Aggressive Patient

Dental Revelations Blog-

The lift is broken and my dental surgery is on the 6th floor. The last patient is slightly obese 50+ year old lady who has a heart medication. It is the last appointment of the day and most of the practice staff has left the building.

She walks into the reception. She huffs and puffs when I call her in. The first wave of complains hits me. Apparently it is my fault the lift is broken. I manage to calm the situation and she sits down in the patient chair.

I am super-cautious with everything what I say but she – still out of breath – takes another round at me. Now she’s shouting. I try to follow the protocol of how to deal with an aggressive patient. No help. I ask if she’d rather cancel the appointment. She wouldn’t. Instead she demands me to start the treatment and not to speak to her.

But I must speak. This job cannot be done without informing of certain things.

I suggest again that we could reschedule the appointment. It’s the end of the world for the patient and she nearly screams at me. I sit silently, my whole body trembling (which I pray God she wouldn’t notice). The patient demands me to carry on with the treatment and I do so in a fear of… not sure what but I rather carry on than stop the treatment to find out.

I must use calming deep breaths every time the patient does not notice as otherwise it would be difficult to hold an instrument in my hand. But still I must support my mirror hand with the other hand to stop the handle clattering against the patient’s teeth.

Once we are finished with the treatment the patient has calmed down. She even apologies her behaviour. I smile and I’m friendly towards her but inside me I am totally worn out and in a need of comforting.

Aggressive Patients And the Protocol

When a patient is hostile towards you and criticises everything you do there is no way to stop your heart pounding. You may try to hide it and act as we are thought – be calm, remember to listen, listen, listen, address the patient’s feelings with sympathy

I’m sorry you feel this way…

I understand that you are upset…

and let the patient finish until you ask

Do you want to continue with the treatment or should we reschedule?

At the same time your heart is racing like mad and you think the patient can hear from your voice that you are far from being calm. If she doesn’t notice it from you voice she will notice your hands that shake frantically.

Sound familiar? Been there done that!

We Are Not Perfect And Definitely Not Superhumans

No matter how good people skills you have there will be a day when a patient does not like your chair-side manner. The patient might be verbally aggressive towards you or passive-aggressive when you sense that all is not well (arms crossed and hardly answering your questions). Or the patient might act normally during the visit and later on you find out that complaint was made against you.

Whaaat? Me? But I’m always liked by my patients!

I have learned long ago a very important thing that keeps me sane in my professions when it comes to the patients:

You cannot please everyone!

Embrace this sentence and remember it when you hit a difficult time with your patient. If you feel that you have done your best you can calm yourself down by repeating this simple sentence in your mind. And offer it to the newbie who has met her first aggressive patient.

The same was done to me by a kind and wise dentist after one aggressive patient.

Y o u  c a n n o t  p l e a s e  e v e r y o n e!

After Words

I have noticed that there is a pattern of the aggressive behaviour amongst the patients. The fear of dentist is one thing for sure. But the ones that have given the hardest time on my professional life have been female patients between the age 50 to 60. I cannot help but thinking that this unstable behaviour (from 0 mph to 70 mph and back again) could be due to an undiscovered menopause.

Now could it?

But for your safety do not under any circumstance suggest this to the patient. It might be the last thing you do.

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Should You Use a Mouthwash?

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Yes and no.

If you are a patient and you ask this question from two dentists there is a BIG chance that you will get two answers. The other shows you the green light and the other the red.

There is no consensus amongst the dental professionals about the recommendations. Even the professors in dentistry argue about the recommendations publicly. They give statements to the press for and against the mouthwashes after a new study about the risks of the mouthwashes is released. Some negate all the study’s conclusions.

So no wonder it leaves patients confused if us professionals are too.

Well Should You?

Generally no.

If you have a good oral hygiene – brushing twice a day and cleaning between the teeth most nights – and you use a fluoride toothpaste there’s no reason to use a mouthwash.

But there are exceptions – naturally!

If you suffer

  • from a gum disease you might be advised to use a mouthwash containing chlorhexidine (CHX) during and after a periodontal treatment. It is a very effective ingredient that kills bacteria. But remember to use it only as advised by a dental professional
  • from an extreme dryness of the mouth through an illness (e.g. Sjögren’s syndrome) you might be advised to use fluoride mouthwash regularly to prevent decay

Remember that in both of these cases you should choose the alcohol-free version.

Dangers of Using a Mouthwash

Oral cancer

If you use a mouthwash that has alcohol (ethanol, but I’m going to use the word alcohol instead) levels of 25% or higher and you have been using it since your teenage years the studies state that you have higher chances for getting an oral cancer.

One leading brand (the one that rhymes with word blistering) can have alcohol levels as high as 26% and this high level is thought to be toxic for gingival tissues when used in abusive amounts. But – and it is a big but – why do they add alcohol to the mouthwashes when it is a known fact that for alcohol to be toxic for bacteria it must be used at 40%? This means that there is no help from alcohol levels as low as 26% but it can still be harmful to the gingival tissues.

