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Dental Screening is it Necessary? Part I

May 18, 2015

Filed under: ARTICLES — Tags: , , , — Barry @ 11:02 AM




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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Don’t Ignore the Truth

March 20, 2013

Filed under: Art of the Examination,Philosophy — Tags: , , — Barry @ 1:04 PM



untitled-5-3 Predictable results depend on paying attention to a process and not ignoring any steps.  One missed step can follow through the entire case and leave the dentist and technician wondering what went wrong.

As a dentist and a lab owner I get to see some of the innocent omissions that can come back and haunt the dentist.

The other day a new technician brought me a set of study models sent in from another dentist.  She asked me if I thought they were mounted properly because the bite was open and it looked a little funny to her.

I told her to drop the pin and put the casts into maximum intercuspation.  She asked me why the dentist would take an open bite.  Hmmm, I wondered, “Do you know the difference between centric relation and centric occlusion? I asked.

It seemed like a good opportunity to explain what we know about occlusion and how we apply it in the lab.

I could tell tell that she was interested by the eager look in her eyes.  As I went through the explanation she began to understand the reasons for doing everything.  I was reminded of a book I read years ago, The Greatest Management Principle in the World, by Michael LeBoeuf.  In that book the author explains that managers need to go around the workplace and explain to employees “why” we do things rather than just telling them “what” to do.

Invariably, I have always felt that telling people why, always raises their commitment to the work and puts more meaning in the work.

I also believe that employees feel a greater amount of respect when the manager takes the time to explain things to them individually.

This same principle works for patients as well…I called it a “reason why” philosophy in my book, The Art of the Examination.

Of course, it takes time to do this but you will see it is time well spent.

After explaining the process to my new technician, I asked her for the “first point of contact.”

She looked confused.

I said, “there is no way to know if the models are mounted correctly unless we verify the mounting with some information like the first point of contact taken from the doctor’s examination process.

She said he never sent it.  I then directed her to my chart which has a summary of my entire exam process that starts with the mouth and ends with the presentation structure.  I showed her the first question on my checklist ( I am a big fan of Atul Gawande’s book, The Checklist Manifesto).  The checklist showed her the following question: “Do the models accurately represent what you saw in the mouth?”

Now her eyes really widened.  She really began to see the practical application of the knowledge of occlusion.

Now she said she had a job to do.

“What’s that?” I asked.

“I have to call the doctor and get that information.”

Now that’s great learning!