I sit down next to my patient who has just had her teeth cleaned. The hygienist gives me a quick update of the patients health history, how the patient’s teeth and gums look and alerts me to a couple of teeth that we’ve been keeping an eye on. One tooth has a big silver filling in it with some pretty suspicious looking cracks and the tooth behind it has a pretty suspicious looking shadow around another large silver filling.
The patient says, “I’m not having any troubles with any teeth, doctor.”
I take a look at the teeth. They’re in trouble. Although I don’t have a functioning crystal ball, I can see that one tooth is at risk of breaking. I can follow a crack down the side of the tooth and I can see some discoloration along the crack. Not a good sign. And the filling looks like it’s starting to break down at the edges. The other tooth has a small to moderate sized cavity under the filling. The hygienist and I take a photo of the offending teeth and show it to the patient on the iPad.
I point out the fracture, the broken down filling and the suspicious discoloration. The patient can see my concerns. I explain my treatment recommendation: place a crown on one tooth and replace the filling in another.
So, she immediately makes an appointment to have the work done, right?
Well, sometimes. Sometimes it’s not enough to just describe the problem. Sometimes it’s not enough to show them the problem in living color. Sometimes, patients have objections.
Assuming the patient understands the problem and understands the solution I’m proposing, there are four main objections patients typically have: time, fear, cost and trust.
Time: Sometimes the patient is just too busy to do anything about it right now. It’s not that they won’t do anything, but right now isn’t good. Perhaps they have their daughter’s wedding coming up. Maybe they’ve got everyone coming to Thanksgiving dinner at their house. Often, it’s other medical issues that are just more pressing at the moment. It’s happened many times that a patient breaks a tooth a couple days before they’re scheduled to have a hip replacement or some other surgery they’ve been waiting to have for awhile. When time is the issue, it’s rarely a big problem.
Fear: Some people are going to avoid dental work because they’re afraid of the process. No surprise there. A lot of adults had bad experiences at the dentist when they were younger. Some folks have had experienced negative stuff in the dental office as adults. It seems like everyone has a horror story of their experiences in the dental office. Technology and techniques in dentistry have come a long way over the years. We can usually keep patients comfortable through procedures and afterwards. For those that need help with their anxiety, dentistry has various pharmacological options to help keep patients relaxed throughout procedures. However, this fear is real. It keeps a lot of people out of the dentist and in pain. It takes a lot more good experiences to outweigh past bad experiences, so we go out of our way not to be the bad experience that a patient remembers for the rest of their life! If fear is your objection, we’re happy to talk to you about it and see what we can do to help control that fear.
“Wait one minute there, Doc!”
Cost: Cost is always a concern. It’s not always an objection, but no one wants to spend any more than is necessary to get a great result. Dentistry can be expensive. Especially if you’re surprised by something that you can’t plan for. That’s why we believe strongly in preventive visits. If you come in regularly and have us look things over, there’s less likely a need for the expensive stuff. And if there is need, we can plan for it so it isn’t such a financial hit. On the other hand, if there is one objection that keeps most people from getting the best dental care, it’s cost. Many people can’t or won’t spend any more than the absolute minimum on dental health. I’m frustrated by this on a daily basis. There are some pretty amazing treatments that dentistry has to offer that people don’t choose because of money. I often have to remind myself of my duty to patients, which is to diagnose their problems, explain treatment options (including the financial arrangements) and let the patient choose. Sometimes it’s hard not to take a patient’s rejection of these awesome treatments personally.
Trust: I’ve written about this on several occasions in the past. Sometimes a patient just doesn’t trust that the dentist has their best interests in mind. It’s not the timing, it’s not the fear and it’s not the cost. It’s just that they don’t believe that they need that treatment. I feel helpless as a dentist when this happens. When a patient feels that way, they probably need a change. Perhaps a second opinion or even a new dentist. If you don’t trust what your dentist is telling you, do yourself a favor and do something different. Whatever you do, don’t just keep feeling like your dentist is trying to sell you unnecessary treatment. If the relationship doesn’t work, move on. Seriously! It will be better for everyone!