Discolorations

If you use a mouthwash containing CHX for a longer period of time it will stain your teeth. Stains can be removed but it will cost you of course.

In my professional life I have noticed that for some unknown reason the leading blistering-rhyming mouthwash stains the teeth with some patients eventhough it doesn’t contain the CHX. Actually the looks of the stains is different to those that build up from the CHX. After a thorough interview of the patient no other explanation was found to the stains than the mouthwash the patient had been using. The staining stopped once the patients stopped using the mouthwash.

Dry mouth and bad breath (halitosis)

Alcohol in mouthwashes can dry the mouth and the dry mouth is prone to halitosis. People often seek help from the mouthwash for the halitosis but it can actually make the matters worse.

Lichen planus

If you have been diagnosed with lichen planus you should not use any mouthwashes unless advised by a professional. But even in this case you should not use mouthwashes with alcohol.

WELL SHOULD I?

Wouldn’t it be the wisest thing to do if you DIDN’T use a mouthwash whilst us professionals argue about the health risks of the mouthwashes? It’s your health that is gravely at risk if the alcohol in mouthwashes is proven to be harmful.

I have seen patients who are going through the cancer treatments for oral cancer and I have seen the 50% of them who survived the cancer. I can tell you that it’s not a pretty sight. Not during the treatments or after surviving it.

Why would you play a Russian roulette over your health? I wouldn’t and therefore I am not using any mouthwashes.

If You Still Want to Use a Mouthwash

Always choose the alcohol-free fluoride mouthwash.

Remember

  • it can stain your teeth
  • it never replaces brushing or cleaning between the teeth
  • that in many countries the mouthwashes are considered as cosmetics by law. In some countries they are considered both cosmetics and drugs. But when considered as cosmetics they are not that highly regulated as drugs are. So what you could actually be rinsing in your mouth is a cocktail of chemicals that no-one knows (or cares) how they affect the health
  • that if you are also a heavy smoker it increases the risk of getting an oral cancer. If on top of that you are a high consumer of alcoholic drinks you are even at higher risk

Conclusion

I really don’t get it how we cannot decide if the mouthwashes containing alcohol should be recommended or not. It’s just ridiculous that even inside one dental practice opposite recommendations are given to the patients.

What all of us professionals agree is the fact that alcohol is an aldehyde and it is metabolised by the oral bacteria to acetaldehyde which is carcinogenic in humans. Carcinogens cause cancer! And yet we argue about the risks of using an alcohol containing mouthwash.

What are the reasons behind all this? Some have suggested that some of the dental professionals have financial commitments to the manufacturers of the mouthwashes. I must emphasise that this is a hearsay. But if you have read my previous post about the integrity amongst dental professional you understand that everything is possible.

If you are interested to read about groundbreaking study about the risks of using the alcohol containing mouthwashes (one that caused a mayhem amongst dental professionals) visit here.

Morals in Dentistry

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It’s time to get serious again. In this post I will get to the bottom problem of the dental industry. The lack of morals and the urge to maximise profit at the cost of the individuals is like a plaque that sticks around before the cure is found. For about half of the dentists I have met fall into that category and that’s a lot considering that we – the health care workers – should be the ones having the highest integrity of all.

What I will do next is give examples of the lack of morals amongst dental professionals. It will be just a (thin) slice of a (big) cake but you will get the idea no doubt. For clarification, all the examples are from real life and witnessed by yours truly.

NHS Dentists

For those who are not familiar with the NHS, it is the UK’s National Health Service. The NHS dentists work under a contract and receive payments for the treatments done.

Before the year 2006 (when the contract was replaced with a new one) the misuse of the system was widespread. The dentists were laughing at the system that was like a gold mine to them. They could easily make an outstanding pay by doing certain treatments that would not raise questions. It did anything but raise questions. The treatments made them look like they were concentrating on preventive care and looking out the patient’s best interest.

A revelation:

The truth is that they did not care about patients. Patient was merely a tool for money making. An example: The dentists made fissure sealants for every patient who did not have them and they made them from first premolar to the last molar. There was no evaluation if the fissure sealant was needed and it was an easy treatment to justify to the patient as it was preventive treatment.

“It prevents you getting a decay…”

Who would say no to that?

Fissure sealant was very quick treatment to do as it could be done in batches (all the premolars and molars from the left side in one go and next the right side) guaranteeing a very productive day moneywise for the dentist. There are probably millions of people in the UK whose teeth are coated with fissure sealants.

Eventough the NHS contract was renewed in 2006, the dentists found new ways of misusing the system.

Root Canal Treatment on Wisdom Tooth… What The?

