Advocacy in Dentistry - ADA Storms Capitol Hill - Washington, DC

United States Capitol at Sunrise

I was honored to be part of a delegation that went to Washington DC to provide dental care advocacy on behalf of the Colorado Dental Association and the American Dental Association.  We had a chance to meet with most of our Colorado legislators in person and if they were unable to meet with us personally, they had their health care staff expert meet with us.

This year we had three issues to bring forth.  The first was a reform on student loans hoping to get a reduction in interest and an increased tax deduction.  This is for everyone with student loans, not just dentists.  An interesting stat - Americans collectively owe $1.1 trillion dollars in student loans, much of it subsidized by the government.  It is quickly approaching the amount of money that we owe China ($1.4 trillion).   Congressman Paul Gozar, DDS (R-AZ) calls this a bandaid, a good start - but not a comprehensive solution.  The cost to go to college/graduate school must evolve as it is unsustainable.  Dentistry is the costliest of the professions to train and it is not unheard of for a dental student to finish with a $500,000 student loan debt.  This is a 30 year mortgage, not a student loan.

The second issue we discussed was an ask for grant money to help start initiatives that will serve those in need.  These grants will help states with initiatives such as "Give Kids a Smile", "Missions of Mercy" and community coordinators that will help people find a dentist via emergency room referrals, nursing homes, schools, etc.  The legislators asked where is the money going to come from.  We call this designated grant money an investment, not a cost.

For example, in Colorado - we have an event called Colorado Mission of Mercy (COMOM). COMOM is a 2 day event where dental professionals set up a temporary dental clinic in a big way.  Over a thousand patients are treated for free over the course of the event.  All of us bring our own dental tools and supplies and treat what is needed.  The cost to put on a COMOM is $160,000.  The amount of dentistry given to the community over a $1,000,000. This is money that won't have to come from government benefits such as medicaid.  The next COMOM is in October in Henderson, CO.

The third issue was a letter initiated by Rep. Paul Gosar, DDS (R-AZ) that we want our legislators to join in and sign.  This letter asked the Center for Medicaid and Medicare services to improve the fairness and transparency of Medicaid recovery auditors and their review process.  We believe that audits of medicaid providers should be done to catch providers trying to beat the system, but not on those that are doing their best to serve those in the community in need.

Currently, in some states, the process is "guilty until proven innocent" with very little opportunity for the provider to have any recourse to defend him/herself. It is difficult for dentists to want to join up to become medicaid providers when these type of audits are in place.

We also had a variety of speakers give us the current state of the political climate in Washington.  There is less than 40 legislative days left in session and due to stalemate political party posturing, they predict that very little legislation of any significance will get done.  Sad that this is the case.....

One of the best speakers was Rep. Peter Roskam (R-IL).  He was preaching to the choir when he said that the Affordable Care Act cannot put a price tag on caring for our patients.  He predicts that the "commoditization of health care" is going to drive down the opportunity for us to truly care about our patients.  I am doing everything in my practice to not let this happen.  I hope my colleagues will too.

A big revelation was how important our political action committees (PAC's) are.  Both ADPAC (national) and CODPAC (Colorado) raise funds to advocate to keep dentistry a profession of relevance.  This year alone, these PAC's have allowed us to spend time with our legislators to explain our needs so we can provide the best dentistry and services to our communities that we serve.

Is Dentistry a Commodity?

From 1991 - 1995, I went to dental school to learn my craft.  I found out that early on, that the scientific based classes came very easy for me as I was a biomedical engineer prior to dental school.  What didn't come so easy, was the artistic training that was required to be a dentist.  We had to learn how to create teeth out of wax, plastic, amalgam, composite, gold, porcelain, etc.

Looking back to grade school, I was the kid that got sent to the principle's office from art class for being disruptive.  I would do anything to not do art.  I was quickly slapped with reality when I struggled in these early training exercises in dental school.  I had no artistic skills!

I struggled so much that I was required to go to what I call "wax camp" during the summer after the first year of dental school. (Does the movie"The Breakfast Club" comes to mind?)

The other "campers" and I huddled around bunsen burners flames and honed our skills with one-on-one instruction from some very talented instructors.  One day, I don't know when or why, the switch flipped and my right brain connected with my left brain and I was able to wax up teeth at a proficiently high level.  As time went on, I became better and better at it.   In fact, I taught this very same class at University of Colorado School of Dental Medicine for 7 years.