These are the 4 main objections I run into on a regular basis. Sometimes I’m able to help a patient move past them. Other times, not so much. I keep coming back to what my duty is. I can’t make choices for patients. What I can do is: diagnose, explain the options and allow the patient to make the right choice for themselves. I’ll keep doing my best at that!
Did you find this post objectionable? Mind changing? I’d love to hear about it! You can share any Mead Family Dental post with a “Like” on Facebook, a “+1″ on Google+ or you can even “Tweet” it with Twitter! All you need to do is hover over the heart shaped button next to the title of the post. Or you can leave a comment by clicking on the balloon shaped icon next to the title.
If you’re looking for a dentist in Saginaw, we’re always happy to accept new patients! Especially ones that want to punch tooth decay in the face! You can request an appointment online or call the office at (989) 799-9133. And, as always, you can email me at firstname.lastname@example.org. I always answer my own emails!
I have a friend who told me about something that happened to him recently.
“So I was jogging the other day and one of my toes fell off. It was weird. I wasn’t even jogging on gravel or anything. Smooth blacktop. Anyway, I’m jogging along and then BOOM, my big toe falls off.”
I said, “my gosh, that’s terrible! What did the doctor say?”
“I didn’t go to the doctor. It didn’t really hurt much. Only when I walked on it just the right way. I just avoided walking on it.”
You’re thinking, “you expect me to believe that?” Well, kind of.
I take part in similar conversations quite often. People look me right in the eye and tell me that a part of their body has broken off, but they just weren’t that worried about it. The difference is, it’s a piece of tooth and not their big toe.
It isn’t normal for teeth to break. Just like it isn’t normal for your toe to fall off. If a tooth breaks, something happened. The tooth might have had a cavity. Or maybe a huge filling in it. The patient might be an untreated night time grinder and there was an undetectable crack in the tooth. Maybe there was an unusual trauma to the tooth (olive pit, anyone?) But that piece of tooth didn’t just fall off.
“But doc, I was just eating bread.”
Dentists hear that one all the time, too. No one ever comes in and says, “I was chewing on huge hunks of ice and broke my tooth.” It’s always soft bread.
How the piece breaks usually isn’t that important. It’s what you do next that really counts. If you think to yourself, “well, it doesn’t hurt that much. I’ll just wait until my next appointment,” you might be looking for trouble.
It’s not going to grow back. Honest.
If you’ve broken or worn the outer layer of the tooth (enamel) off, the tooth becomes much more susceptible to decay. Which also means you’re much more likely to need root canal treatment or even at greater risk of losing the tooth.
So if a part of your mouth breaks off, call us today. Not tomorrow. I promise you, that piece isn’t going to grow back.
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Me: “Gloria, you have several cracks in this tooth. Some cracks need to be treated more aggressively than others. Unfortunately, the ones I’m seeing here are some that I would recommend you treat right away.”
Gloria: “Really, doc? I’m not having any trouble with it at all. Do I really need to fix it?
I have this conversation quite often. When I suggest to the patient that now is the time to treat what I’m seeing it makes me feel kind of salesy, if you know what I mean. I just created a problem in the patient’s mind that they didn’t have a moment before. Just a minute ago the patient had been enjoying their clean and “just polished” teeth while hoping I wouldn’t come in and find anything expensive to fix.
Here’s the problem. I use at least 6.0x magnification and a ridiculously bright LED headlight for every procedure or exam that I do. At least. Sometimes I use my dental operating microscope which can bump the magification up to 20x along with the insanely bright plasma light source. But I digress. In any case, I see a lot. I have to use the judgement and experience that I’ve gained through 15 years of treating patients and learning new things to decide what’s important enough to suggest treating to the patient and what’s not all that important. This is not an easy job. Often I wish the patient could just see what I’m seeing.