The most immoral dentists have found a way to make the most out of every tooth – moneywise. Normally the decision to remove a fully erupted wisdom tooth is made lightly if there are any problems like decaying, periodontal problem, malocclusion with the tooth. But more than once I have seen wisdom teeth that have been heavily filled, root canal treated and even have had crowns on them (on top of the root canal treatment).

There is no other explanation to this than a dentist who is practicing dentistry only to gain wealth.

Performing Treatments Without Having the Skills

Some dentists suggest treatments they have no skills to perform and charge the patient as if they were specialists. An example: A dentist recommends periodontal treatment to the patient. The course of treatment consists four 30 minute visits to remove calculus one quadrant per visit and the cost is the same as if a periodontist would perform the treatment. Once the course of treatment is done by this wannabe specialist, the patient goes to see a hygienist for oral hygiene instructions. The hygienist soon realises that there is still lots of subgingival calculus left and therefore the gum disease is still active.

The hygienist does her best to remove the calculus (which she has skills for) and the patient is left under an illusion that nothing is wrong.

It is called collegiality what just happened. Dental professionals covering for each other’s mistakes and malpractice.

Root Canal File in the Root Canal

In our business the equipment can malfunction and instruments can break in use. In these cases it is good practice to tell the patient what happened. For example a curette’s tip can break inside the pocket of the tooth. It can be found from there but the patient needs to know what happened. Some dentist cover these kinds of incidents or mistakes they have made by simply not informing the patient. Now THAT if anything is malpractice.

An example. A root canal file broke inside the patient’s tooth whilst the dentist was performing a root canal treatment. The nurse did not notice the incident until a control x-ray was taken and the file was clearly visible. The dentist did not inform the patient about the broken file or attempt to remove the file.

Conclusion

The dental industry draws in immoral individuals because it has been allowed to happen. It wasn’t until the 21st century when the dental schools started to interview the applicants for the undergraduate programmes of dentistry. Before this the suitability of the applicant’s personality was not measured by any tests. This means there are dentists in the field that should not be dentists.

In my opinion all the dentists who have not gone through the MMI should be asked to have one. If they fail, they should be struck off their profession.

But no test is a fool proof way of finding the bad seeds. The most rotten souls can often talk their way through any obstacles. And the reason why these individuals are drawn to the dentist’s profession is the well known fact that they make rather nice pay (here’s one article about it).

 

 

 

My take on the US elections 2016

Henna blog

Are the candidates just spinning a web of lies before the elections?

I’ve worked in the heart of two capitals on my professional life. Every now and then there were well-known people who came to have dental treatment done at our practice. Millionaires, pop-stars, politicians. Some of them I saw regularly and got a pretty good idea of the person behind the public figure.

There has been lots of discussion about the presidential elections in the US. Which candidate is the best one to be the number one leader in the world (was tempted to use the Master of the Universe comparison again, but managed to hold my tongue)? Who definitely should not be elected, let alone to be a candidate? Clinton, Sanders, Cruz, Trump… One of them will be elected.

But how do the US citizens know if the candidate is able to look after the country and it’s people? Do they keep the promises they make? The time after the elections often reveal that the promises were just promises and they were made only to win votes. Highly annoying in my opinion.

But guess what? I have an answer for that problem.

Let’s make the dental records of the candidates available for everyone to see. I mean every detail from the charts to the dentist’s/hygienist’s reports of the visits.

Why?

What we record on every visit is the state of the mouth. The amount of plaque, calculus and bleeding. We record the interview of the oral hygiene habits and the recommendations given. Often we write to the patient record the state of the oral hygiene.

OH good

OH poor

OH needs improving

In my opinion it tells a lot about any person if a visit after visit the patient’s records state that patient’s oral hygiene is poor and that the patient has been given recommendations and information but there has not been improvement in oral hygiene.

If the person is not able to look after her/himself (for any reason), how is she/he able to look after the whole nation? This comes to my mind every time I see a familiar face of a politician in the papers. A politician who I have unsuccessfully tried to put in the right path in dental health for many years.

P.s. That was the closest this blog will get to the politics.

 

Have you dropped your dentures in the toilet?

Henna blog

You know the feeling when you have just finished writing an important project like a novel, report or a BLOG POST and the device throws in a blue screen of death. Well my equivalent to blue screen today was to drop my mobile phone into the toilet. In it went and so did my nearly ready next blog post stored in the phone’s memory.

At the moment – 3 hours from the moment of doom – the phone is still dead and I have arrived to a holiday destination in a remote area where replacement for my device is difficult to get (thank god for spouse’s pc that makes this post update possible). So I am sipping away well deserved wine despite the fact that the bacteria in my mouth will metabolise it to nasty carcinogen and cause me an early death.