So back to the question, is dentistry a commodity?

Dentistry is an imperfect blend of art and science.  It is not mass produced on a conveyer belt in a factory.  It is provided uniquely and personally to our patients.

A mentor and master of dentistry, L.D. Pankey once said, "I've never had a tooth walk into my office. It was always attached to someone.  Get to know that person, and I may get the opportunity to treat that person's teeth."  Words which I live by in my practice philosophy.  We treat people holistically - mind, body, spirit. You are not a set of teeth, you are a "whole" person.

So is dentistry a commodity?

Can a person go to a dentist and say that he needs a size 12 upper molar and the dentist picks one off the shelf and glues it in?  NO

Can a person go to a shoe store and ask the salesman to fit him in a size 12 shoe? YES

Can that person buy a size 12 shoe for $30, and a size 12 shoe for $300?  YES

Is that shoe store being chastised by community organizations for "gouging" its clients?  NO 

Why then do dentists get chastised by insurance companies for charging a fair price for their services provided uniquely to an individual?  Usually people (insurance agents) placing unfair judgements on things they have no experience with.

If a dentist charges more for a service than a patient values, the patient will not buy that service. Simple economics - supply and demand.

If a person sees a value in either price point for the shoe, he/she will buy that shoe.

The same thing goes in dentistry.  There are different levels of service and challenges in treating patients.  A more difficult procedure may cost more as the dentist to takes more time, care, judgement and skill to perform that procedure to the level of care that the patient expects.

And any patient has the right to put value on things important to them.

Most third party entities (insurance companies, government agencies, etc.) have been masterful at creating a "dentistry is a commodity" mindset to the consumers.

I am emphatically saying that it is not a commodity.  Dentistry is a blend of art and science executed with proper judgement and skill that only comes from our highly specialized training and experience.

There may come a day that one can choose a size 12 upper molar off the shelf -

Then again, there may not...

All this could be a moot point as clean teeth do not decay - AND - 95% of dental problems are preventable!

If you like this blog post, I would love to hear about it.  Please comment or share it on Google+, Facebook, Linked in, Twitter, etc.  If you are looking for a dentist in the Denver area, we are always looking for new patients.  Please visit our website http://www.tcdodenver.com/ or like our facebook page,  https://www.facebook.com/TCDOdenver.  Or you can contact us  the old fashion way - call us at 303-321-4445.

Thanks for reading!  BK

Cracked Tooth - Ouch!

My friend Dr. Alan Mead - a dentist in Michigan wrote a very informative blog about cracks in teeth a while back.

 http://meadfamilydental.com/2012/05/dont-wait-until-it-breaks/

As a dentist, I see cracks in teeth everyday.  After personally experiencing teeth breaking around old fillings, I find myself sharing how painful it was and how it always seemed to happen at inopportune times.

There are two factors that if addressed properly, can pretty much ensure that you can predictably keep your teeth:

The first is health - we emphasize brushing and flossing.  Clean teeth do not get cavities and minimizes the chance of gum disease.

The second is function.  If you are putting too much force on a tooth - something is going to give once that threshold has been exceeded.

The functional threshold of one of my patient's tooth was exceeded this week. Here is her story -

She presented with EXTREME pain that began suddenly while eating dinner the night before.

I looked at her tooth and saw a fracture on her lower right molar. The fractured part of the tooth was still present and when anything touched it, the segment would move and it sent her into writing agony.  The tooth has a well placed conservative filling.  I would put this tooth at low risk for a fracture if she presented for a routine exam.  The radiograph that we took was inconclusive for a fracture or any other infection.

Figure 1 -(Tooth #30) fracture noted on left side of tooth extending along the filling through the middle of the lower (lingual) wall.  It is slightly brown colored along the filling.

We discussed her options: Remove the fractured portion of the tooth and determine if it was restorable. It would need at very least a foundation build-up and a crown.  I informed her of the potential additional need for a root canal or a possible extraction.

We attempted to get her numb but was unsuccessful due to the acute problem.  Sometimes a tooth is so "hot" (or inflamed) anesthetic doesn't work. When this happens, I get more confident that root canal therapy is indicated.

We referred her over to Dr. Rahim Karmali, a root canal specialist here in Denver, who then did an evaluation that included a three dimensional - CT scan of the tooth.