Showing the patient what I can see isn’t as easy to do than you would think. Over the years I’ve used handheld mirrors, patient education software, intraoral cameras, digital SLR cameras of all types among other things to help the patient visualize what I’m seeing. I’ve found that I can explain things much more easily when they have a picture of what I’m describing. According to neuroscientist John Medina vision trumps all other senses. We humans are visual animals. A pretty big part of our oversized brains is used to process the visual images that our amazing eyes take in. We understand things better when we can see them. Or at least when we can form a picture of them in our mind.
Back to my somewhat awkward conversation with my patient. She thought everything was great with her teeth. They were smooth and shiny and pain free. Then I come in and tell her that I see a problem that she should probably fix that’s going to cost her money that she’s rather spend elsewhere. How does she know I’m not trying to sell her something that she doesn’t really need? If she listens to the news she may think that I’m just making up treatment in order to charge her a bunch of money! How can I help the patient understand her dental problems?
First, if I have a relationship with the patient and she trusts my motives, that helps a lot. Secondly, I try to show her a picture of what I’m seeing. Not only can she picture the problem, she sees that I’m not just making stuff up in order to do treatment on her. Most recently I’ve been using a digital SLR camera wirelessly connected to an iPad. This is a very elegant solution because the patient can instantly see the image come from the camera onto the iPad screen. I can show them the problem that I’m seeing at high magnification without the patient having to be leaned back with their mouth open. They can point, zoom and move the image around to ask questions I might not have thought to answer. It helps make the patient part of the diagnosis process. No longer does the patient have to “take my word” about a problem. They can “touch it” as well as see it.
Dental patients should demand this kind of technology from their providers. It’s no longer good enough to just take the doctor’s word for it. When a patient can own their diagnosis, they can own the treatment and make better decisions. Health care and dentistry continues to become more expensive, so we need to be better consumers. These kinds of pictures really are worth a thousand words for well informed patients!
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I was doing an exam on a patient recently. The patient had quite a few silver fillings that were probably 20 years old or older. I had some concerns for some of the teeth. Not because of the age of the fillings. Fillings like these can often last 20 years or more. It was because of the fracture lines I could see.
This tooth exhibits several stained and diagonal cracks. The tooth had no pain.
I put took a photo with a digital camera and it popped up on the screen of the iPad after a couple of seconds.
“This tooth is showing signs of trouble. Can you see these little lines?”
I zoomed in the cracks.
“Those little lines are fractures in the tooth. Incomplete fractures. In other words, it’s a broken tooth waiting to happen.”
“I see, Doc. But it doesn’t hurt at all.”
“Interesting. Sometimes they’re painless. Often they’ll become sensitive on biting, but occasionally they’re free of any kind of symptom until they break.”
“Maybe I should just wait until it breaks. I mean, it doesn’t hurt.”
“We absolutely can do that. A lot of times, nothing bad happens by waiting. If it breaks, we’ll fix it. But sometimes the tooth breaks in an unpredictable way. Like underneath your gum, or even under the bone. When that happens fixing it can involve a crown and a root canal and possibly even gum surgery. Sometimes the tooth can’t be saved if it breaks in a bad way. That’s why I would recommend putting a crown on it before it breaks.”
“How do you know if it’s going to break badly?”
“I don’t. So really, I recommend you fix it the day before it breaks.”
The patient gave me an exasperated look.
An "internal" fracture that was underneath a filling. This tooth had pain on biting.
I know, I know. That is a very cheesy line. I use it all the time because it’s so true. A tooth with this kind of crack, particularly a stained or diagonal fracture is at great risk of breaking. The very best thing we can do for it is to cover it with a crown or onlay. As soon as possible!
In many cases there are internal fractures underneath fillings that have been in place for a long time. Sometimes we don’t see those until we remove the existing filling. These internal cracks are much more likely to be sensitive on biting. Sensitivity to biting is another symptom that shouldn’t be ignored and should be treated right away!