Anyway about toilet seats. I live in a country where the toilet is flushed with a drinking water and if you have read my previous post you know that the quality of the drinking water needs to be of certain level. So dropping your dentures or mobile phone into the toilet is not THAT disastrous thing really (if only the mobile phone would survive the wet conditions). Plus I have a memory of my teacher in dental school – the same scary periodontist as on one of my previous post. She was teaching us about different bacteria in mouth and said with great wonder that

“they have found even bacteria that is normally found from people’s rectum”

To us young students it was no reason for wonder (like it was to this near-retirement-age teacher) that bacteria from rectum was found from people’s mouth. People mingle with all sorts of things nowadays.

So there is more reason not to worry if you dentures accidentally fall into the toilet. If they survived the fall without cracking, just pick them up, wash your hands and clean the denture with washing up liquid like Fairy (not toothpaste) and they are as good as new.

Now I must apologise my rampant writing, just poured down my third glass of wine. Also, I hope you understand that my blog post might be quiet for a week or so.

Chin-chin!

 

Do You Recognise the Gum Disease?

Dental Revelations Blog

Be careful next time you open your mouth in the bus. I might be sitting next to you.

Many people have gum disease without knowing it and it often comes as surprise when they are told about it at the dentist. Even bigger surprise would be if they knew how many dentists do not recognise the gum disease or know what a comprehensive treatment is for it.

I have seen countless amounts of patients in my career whose gum disease has gone undetected. It’s astounding! I’ve had patients who have visited the hygienist and the dentist every six months but still there is massive amounts of subgingival calculus around every teeth. And it is deep and tough to remove.

Just guess the surprise of the patient when instead of having a 15 minute check-up and 30 minute hygienist visit like normally, she will now need three 60 minute visits to remove the calculus thoroughly and a 4th visit in three months time. To be honest, this upsets me often. It’s not that difficult to diagnose the gum disease. It’s not rocket science for crying out loud!

I have spent way too many hours explaining why my colleagues have not noticed the gum disease. And my efforts for not sounding too annoyed at my fellow professionals sometimes fail miserably. Luckily, most of the patients take it relatively easy and do not demand compensation from the previous dentist. Instead they are normally very grateful that somebody caught the condition.

There will be information for professionals next but the patients benefit of reading it too. If you are a patient you can move on to the end of this post if you want to skip the professional part.

So Why Don’t You Recognise the Gum Disease?

There are five probable reasons (add more to the comment box if you wish).

Lack of time. In 15 minute check-up the dentist should go through the medical history of the patient, check the teeth (loose fillings, decay, fractures etc.), the soft tissues (inside the cheeks, tongue, lips, roof and floor of the mouth and the throat) and the gums. Plus there might be need for the x-rays. Fifteen minutes simply is not enough for this considering that the disinfection business before the next patient should be done as well. Even 30 minute appointment might not be enough.

The X-factor. By X I mean money and it is related to the time issue. Dental practices have 15 minute check-ups because instead of having two patients in an hour that pay X amount for the visit they can have four. Four times X is better than two times X. At least for the practice.

Lack of basic skills. We have an instrument which finds any gum disease from any patients mouth when used correctly. Or when used. It is not by default that this instrument, perio probe finds it’s way to the check-up tray. I have seen dentist doing the check-up by using the sharp explorer only. And even if the perio probe is used, it is used incorrectly and the gum disease goes undetected. Even a gum specialist (periodontist) has failed at this and I will tell you more about it later in this post.

Lack of experience. When you are an experienced dental professional (either a dentist with a great interest in the gum disease or a hygienist) you can recognise gum disease from a distance. I will give you an example.

You sit in a bus on your way home and somebody sits next to you. He yawns and 3 seconds later your nose detects an odour you rather not smell on your free time. Periodontitis (aka gum disease)! Thank goodness the bus has a good ventilation and the odour is soon gone and you hope he keeps his mouth closed for the rest of the journey. Then the guy’s phone rings and it’s his mother…

I can often recognise the gum disease by just looking at the patients mouth. The gums have a certain look on the sites of the pockets. Even if there is only one deep pocket in a healthy mouth, you can spot it out by the looks of the gum. It is difficult to explain how they look so I won’t even try. Anyone experienced know what I mean. The point is that the more you examine the gums and find the sites where the deep pockets, subgingival calculus and gingivitis (bleeding of the gums) are, the more you learn to tell what looks normal and what doesn’t.

But do not worry if you are a newbie. Just learn to use the perio probe correctly and you will be fine!

Forgetting how smoking hides the gum disease. Heavy smoking can make the gum disease invisible to the eye and often the dentists and hygienists are misled by the looks of the heavy smoker’s gums especially if the oral hygiene is good at that very moment. Heavy smoker’s gums look healthy and pale. There’s no sign of the red and swollen gums. No sign of the bleeding after probing. And yet the disease is there.