Figure 2: CT scan clearly illustrating the extent of the fracture.

Figure 3 - Sagital view - fracture down to the boney crest

Figure 4 - Shows the fracture extending on the root surface

The technology that is available to us allows us to better predict the restorability of teeth.

It was obvious to Dr. Karmali, myself and the patient, that this tooth, unfortunately, was not restorable.

So as I mentioned previously that I see cracks in teeth everyday.  I am proactive when I see these fractures and tell and show my patients what I see and give options to fix the situation.

When my patient asks me how long before this tooth needs to be fixed.  I will reply with the words of my good friend Dr. Mead, 

"I recommend that you fix it the day before it breaks!"  

I also share this unfortunate experience and hope that it doesn't happen to your tooth...

Case study - Addressing Jaw (TMJ) Problems to a Wonderful New Smile with Veneers and Crowns.

I haven't blogged in a while....My patient care coordinator Monique asked why?

"I haven't been inspired to write lately!"

She said, "Why don't you share some of the smiles that we have improved?  They are life changing!"

I thought about it for a moment...""Not a bad idea!"

So here it goes.....

This particular patient of mine presented with jaw pain after a car accident.  He had many broken bones and chipped teeth. He went through many surgeries and has healed up nicely.

I treat a lot of patients with jaw pain.  I enjoy it - When I was in dental school, we were taught to do bite splint therapy. If they don't get better, send them to their psychiatrist as they are crazy.  I didn't buy that as I had a history of jaw problems and I wasn't crazy...

I spent many years after dental school taking classes on how to treat patients comprehensively -and this included the orthopedic treatment of the jaw and how it relates to the bite. By following some of these protocols, I am now able to treat a wide variety of dental issues predictably.

So we started with bite therapy that included various types of splints over two years to allow the jaw to heal. As his jaw healed and then stabilized, we started discussions on idealizing his bite.  He didn't present with esthetic concerns, but as we got to know each other through his treatment, he revealed to me that his front teeth chipped during the accident.

Adding length to the front teeth without addressing the function could be a very risky procedure.  The length of the front teeth could affect how one chew's food, how one grinds their teeth and also could affect how one speaks.

If the increased length interferes with the normal jaw movements or grinding patterns, the restorations are at high risk to break. It could affect the jaw muscles or one could develop headaches.  Teeth that are too long will compromise the 's', 'f', and 'v' sounds - giving the patient speech impediments.  They must also fit the features of the face to look as natural possible.

If any of these factors are not addressed, the results could be devastating.

Fig. 1 - Multiple short and chipped teeth

As part of idealizing his bite, we were able to add length and repair the smile within the harmony of his function.

Here is the after photo.

Fig. 2 -Restored smile with veneers and crowns

Happy patient.  He admits to me that he was very self conscious with his smile prior to the restorations.  Now he smiles confidently and most important, he is comfortable!

Discovery

"I never had a tooth walk into my office.  It was always attached to a person." L.D. Pankey

When I first heard Dr. Pankey's quote, I really took it to heart.  Treat the person, you may get the opportunity to treat their teeth. In dental school, we had requirements.  I needed to do 'x' amount of crowns, 'y' amount of fillings, cleanings, etc. All my efforts were to fulfill my requirements.

Once in private practice, the 'teeth requirements' became people that chose to be patients of mine.  I consider it an honor to be able to provide the best care that I can to my patients.  They choose me from personal referrals or a direct result of a marketing piece.  They stay because they trust me and my team.  In my heart, I have always wanted to get to know my patients.

In my practice, I spend a great deal of time with my new patients in consultation before we enter the clinical area.  I call this the discovery meeting.  It is an opportunity for us to get to know each other in a relaxed atmosphere.

It usually starts with some simple, "get-to-know-you" type questions - e.g. (What brings you in today? Do you live in the area? What do you do for work? What are your hobbies? etc.)

The conversation usually shifts into an exchange of values.  I describe who I am and how I practice.

I then have a series of questions for my patient to answer regarding their dental history, their perceived state of their oral health, and what their goals are for their teeth.

Now most people don't obsess over their teeth (of course, some do!).  The questions I ask are designed for the patient to start to think about potential problems- especially around the health, function and esthetics.

This leads to a discovery what the true status of their oral health.  It is key that the patient begins to "discover" this themselves as we guide them along the path.

