal passages, hair and so on—every external part of us is, in a manner of speaking, continuously falling off and being renewed from within. It’s rather wasteful, but apparently also necessary, as it makes it very difficult for bacteria and even viruses to invade. They can’t gain any footing.

Teeth are different.

Teeth are the one and only place in the body where a hard tissue comes through to the surface. (Fingernails are a specialized skin structure.) Teeth don’t shed, teeth don’t have turnover, teeth don’t renew. They only time they fall off is during Flyers games.

Unfortunately for us, in their own strange haven’t-got-a-brain way, bacteria “know” this about our teeth and are constantly, relentlessly attacking us at this unique interface, this special place where our teeth come through to the surface, this vitally important 3-millimeter-wide band of protective gum tissue in our mouths. This is why periodic examinations and continuing care in which we remove the plaque and tartar from the teeth remain so important, even—perhaps particularly—during this pandemic. In fact, a June 26 British Dental Journal paper by Sampson and Kamona suggests a link between oral hygiene and the severity of Covid-19 outcomes. Current evidence shows that periodontal disease has a terrible effect on cardiovascular health, as well. There’s hope, of course—periodontal disease can be treated, and even more importantly, prevented!

In these strange and anxious times, we are all balancing one risk against another. As you know, in our practice we have put in place airflow and surface disinfection and patient-flow protocols such that our dental office is one of the safest indoor spaces in Philadelphia. We live and work by mindful mask wearing, handwashing and by the nature of a dental practice with five treatment rooms, social distancing. We vigorously encourage you all to maintain your periodontal health by keeping your continuing care visits with us.

We all need to keep our guard up, and conscientious dental care is significantly contributive to overall health.

If Calvin Coolidge, that eminently practical man of few words, were to come back today as a periodontist—which would be an absolutely wild thing, in my view—I know exactly what he would say, to the dental profession, to the medical profession, and to all the patients he would treat:

“Focus on the part that doesn’t shed.”

Dental "Insurance" is Just a Coupon (the short version)

Here is the short version of my last post.

In 1967, when dental insurance first ramped up in America, employers commonly purchased plans with $1,000 yearly maximums.

Today, in our experience in Philadelphia, some 95% of PPO plans from United Concordia, Delta Dental, Aetna, Guardian, Cigna and MetLife are purchased with $1,000 for their yearly maximums.

$1,000 in 1967 is the purchasing equivalent to $7,700 in 2019.

Implications:

(1) For 2020, you would need an $8,000 maximum to enjoy the same dental financial benefits that your 1967-era predecessor did.

(2) Your 2020 $1,000-a-year dental insurance plan has decreased in relative value to less than $130-a-year, if you compare purchasing power to what it was for your 1967-era predecessor.

(3) Your payroll deductions are generally much larger than your 1967 predecessor faced. In fact, in those days, there often were no payroll deductions for dental insurance; it was an actual benefit. Something extra.
While there are regional differences, today, Americans who have dental insurance pay an average of around $360 a year for the privilege. Most payroll deductions range between $15 and $50 a month.

In one sense, thus, a modern employee who has dental insurance pays $360 per year to gain $130 per year in inflation-adjusted value, as compared to the tangible value their 1967-era predecessor received. For free. With myriad restrictions and plan limitations and "sorry, not-covered's."

Does this, perhaps, make you angry?

Modern era dental insurance is not insurance at all. It's a yearly coupon, albeit a thousand-dollar one.

The Other Side of the Sheep

A long time ago, future President Calvin Coolidge was riding a horse through rural Vermont with a friend.

His friend, taking in the rough-hewn Yankee countryside, remarked, "See how closely they have shaved those sheep?"

Coolidge replied, "At least on this side."

*

As we all recognize, we now live in an era of information overload. What is recognized less than it should be is that much of the information we are exposed to comes with the bias of the presenter. Nearly everything we read and hear has been pre-digested for us. Editorialized. Opinions laid in. Content honed to elicit specific emotions--usually fear or anger. We are constantly being battered with the terrible cudgel of being told what to think.

President Coolidge's five simple words remind us of the importance of believing what we know. And that's it.

Let us then seek the objective truth and think for ourselves more often than not.

 

Commodity Versus Bespoke in Dentistry Revisited

In an online public place, a prospective patient who never actually met us in person railed at us for being expensive. This particular raillery was in response to a phone conversation only, no other interaction. The person's main point was in regards to dental implant crowns, and the crux of it was stated:

"Other Dentists START at $499!"