Even if the gum disease is not visible to the eye with the smoker, it is still there for the perio probe to find but with the smokers you really need to master the technique. Often the smokers gum line is very tight and it is difficult to find access to the pocket (once you do, don’t let it out until you have probed the whole side of the tooth).

Use of the Periodontal Probe

When I was at dental school learning the arts of the dentistry, one of our teachers (a periodontist) said one day annoyingly “They didn’t even know how to use a perio probe!” At that moment we were practicing scaling in the school’s clinic but this outburst was not addressed to us students (thank god as the teacher was scary as hell) but to a group of dental hygienists who had come to revise perio skills at the dental school. This one sentence has stayed in my memory for some reason and only until now I understand what she meant and why she was so annoyed.

Not only the hygienists fail in the technique of the perio probe but also the dentists and even the periodontists. I will tell you about one periodontist who saw one of my patient.

I had referred the patient to the specialist with all the relevant documentation (x-rays, perio chart etc). When I saw the patient 6 months later a course of treatment was finished with the periodontist. I examined the patient’s gums and found a 10 mm pocket on one of the molars. The depth was the same as before referring. The patient told me she was going to have a control visit soon with the periodontist so I wrote letter about the persistent pocket.

Three months later I saw the patient again and nothing was done to it. A periodontist had said to the patient that there is no pocket.

No pocket! I’m going to show you the pocket!

I took my DSLR and put a perio probe into the pocket and fired away. The patient got the photo on cd and gave it to the periodontist on the next visit. I’m afraid my story ends there. I never saw this patient again as she got retired and was not able to see me as we were too expensive.

Ten millimetres deep pocket and it went unnoticed by the specialist even when the location was pointed out. What chances do the rest of us less-educated ones have if the one wearing the black belt in our industry is not able to do it?

Note to all dental professionals who examine patients gums: Please check your perio probe technique. There are plenty of information about the use of the perio probe on the internet plus hands on courses at the dental schools. And those who are not using a perio probe, shame on and start now!

What Is the Gum Disease?

I won’t go much into details about the gum disease but I will tell you the warning signs when you should visit your dentist:

  • your gums bleed when brushing/flossing/eating or they bleed spontaneously
  • your gums hurt when brushing/flossing/eating
  • your teeth have become longer over the years or they have tilted/rotated/moved
  • your teeth feel loose
  • you have wider gaps between the teeth than before
  • somebody has told you often that your breath smells. Gum disease doesn’t always produce bad breath especially in the early stages. It is the advanced periodontitis when the smell can be obvious to everyone else except to the bearer. But how many of you tell the other person that their breath stinks? Not many, unless it is your spouse in concern

The gum disease is always caused by the bacteria in your mouth. When the bacteria is removed effectively and regularly the chances for you getting a gum disease are minimal. But even if you are looking after the teeth well (brushing thoroughly twice a day and cleaning between the teeth once a day with a product that was recommended by the hygienist) go to see your dentist if:

  • you are a heavy smoker (here‘s why)
  • you have a diabetes
  • you are pregnant

If the gum disease is left untreated it will result in loss of tooth. It is also associated with certain illnesses so your general health is to be concerned as well.

If you want to find out more please visit American Academy of Periodontology’s site which provides lots of useful information for the patients.

How Is It Treated and Can I Do It Myself?

The gum disease is treated by simply removing the bacteria (both soft bacteria, plaque and hardened bacteria, calculus) and teaching the patient the correct techniques for removing the soft bacteria regularly by themselves.

Anyone can start better oral hygiene routine at home without seeing a dentist. Getting rid of the daily build up of bacteria effectively may cure the gum disease. This means brushing twice a day with electric toothbrush and cleaning between the teeth preferably with something else than a floss (floss is better than nothing of course). You could try Gum Soft Picks at first. Aim to the size that feels slightly tight between the teeth.

But remember, you are not able to remove the hardened plaque (calculus). Also if the calculus has build up below the gum, you will need to see dentist (for an assessment) and hygienist (for scaling) to stop the gum disease progressing.

A revelation:

There is no easy way out of the gum disease. It will most probably hurt like hell and the gum will bleed (in some cases heavily) in the beginning when you brush and clean between the teeth. If you at this point stop e.g. using an interdental brush that was recommended to you or you use it every second night because you think you are harming the gums, the gums will keep on bleeding and hurting. You will never get out of the vicious cycle. So persevere, be brave and have a faith on us professionals.

Sometimes if the gum disease has advanced to severe stage, you might need surgery on your gums (performed by the periodontist).

 

 

Anti-Patients

Dental Revelations Blog-24982

I have a confession to make. I am not perfect as a dental professional even though my posts may give the expression that I do everything as we are taught at the dental school. I do my best but I have weaknesses as well.

Another confession. I sometimes feel quite overwhelmed by some patients’ way of arguing about the well researched facts on dental health. Banging your head against the wall is not fun in the long run and in our business it tends to make us cynical and worn out mentally.