The moral of this story is…don’t wait! A tooth is less likely to have complications (like needing a root canal) if it’s treated as soon as problems are diagnosed. This dentist REALLY prefers no complications!
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Dental insurance is a funny thing. It’s almost always purchased by an employer. This employer is usually trying to spend as little on dental benefits as possible. The insurance salesperson explains that they’re getting a great deal as well as fabulous coverage for their employees. The benefits selected by the purchaser don’t really have anything to do with the patient’s dental health or dental needs. Dental insurance is a contract between the purchaser and third party payer that will pay a certain amount, for certain procedures (selected by the benefit company/employer) for a certain amount of time. Dental benefits are like getting a gift card from a control freak. If you need treatment that falls out of these parameters (amount, type or timing) for service, your benefits won’t cover it. Which brings me to my real point.
Dental benefits offer perverse incentives to patients. For one thing, patients almost always choose to break up more expensive treatment into pieces. If a patient could really use two crowns they’ll often choose to do them one at a time in an effort to maximize their dental benefits over a period of years. In some cases this makes sense, but it assumes that there’s no advantage to doing all of the work at once. A perfect example is the patient that could use 2 or 3 crowns on one side of their mouth, say the lower right. What advantages could there be to doing all of them at once? First, it would require less appointments and less numbing. Secondly, if we have a lab fabricate the crowns all at the same time, the shade match can be perfect. As soon as you break up treatment…the shades will invariably be slightly different. Every batch of porcelain is a little different and every lab tech is a little different. Perhaps neither of these things are as important as cost savings to the patient, but they really should be made aware of them.
Another goofy incentive that dental benefits encourage is waiting until the end of the year. The theory goes like this:
“Sure, I know I need a crown on this tooth with a giant filling. But what if I go ahead and do that now and then I break a tooth in October. My insurance benefits don’t renew until January and I’ll be stuck. It’s probably smarter just to wait. I’ll do what he recommends at the end of the year, that way I’ll have my benefits if something happens.”
Admit it. If you’ve got dental benefits, you’ve probably gone through this in your mind. Human beings are great at figuring out the catches in deals that we’ve made. Economists call these incentives. Put simply, they’re the little nudges you get to act a certain way. In this case, the incentive is to wait to do treatment so you’ll have more of the dental benefit gift card (that you’ve already paid for) left at the end of the year, just in case. Why wouldn’t you wait? Let me suggest a few reasons that you shouldn’t wait.
Limited appointments: Everyone waits until the end of the year. If your dentist’s office is anything like mine, we get crazy busy in November and December. Since so many holidays fall in these months, the appointments available fill up quickly.
Seat date requirements: the same dental benefit companies that create this “let’s just wait” mentality usually require that any lab fabricated dentistry (crowns, bridges, partials, dentures) be billed on the day that they’re placed and not the day that they’re started. Which basically means that unless the dental lab can turn a crown around superhumanly fast, you’re going to need to plan ahead. I cannot bill your insurance on the day that I impression for your crown. Also, labs have a tough time speeding things up at the end of the year…because everyone waits until the end of the year!
Insurance companies DO care: they would love it if you’d wait. Because maybe if you wait long enough, you won’t be able to get the work done this year. Then they score by not paying out on their dental gift card that you paid for. That’s why predeterminations take several weeks…(don’t get me started!)
So next time that you’re having that inner dialogue about when you should have some dental work done…just do it! At the very least, you’ll have Murphy’s Law on your side and you and your dentist will have the very best chance to head problems off before they become painful and expensive!
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Have you ever had a new filling or crown placed that felt kind of foreign? It was smooth as silk, it wasn’t pointy and the bite felt just right. But yet, it was different. Your tongue acted like it would never get used to it, constantly running circles around the newness of it.
Do you remember what happened to it? Yup. You forgot about it. A day or two later, it didn’t feel new. How does that work? I mean, two days ago you were pretty sure that you were going to need to call the dentist. There had to be something wrong with this weird new filling. But now you’re not even sure what tooth it is. How bizarre is that?