I've re-posted my response here, as this assertion is a superb springboard for a discussion of what I've come to think of as the spectrum that runs from "commodity" to "bespoke."

Here 'tis:

*****

With every consumer decision we make, we ask the question: "Do I want a commodity or do I want something bespoke?"

If a person wants a $499 crown, made at a foreign lab with unspecified materials, from an impression made with alginate not a precision material, then that is a decision to purchase a commodity. We all do this in many areas of our commercial lives (who would purchase bespoke paper towels??). There are risks, however, when making health care decisions that are skewed towards the commodity side of things. With dental crowns? Recurrent cavities, porcelain fractures and increased risk of root canal complications are all possible sequelae of poor fit and fabrication.

Our fees are what they are because we made a decision long ago to diagnose with great care, provide the finest treatment, and, along the way--listen! In a world of Big Data and corporate seeking after profit at any cost, the act of actually listening to a patient has become almost an act of reverence.

It does cost more to diagnose and treat our patients with high technology (like our Operating Microscopes through which we do our treatment, and our use of the finest dental adhesive materials made, and the excellent dental laboratory we work with). Listening to patients is technically 'free' but I suppose there is a cost somewhere because there are only so many hours in a day, and we constantly have to decide where to direct our time. But what could be more important than listening? Even arriving at the correct diagnosis depends on that.

So, xxxxx, if ever you are unhappy with a lowest-bid, commoditized dental treatment decision, I hope you will return to us or seek care at one of our many conscientious dental colleagues who see the word "finest" as one of the most important words in the English language. 

Why Microscopes in Dentistry?

I was recently asked why I have four Microscopes; specifically, why did I purchase one extremely expensive Operating Microscope for each doctor and hygienist in the practice? I answered:

There are lately many dozens of new dental technologies, all of them bringing great benefits to specific areas of dental treatment outcomes. One technology, though, bestows astonishing benefits on ALL forms of dental treatment: the Surgical Operating Microscope. Our practice is one of the few in the world to have Microscopes in every treatment room, used by every primary caregiver in our practice. This remarkable tool gives us unparalleled views of the mouth and teeth. We can diagnose better because we can see better. And as to treatment? Microscope dentistry is defect-free dentistry. It's a spectacular change.

 

Only One Correct Diagnosis

I recently met a new patient, a remarkable and engaging young woman with complex medical issues. She falls under the rubric 'disabled' from a physical definition standpoint, but there's absolutely nothing disabled about her splendid expression of the human spirit. In my brief experience of her so far, I've noted that she accomplishes and creates more in a day, in the face of endless challenges large and small, than many of us accomplish in weeks.

One striking thing that comes out in our conversations is how many of her young friends haven't been to the dentist in awhile, and how often this reluctance is because of concerns about cost. Hearing this always sends a sort of shock through my finely attuned dentist's body. Because, you see, most dental problems don't ever get better on their own.

In point of fact, they always get worse.

By 'most' I include cavities and all the complications that go with them, like root canal treatments and even extractions, should the decay get deep enough. I include gum disease, certainly. Even crowded and misaligned teeth--they get more jumbled up over the years. The most severe concern of all is of course the specter of oral cancer. It's one of those cancers where you actually have a pretty good chance of a cure--IF it's caught early.

Many oral diseases are actually silent for long periods. Early cavities, much of gum disease, oral cancer--all painless and sneaky for quite some time. The opposite problem of course is pain. Patients can face physical pain and they also can face esthetic pain; the pain or social embarrassment that results when front teeth go bad.

Mulling on all those concerns, I really want to meet the folks, especially the young folks, who are fearful of cost. Because whatever the cost of dental treatment might be just now, it's going to cost more the more time goes by. On account of the worsening ...

Why am I so keen to meet them?

One of our greatest dental educators, Dr. Morton Amsterdam, famously asserted, "There may be many ways to treat a case, but there is only one correct diagnosis."

I live by that.

Only once we have a diagnosis can we start to talk treatment. Yes, what it takes to treat oral health problems may be expensive at times. Once we have our diagnosis, though, we can suggest options. Once a patient understands and wants a certain kind of dentistry, the question that remains is simply, "Is this the kind of dentistry you would like to have done, if you could fit it into your budget?" And then it's purely a matter of fitting it into one's budget.