Of course there are good days and bad days. On bad days I have thought about changing my profession to the one where I could sit between piles of paper and no-one to talk to (anyone care to hire me?). On bad days I have given up trying to convince the patient about cleaning between the teeth when I have faced a non-cooperative patient the fifth time that day.

Fine, carry on practicing your beliefs…

Sooner or later you will learn I was right…

It’s your teeth not mine…

This does not happen often, but I wanted to bring out the great mental load we have on our profession. We need to have sort of a mental radar on ALL the time so that we can find the right approach to each patient. As each patient is different. But there will be a patient that slips beneath our radar. I have come to conclusion that with these patients there is no right approach. I call these patients Anti-Patients.

There are at least 5 types of Anti-Patients that I have listed below. If a new one comes to your mind, please share it in the comment box.

Anti-Fluoride

When I interview patients on their first visit, one of my questions is:

Which toothpaste do you use?

The most common reply is:

Dunno… Anything they sell in the supermarket.

But if the patient is a health-conscious one, they know exactly which toothpaste they use. And it won’t be just anything from the supermarket’s shelf. They also know that often their beliefs in health can be found controversial amongst the health professionals.

So after they have told that they use the aloe vera toothpaste/herbal toothpaste or any other non-fluoride toothpaste, they will carry on explaining the reasons behind it with fists raised into boxer’s pose (not really, but you get the gist?).

The fluoride is toxic..

There is fluoride in the drinking water anyway…

The fluoride is linked to health problems like cancer…

I only listen, let the patient finish and then carry on to the next question on the interview. I leave the toothpaste issue until I have build up a little bit more trust and until I have examined the patient’s mouth.

I know what I am going to find especially when the patient has used non-fluoride toothpaste for a long time. In my experience about 1 in 1000 patients has oral hygiene habits that good that my interference is not needed. One in thousand! And the likelihood that this one patient is the one who uses the non-fluoride toothpaste is close to zero. This means that poor oral hygiene together with non-fluoride toothpaste results in decay. And that is what I am going to find from the anti-fluoride patient’s teeth.

A faint white line on the enamel of the tooth close to the gum line that is the first stage of the decay. They are still reversible lesions of decay but they will often get discolouration that ruin the aesthetics of the smile. Sometimes the decay is already beyond stopping and requires a filling.

As some anti-fluoride patients take the advice on board, many don’t. And the most disheartening are the ones who practice their anti-fluoride beliefs on their children as well.

Want to know more impartial information on fluoride? Click here.

Anti-Amalgam

Amalgam has been used for about 150 years on people’s teeth. Although we have passed the peak of the amalgam phobia long time ago, there are patients who still believe the amalgam is a health risk. They either do not want to have a new filling made of the amalgam or they want to have the existing ones to be removed and replaced with white ones.

Now, there are dentists who have dollar/pound/euro (or whatever your currency) signs in their eyes whenever this kind of a patient walks in. They do not discuss about the reasons behind the patient’s wish or what the operation of changing the amalgam into white fillings mean. Of course they don’t. They do not want the patient to change their mind.

When a patient expresses this kind of a wish to me, they get this info every time:

  • Composite filling is not an option for an amalgam. Instead the ceramic or gold fillings are and those are many times more expensive than amalgam
  • Amalgam can last a lifetime, whereas average lifespan of a composite filling is somewhere way under 10 years and ceramic’s just slightly higher
  • If there is no problems with the amalgam filling, there is no reason to replace it
  • Replacing many amalgam fillings with white fillings will affect the bite
  • There are no health risks with amalgam as a filling
  • If choosing to have all the amalgam replaced with white fillings anyways, find a dentist who does laboratory-made ceramic/gold fillings and uses proper protection when removing the amalgam fillings as it is the most hazardous part of the life of an amalgam filling

I am always happy when I learn on the next visit that the patient has changed his mind about having amalgam replaced. And for some reason the patient is relieved as well.

It makes me sad when beautiful amalgam fillings have been replaced with composite fillings. It just isn’t right.

Note for professionals: Do polish the amalgam fillings regularly as the darkened amalgam fillings work as retention for bacteria. This is important especially with patients who have advanced periodontal disease.

Anti-X-Ray

X-rays are the vital part of making a diagnosis for the dentists and certain conditions will go undetected without them.

Refusing to have an x-ray taken is just pure madness. It is almost the same as if you would take your car to the car mechanic and tell him that

There is something wrong with the car but do not look under the hood.

In the worst case scenario, your life might be at risk. In the matter of the car and refusing the x-rays.

Anyone concerned about radiation with dental x-rays should read this and simply trust the dental professional’s judgement on whether or not you need to have x-rays taken.

