When my mother passed away some years ago she took one of the ugliest wisdom teeth you will ever see to the grave with her.  For years I looked at her x-rays and defied everything I learned in dental school.  I chose to leave it alone…and happily spared her some pretty gruesome surgery.  I wish I knew more about radical prostatectomies a few years ago when I was asked about that choice.  Things have changed in the world of urology since then.  And hopefully they’re changing in the entire world of medicine and dentistry.

From wisdom teeth to breast and prostate cancer, applying wise clinical judgement may be a patient’s best defense.

A recent article in USA Today asked the question about wisdom teeth: Should they stay or should they go?

We live in a time of what Dr. Atul Gawande calls, over-diagnosis….that goes way beyond the question of wisdom teeth.  I have included links below to discussions of Gawande’s recent article in New Yorker magazine, Overkill.

I highly recommend that you click on the link to Gawande’s New Yorker article…it is worth reading, and if you haven’t read his recent bestseller, Being Mortal…I recommend that as well.

What I found most interesting is that Gawande refers to the research of Dr. H. Gilbert Welch, an epidemiologist from Dartmouth University.  Coincidentally I recently read Gilbert’s new book Less Medicine More Health.  It was the impetus behind one of my recent blog posts about managing vs. fixing conditions.

Two things I took away from that book were his excellent metaphor or conceptual model of cancer he calls the  “barnyard pen of cancers.”
Basically Welch claims that all cancers do not kill, and many of us have small cancers “that never bother us during life – particularly cancers of the prostate, breast and thyroid.”  The goal, he says is not to let any of these cancers escape the barnyard pen to become more deadly.  There are three types of animals in the barnyard…turtles, rabbits and birds.  Most of the above mentioned cancers are turtles, and they’re not going anywhere.  You can read more about this model in Gawande’s article or in Welch’s book…fascinating stuff.

But in the meantime, we scan and probe…looking for rabbits and finding and treating turtles.  Forget the birds—-too late.

What I really found interesting in Welch’s book is how many times he referenced dentistry.

In the first instance he writes about the value of screening…asking whether it’s a good idea.  He uses oral cancer as his example.  He chose oral cancer because a health reporter contacted him about an article she was writing about the benefit of oral cancers screenings.  He admits that he doesn’t know much about oral cancer.  Just that about 8000 Americans die from it every year, compared to lung cancer which kills 160,000 people.  It’s number twenty on the list of cancer deaths.  What Welch said he did know something about was screening.

There seemed to be a discrepancy.  In a recent Consumer Reports article it was recommended that only people who were at risk should be screened for bladder, lung, skin and oral cancer…but the Oral Cancer Foundation and the American Dental Association recommends oral cancer screening on everyone.

So what’s the harm?  I guess, as a dentist who actually screens all of my patients, that’s a natural question.  But the answer, according to Welch, reveals much more about screening in general.

I might say, as a dentist, that it doesn’t cost anything, unless the dentists is using fancy screening applications, the number of new cases of people without known risk factors keeps growing (at least that’s what I am being told), and there is evidence that people being diagnosed with early cancer did much better in later stages.

But when I thought about these answers they didn’t jibe with my experience.  In all of my years of visually screening for oral cancer I have found only four cases —and they were all birds.  I couldn’t have missed them.  They were all smokers.  Only one is still living.

Then I thought about another harm.  For a few years I was using more sophisticated methods of screening…and I found a bunch of false positives.  Off to the surgeon for biopsy.  I actually set off a series of events that lead to unnecessary worry, not to mention the cost and the surgery.

I am not blaming myself…nor do I blame the dental community.  This is what we are intuitively lead to believe—that the anecdotes are true, that more treatment is better and better to be safe than sorry.  Welch takes the counter-intuitive view…and after my own medical history and my experiences…I agree.  I still look, but I don’t get carried away.

Welch went on to write about wisdom teeth—but this blog post is too long…to be continued.


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Most dentists are always on the lookout for ways to increase their productivity.  Today’s marketplace is overloaded with new tools to make the dentist more efficient.  An alternative to efficiency, and one I have been obsessed with since reading Covey’s 7 Habits twenty five years ago, is effectiveness.

Becoming more effective trumps efficiency everyday, and it doesn’t require a huge investment in technology.  Efficiency is the language of hardware, machines and computers, but effectiveness has its own language…the language of human interaction.

Years ago practice management people taught dentists to “fill their chairs” with warm bodies.  Ergonomics, the study of people’s efficiency in their work environments was all the rage.  I was there when four-handed dentistry was actually a fresh concept.

I started in dentistry when most of my colleagues were still standing.  Ergonomics in dentistry helped dentists become more productive while staying pain-free (their back pain, not dental pain).

Today, we have all kinds of gadgets and devices that promise to make our work easier, but I’m not sure if it will make us more productive.  Production is a function of effectiveness.

That is why I placed so much emphasis on the complete examination…because it is still, when done correctly, the most efficient way to create effectiveness in a dental practice.

Yes…the complete examination is and always has been the Ultimate Productivity Tool available to a dentist…and it’s so cost efficient.

For many dentists it sounds counter-intuitive to spend so much time doing a complete examination when they could be producing real dentistry.  I agree that the exam is not very productive, but it gives the dentist the capability to produce so much more dentistry.

How would you like to spend every morning doing implants, crowns and veneers?

Not only is that dentistry more effective for the dentist and the patient but it is meaningful as well, and when a dentist spends time doing meaningful work…well that’s just what happy dentists do.

So what is the rationale for doing the complete examination?

  • It allows the dentist to slow down and create a trusting relationship.
  • It allows the dentist to think…to take the time to make the most rational decisions about patient treatment and care.
  • It is sacred time, so that it can’t be interrupted with distractions, allowing for more focus.
  • The dentist preserves his or her mental energy and can preserve energy for when it’s most needed.
  • The exam helps the dentist organize and align the practice so everyone knows exactly what their role is at all times.

I could go on and on…I actually have in my book The Art of the Examination, because it is an art.  With practice this art becomes the Ultimate Productivity Tool.  I felt I needed to write this blog post to remind dentists of the importance of the comprehensive exam in this rapidly changing world of dentistry.  This will never change.



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