If the questions are asked correctly, the patient does most or all of the talking, I just sit there and take notes.

I am very consultative in nature and I continue to ask questions. During the exam I continue to ask relevant questions and show patients areas I have concerns with.  This allows them to remain engaged in the process and they start to discover things at a deeper level.

I find that my job is to educate and offer solutions to potential or active dental problems.  The patient is usually armed with enough information that they can move forward with treatment at their pace.

Occasionally (this happened recently!), from the discovery interview, we decide that it is probably not a good fit to move forward with the exam.  Which is fine -  If we have different values and we discover this up front, it will save all sorts of problems and animosity down the road for both of us!

I have identified the demographic that I wish to serve.  I treat people that are truly concerned with their oral health and are willing to take an active role in optimizing it - Optimal dentistry specific to their goals.  Sometimes this is a full mouth reconstruction, sometimes it is twice a year cleanings and check ups -Whatever is appropriate.

This has led to a satisfying practice, knowing that we are partnering with our clients helping them along the path!

Who Are Our Role Models?

I recently gave a leadership lecture at the Rocky Mountain Dental Convention.  In one key part, I ask the audience to identify who inspires them. Who are your role models?

For me, it had been Lance Armstrong for many years.  I am an avid cyclist and I never missed a stage of the Tour de France - either live stream on the internet or on tv.  In fact, I remember watching late night recaps on ESPN during the Greg LeMond era - before it was really popular.  When Lance came along, I was hooked onto the entire phenomena.

I also have contributed to LIVESTRONG both through donations as well as spirit.

For years I have been defending Lance Armstrong.  He claimed to ride clean, and more importantly, he gave inspiration to the many afflicted with cancer.

I heard him speak once.  He was challenged by his oncologist after his cancer surgery/treatment that when he left the hospital, he could take one of two paths forward: 1. He can go on with his life and keep his cancer experience privately behind him, or 2. he could accept the challenge of the "obligation of the cured" - a mission to help those who are directly or indirectly suffering from the disease.

He obviously chose the second path.

That is what was most inspiring to me about Lance.

So now he comes out about his performance enhancing drug use.  The rumors were true.  I watched the Oprah interview. I felt let down by him.  He admitted his wrongdoings, but his body language showed very little remorse.  To live with that lie for so long must have been killing him spiritually.  He believed the lie, he believed the media hype.  He has a long road to redemption.

He has hurt a lot of people.  He has a lifetime of amends to make.  Hopefully he will dedicate the rest of his time here trying to right his wrongs.

But he is human!  We all make mistakes, no one is perfect.  I know I made my fair share, and I am sure I will make more as time goes forward.

Charles Barkley said in the 80's, "I am not a role model!"  It was very controversial at the time, but how true his words were. Here is a video from that era.

"I am not a role model"

He then goes on to say, "Parents should be role models" - Amen to that!  We shouldn't listen to the media on who should be our role models.  Our role models (whether we know it our not) have been with us all along the way.  They are our parents, our families, our teachers, our coaches, our friends, our colleagues, etc.

Take the time to identify them and thank them.  Then pay it forward!

I forgive Lance Armstrong for his transgressions.  At this point, I don't trust him - but I forgive him.  Consistent action towards change and amends will be the determining factor for trust from me.

That's what I am rooting for....

Here is a video from the late George Carlin on Lance Armstrong/role models that drives home my point. Warning: It contains some pretty foul language

George Carlin on Lance Armstrong

Easy on that Bite!

I practice comprehensive dentistry.  In my process, I have a three-pronged approach to address all things that could affect the oral health.  The first is health related - where we evaluate the health of the teeth, gums and oral tissues.  The second is functional - all things relating to the bite and jaw joints.  And finally, Esthetics. - anything related to the smile.  When all three are addressed, the dentistry becomes predictable.

About 70% of my patients have issues with their bite. Some knowingly, most are unaware.  Through a discovery process, my patients who were unaware, become aware of bite (occlusal) issues. This leads to discussions about how function can affect both the health and the esthetics of the teeth.

Here is an explanation that I give my patients as a take home read to further explain the goals and my process of bite therapy.  Note that the therapy is a process - it is not "here is a piece of plastic for you to chew on..."  It is a process that sometimes takes several months to properly address.  