Anti-Safety Glasses

Why on earth would you decline using the safety glasses that are meant for the protection of your eyes? Beats me.

We drill at high speed just a short distance of your eyes and anything can fly out of the patients mouth – a piece of an enamel, calculus (tartar), a broken bur and all sorts of nasty bacteria and viruses. We use chemicals that are acidic when making a filling. None of these you want in your eyes, believe me.

“We should not treat a patient who refuses to use the safety glasses”, I was told on one of the health and safety courses. In ideal world yes. But when you work at a private practice it is totally different story. What do you think that would happen if I send a patient home for not using the safety glasses. No income for the practice and who is the blame? Me.

So we let the patient to refuse the use of the safety glasses and tell them to keep their eyes closed. But they never do, do they?

Anti-Everything-You-Say-or-Do

I know the fear of the dental visit can bring out the worst in people. But it is always frightening when a patient comes across as aggressive from the moment you call the patient in. They walk to the surgery, throw their belongings to the side table and almost jump to the dental chair with arms crossed. They

  • dismiss everything you say
  • do not take the safety glasses
  • are suspicious of everything you do and want to see every instrument you have
  • tell you that they do not want to have a lecture
  • ask when you graduated
  • tell you how another dentist/hygienist did things differently compared to you

Thank goodness these kinds of patients are rare. But when I am faced with this kind of a hostile situation, I speak only when it is absolutely necessary and just do my job. I am glad when the patient is gone and hope we never meet again. But there is an exception. You see sometimes a miracle happens somewhere between the polishing and goodbyes.

The patient that just moments ago was a manifestation of the devil is suddenly the opposite and full of questions about oral hygiene. “Now he wants advice!” is my thought when I have couple of minutes time left before the next patient. But I do not have a heart to ask the patient to leave when I realise that all the hostility was due to the fear of the dental visit. The amazing fear!


Want to know one more Anti-patient type? Click here for my post Yet Another Anti-Patient.

Where it all started

Dental Revelations Blog-2382

Do you know your dentist behind the mask?

There was whispering behind the reception desk when I arrived to work.
“Morning!” I said cheerfully and carried on downstairs to get changed to my uniform.

I was a dental student working as a trainee and was very happy that I was earning little extra on top of my student allowance. There wasn’t many dental practices who took in trainees on those days to work as nurses until they graduated.

I put the uniform on and went upstairs to the reception before setting up my surgery. There were two nurses and a receptionist still whispering as the reception was filling up with that morning’s first patients. I was a newbie but understood that something was going on. Something that made the nurses very annoyed. I heard a word Harry.

One word and I knew what was going on. Eventhough I had been working as a trainee only for a month, I knew almost all the secrets the practice had. Harry was a dentist and a partner of the practice which meant he had lots of freedom to decide how things were run. He was the one who paid our wages. Or to be precise, he made the money that paid our wages but it was the other partner of the practice, Sally who run the payroll. She had no dental education and dealt with all the finances of the practice.

Harry and Sally had been lovers on and off many years and had had this dental practice in the heart of the city for a long time. It was a very popular practice amongst celebrities who had extensive cosmetic treatment done by Harry. Veneers, crowns, implants… yes, implants as well eventhough he wasn’t an oral surgeon. He was a regular dentist who never attended any annual dental show case to revise. Worrying combination.

Now back to that one morning when Harry had once again done something to stir up feelings at the practice.

Harry had arrived to work drunk. Wasted. Pissed. Drunk as a skunk. And it wasn’t the first time. One would think that a dentist cannot work when drunk as they use various instruments that can cause serious damage to the patient, nurse and the dentist himself if used incorrectly. The drill for example, that is used for drilling through the enamel of your tooth – the high-pitched one – rotates up to 400 000 rpm. Imagine it in the hands of a drunkard. Scary as hell in my opinion.

Did Sally or Harry’s colleagues stop him from treating patients? No they didn’t. Neither did I but my excuse is that I was a newbie and didn’t have any say on anything really.

On this particular morning Harry was guided by his trusted nurse Tina from downstairs office which he shared with Sally to upstairs where the surgeries were. Half way up the stairs Tina realised that on her own she’s not able to prevent him from falling so she called help and another nurse came to her aid. Together they managed to steer Harry safely upstairs.

“Not that way!” I heard Tina whisper to Harry who was entering a wrong surgery. Tina pushed Harry from his shoulder to the direction of his surgery where the first patient was already in the dental chair with safety classes and a bib on. Tina sat Harry down to his chair and put a face mask on.

This is as much as I could see what was happening. The patient was treated and she left without complaints. So did the next one. No-one ever complained that the dentist was drunk. Didn’t they notice? They must have as the smell was obvious.

Why didn’t Tina say anything? She had worked with Harry for ages and had seen everything that is going on. How did she put up with this kind of behaviour and malpractice? I got an answer to this question couple of years later (already after I had left the practice) when I found out that Tina was Harry’s mistress. Love is blind, it sure is in many ways.