It’s actually not bizarre at all! In fact, it means your nervous system is working just perfectly.
Neural adaptation or sensory adaptation is a change over time in the responsiveness of the sensory system to a constant stimulus. That’s a very fancy way of saying, “you just get used to it.” Our nervous system is constantly taking in all kinds of sensory data. What we hear, what we see, what we smell, taste and feel are all giving constant input to our brain. The thing is, not all of this information is all that important at any given time. So the brain has to be able to filter out the stuff that isn’t important while keeping track of the sensory information that is.
Once the brain and nervous system has figured out which information isn’t important at the moment, or salient, it can filter this information out. That way the brain can focus on more important sensory input.
"this is going to be cold!"
My favorite example of this adaptation has to do with swimming in the lake. Each 4th of July weekend for as long as I can remember my cousins and I spend as much time as we can in the lake. Even in early July, when the temperature is in the mid-80’s that lake always feels really cold. At first. If you creep into the lake slowly, just a couple steps at a time, it stays excruciatingly cold. But the longer you’re in, and the more of your body gets wet, the less cold the water feels. Pretty soon, we’re splashing around in the water like it was a bathtub. What happened? Did the water change temperature? Probably not. We just got used to the temperature.
There are probably great survival reasons for our brain to be wary of the shocking cold we feel when we make our way into the lake. We have to maintain our temperature between certain parameters and if our brain feels like this is threatened, it’s going to continue to sound the alarm. After you spend a little time in the water and your survival doesn’t seem threatened, the temperature stops being such a salient stimulus. Your brain begins to focus on other things, like the squishy bottom of the lake or your cousin attempting to dunk you.
So, back to that new crown or filling. It feels new and weird for a little while because it’s a constant and different stimulus to what your brain had been used to up to that point. The longer it stays there without causing a big problem, the more your nervous system discounts the stimuli coming from the touch receptors in your lip, cheek and tongue. Over time, the new filling begins to feel like the norm. Most of the time my patients have gotten very comfortable with their provisional (temporary) crowns and will have to go through the same process with their new crown.
So the next time you have some dental work done and your tongue keeps telling you that there’s something funny going on, just remember that it’s just like jumping into the lake. After a little while, you’ll get used to it!
Did you find this post interesting? Silly? Earth shaking? I’d love to hear about it! You can share any Mead Family Dental post with a “Like” on Facebook, a “+1″ on Google+ or you can even “Tweet” it with Twitter! All you need to do is hover over the heart shaped button next to the title of the post. Or you can leave a comment by clicking on the balloon shaped icon next to the title.
I recently saw a patient with a broken tooth. The tooth had a big silver filling in it and a piece of the tooth had fractured off. This is the most typical dental emergency visit that I see in my practice. Usually it’s a molar tooth. Usually there is a big filling in the tooth that had been in service for years and years. Often it doesn’t hurt, or it hurt to bite on the tooth before it broke, but after it broke the tooth actually feels better.
Unfortunately, teeth break. There’s a lot of reasons for that. Every time a dentist removes tooth structure to place a filling or remove decay, the tooth is weakened. Many (perhaps most?) people grind their teeth to some extent. Some people have stomach acid problems. Your teeth have to put up with a lot of abuse and some of them have been in your mouth since you were six years old! Have you ever had a car last that long? A house? Really, it’s no wonder that I see broken teeth so often.
So how do we fix a tooth like this? Generally, the two options to fix a broken tooth are a filling of some sort or a crown or onlay. A filling is a “direct” restoration, which means it is placed by the dentist directly into the patient’s mouth. A crown or onlay are made outside the mouth (by a lab or a CAD/CAM machine) then cemented or bonded in place. In many cases each of these solutions can work. There are pros and cons to each approach. I usually evaluate treatment options against three criteria. 1) How predictable is the fix, 2) how durable is the fix and 3) how expensive is the fix. Continue Reading…