Everyone has a budget, even those who don't budget (verb).

At that point, having our diagnosis, we'll talk, we'll strategize, we'll solve problems with you and most of all, we'll listen. But first, you have to come in. First, we both have to obtain a diagnosis.

Cost? Fear? Fear of cost? Meh. The vital thing to consider is this:

There's nothing to fear about making a dental appointment so long as you know you're going to be listened to.

Dangers of Corporate Dentistry

Corporate dentistry places the goal of maximizing profit far above all other goals, including that of solving oral health problems for patients. This has real-world effects on the health of those patients.

It essentially works like this--

Corporate dentistry entices patients with low fees for any given procedure. Then, they over-diagnose and over-treat. Patients actually end up paying more. In money--and in health.

Examples:

-The corporate dental definition of the dental pulp is "a small piece of oral tissue that can be readily turned into cash." Endodontics is performed with the thinnest of rationales, or often with no rationale at all, in the name of production quotas. In contrast, a *bespoke* dentist strives to keep the dental pulp alive, in cases where there is no infection or intractable pain.

-Corporate dentistry fabricates periodontal probing depths in order to perform scaling and root planing on all new patients, many of whom do not need it (and will be harmed by it). Over time, this of course makes it more difficult to have treatment discussions with patients who actually have periodontal disease, as the profession's credibility is harmed.

-Teeth that could be restored with direct restorations of moderate size are crowned instead. Crowns are extraordinarily useful when indicated to save a tooth and keep in in function. I wonder, though, how many tons of human tooth enamel are sacrificed in the U.S. each year by corporate dentistry, not because the teeth in question were severely compromised--but because the fee for a crown is eight to ten times higher than the fee for a direct restoration.

Corporate dentistry also treats doctors, hygienists, assistants and business staff as interchangeable, temporary and disposable. Production quotas are the driving metric.

A truly *bespoke* dentist, in contrast, considers this metric to be the most important: "How much difference did I, and my staff, make for this patient who stands before me?"

Socks and Shrubs

An industrialist says, "I need some DNA to get this job done."

The owner of a bespoke, unique, personal business says, "I need your DNA to get this job done."

If the second statement resonates with you, so will my novel, The Man Who Wore Mismatched Socks.

It's on Amazon in both print and Kindle versions:

http://www.amazon.com/Man-Who-Wore-Mismatched-Socks/dp/0991301757/ref=sr_1_1?ie=UTF8&qid=1435506945&sr=8-1&keywords=the+man+who+wore+mismatched+socks

It does, by the way, have four 5-star reviews at the moment.

!*****!

 

And then Tom Bentley and I wrote a short story, Swirled All the Way to the Shrub. We are extending this work into a novel, yet for now, the short story is available on Kindle.

http://www.amazon.com/s/ref=nb_sb_ss_i_1_19?url=search-alias%3Daps&field-keywords=swirled+all+the+way+to+the+shrub&sprefix=swirled+all+the+way%2Caps%2C133

 

Happy reading, folks.

 

All Microscope Dentistry

We are now an all Microscope office, with Dr. Shu-Zhen Kuang, Dr. Derek Conover and myself, Dr. Rick Wilson, doing our dentistry through these magnificent instruments,--and two more on order for our hygienists, Maryanne and Melissa.

The light and magnification is so spectacular, that treating patients in a Microscope is an entirely different level of dentistry than anything that came before. It's Dentistry V2.0, is what it is.

Just to give you some tiny inkling of the idea of how much more precisely we can treat you, have a look at one of my student friend's work at six successive increases in magnification.

2.2x--

3.2x--

5.1x--

8.0x--

12.8x--

19.2x--

That is my friend Jaimin's lab work on an extracted tooth--before she started attending dental school. Such potential!

Bad Words

Words and phrases dental marketers and consultants use that I cannot stand:

get
target
capture
acquire
go after
prospects
manage profile
branded response advertising
team of writers
remarket

It's all so wrong. The words we use do have profound influence on our thought processes, the conclusions we make and the actions we take. Bad words do influence bad behavior.

Perhaps we should not repeatedly use the word "get" to describe our business growth strategies. It's an inherently selfish word in this context.

Perhaps we should not use hunting terms to describe our goals of meeting new patients and enjoying the privilege of serving them.

And perhaps we should also be brave and write our own content and stand for what we stand for, never giving in to the temptation to allow a team of anonymous corporate writers to speak in public on our behalf.