Occlusal (Bite) Therapy

Occlusion is a dental term for how your top and bottom teeth come together—as when you bite.  Biting serves one purpose: to break up your food so it can more easily be digested. When you have a healthy bite all of your top and bottom teeth hit each other evenly with the jaw in it’s most comfortable (or orthopedically correct) position.  When the bite is idealized, you will potentially need very little dental work over the course of your life.

Occlusal (bite) therapy is usually indicated if you present with symptoms (If you find that your teeth look worn, or you are constantly touching, clenching or grinding your teeth together when you are not chewing food) or if the doctor sees signs of over-function (fractures, worn teeth or fillings, advancing gum problems, mobile teeth, etc.)  You may “over-functioning” on your teeth. This will cause problems that may need attention either now or down the road.

If your bite is not balanced, (or if you clench or grind your teeth, chew gum excessively, or bite your nails, etc.) your teeth are prone to poor performance. You can experience cracking, fracturing or excessive wear. Dental work may need to be replaced prematurely. You are more prone to gum recession or advancing gum disease, sensitive or loose teeth. Finally, your smile can be affected with ground down or chipped teeth, especially your front teeth.

An unbalanced bite can also affect the jaw joints (known as the TMJ) and associated muscles that open and close the jaw.  Depending on the problem(s), over-functioning can lead to sore jaw and neck muscles, headaches (even migraines), clicking and popping of the jaw joints during opening and closing, severe pain and limited range of motion of the jaw.

Recognizing bite problems as early as possible increases the probability that you will have good looking and functioning teeth at an elderly age. Much of the dental work in an adult’s mouth might have been avoided if the signs of occlusal (bite) disease had been recognized and addressed in the early stages.

Lucia Jig

The Lucia Jig is the usually the start of occlusal or bite therapy.  It is indicated for a number of reasons.  The first is to help you stop clenching and grinding of the teeth together.  If you are unaware of these habits, hopefully it will make you more aware.  The second indication is to relieve pain in the jaw/jaw muscles, and/or headaches. By stopping the clenching it will shut off the muscles are overworking, dis-coordinated or are in spasm. Most people find relief within a few days to a few weeks.  The more that the Lucia jig is worn, the quicker it will start to work.

This is not a permanent solution.  Once the muscles have been deprogrammed, the jaw joints (TMJ’s) slide into their orthopedically correct position.  It is to be used as indicated by the doctor.  Please if you have any questions, don’t hesitate to ask

Occlusal splint (nightguard, bite splint, etc.)

This hard acrylic appliance is custom-made to fit snugly over either your upper or lower teeth. It becomes a temporary perfect bite for you. It is a process of determining what a perfect bite is and may include several adjustments until it is idealized. The doctor will encourage feedback from you on how things are feeling when you are wearing the splint as well as when you are not wearing the splint. When it is properly adjusted and worn as prescribed, many of the signs and symptoms of bite problems often disappear as long as you wear the splint. 

The properly adjusted bite splint can then be used as a guide to idealize your bite.  In most cases if your bite is idealized, you won’t have to wear the splint anymore, and your teeth have the best chance of working for you over the course of your lifetime.

Idealizing your bite

There are several options when looking to idealize your bite.  These options will be determined once you are stable with the occlusal splint. 

Occlusal analysis: The doctor will mount models of your teeth on a mechanical jaw that can mimic all of your jaw movements.  He will then be able to determine what kind of adjustments/dental work will be needed to idealize your bite.

Options include:

Equilibration:  A focused reshaping of your teeth so that they bite together simultaneously with even pressure.  The doctor reshapes the areas that are interfering and most likely causing you to clench and/or grind your teeth.  This is usually accomplished in 1 to 3 appointments, is usually pain free during and after the procedure. 

Equilibration combined with restoration: Equilibration as above, with the combination of some teeth that need fillings, crowns, veneers, etc.

Orthodontics:  If the teeth are severely malpositioned, orthodontics may be recommended to improve their position so that the bite then be idealized with equilibration possibly combined with restorative.

           

Surgery:  For the most severe alignment issues, the bite may need to be re-set with a surgical procedure. If it is indicated we work hand in hand with some of the finest surgeons in Colorado. You will be referred for an evaluation by an Oral and Maxillofacial Surgeon.


Copyrighted material (2013) Brett H. Kessler, DDS.