One day Tina was off sick and I was told to replace her as Harry’s nurse. I soon realised that the nurse was expected to do much more than what nurses normally do. And that was probably how Harry could carry on as he did. When Harry wasn’t able to do the treatment, Tina did it. Thankfully Harry realised that I wouldn’t be able to replace Tina fully. I wouldn’t use turbine (the high speed drill). So he was only hungover on the day when I was working with him. Phew!

What I saw that day, I never forget.

Patient one.

A 70 year-old man who had had two implants done to replace lower front teeth. The plan was to have an implant supported bridge done once the implants were fully integrated to the bone. He came in to complain odd feeling and appearance of the area where the implants were done.

The patient had a very low alveolar bone and the mucogingival junction was almost on top of the alveolar bone. The alveolar mucosa had probably pulled the area where the surgery was performed and opened up the incision. As a result the alveolar bone was exposed.

“Should it be like this?” the patient asked.
“Well it shouldn’t!” I thought.
Harry examined the area quickly and slurred something vague. Then he sent the patient home until the next scheduled appointment. My eyes were as wide as saucers but of course Harry didn’t see them as he was out of the surgery already before the patient was.

Patient two.

A 50 something year old lady who had started a restorative treatment for her lower teeth. The plan was to restore the bite by two rather long bridge. The bridges were going to be cemented today.

Harry fitted the bridges. He had difficulties in getting them in place and he had to use a drill to file away some of the metal of the bridge. Eventually the bridges went in and the patient was asked to bite the teeth together only to notice she wasn’t able to. Only the very back teeth were in contact leaving the mouth quite open. Harry took the high speed drill and started to file away the ceramic.

He drilled off a large area of ceramic and part of the metal structure underneath. I wanted to close my eyes as he was destroying the beautifully shaped cusps of the bridge but then the mouth of the patient would have flooded. So I carried on watching this mad man’s way of cutting corners.

Once Harry was done, he cemented the bridges into their places.

“The bite does not feel right…” the patient said.
“It will feel odd at first. It needs some getting used to.” Harry replied and left the surgery.

The patient left the practice with horrid looking bridges and bite that was not anywhere close being balanced.

I was in shock after that day. I knew this wasn’t going to be my future work place. Not a chance. And it wasn’t.

 

If you are interested to read more on the subject in another blog, visit here.

Alcohol – The Feared Subject

Dental Revelations Blog-1044

About 60 year-old man came to see me one morning and complained that every once in a while a layer of skin comes off inside his mouth and no-one has been able to tell why. He was concerned and felt that it was happening at that very moment as well.

I took a look at the soft tissues before the treatment and asked if he had used a mouthwash the same morning or the night before. Negative. I asked if he had drank wine last night. The patient’s face went serious and he said he had been drinking whiskey last night. I went on telling without any judgement how alcohol effects the mouth and body – the risks in mouth and the age related risks. He looked like he had eureka moment and was very happy but also shaken as he realised that his alcohol use could be damaging his health in more ways than just one.

Now, this blog post is full of information for dental professionals but there are links that are useful for the patients as well. I will give advice to the patients at the end of this post so move on over there if you want to skip the professional part.

Fear of Asking

Us professionals seem to find it hard to discuss about patient’s alcohol consumption. For some reason we think that alcohol consumption is too personal question to ask. Sometimes also the patients think the same which makes it even more difficult question to ask. But we ask about illnesses, smoking, diet and oral hygiene habits. Why not about alcohol?

Everyone knows that smoking can cause oral cancer. But not so many know that alcohol does the same. And even fewer knows that alcohol and cigarettes combined raise the risk of developing oral cancer many times higher. So dental professionals are on the frontline of preventing oral cancer. This means that asking about alcohol consumption should be a routine thing to do and I’m going to help you with that.

  1. When interviewing the patient about his medical history, oral hygiene routines and smoking, continue without hesitation How about alcohol? Do you use alcohol? Keep the same tone of voice as if you were asking did you watch the footie last night?

This is how the conversation continues:

Patient: Yes, sometimes.
You: How often would you say you drink per week?
P: When we go out after work.
Y: How often did you go out last week?
P: Last week we went out almost every night.
Y: What do you normally drink?
P: Beer.
Y: How many do you drink on your regular night out?
P: Normally 3 or 4 pints and on weekends it can be a lot more…

When you engage patient into discussing about alcohol consumption you are kind of evaluating the patient’s attitude towards the subject. Is he co-operative or defensive? If the latter, you need to advance with very small steps. A piece of information here, a piece there. Whenever the patient is ready to take in information about alcohol.

If the patient is co-operative (you would be surprised how many are!), you can move on to sum up the alcohol units the patient consumed the last week and then give information about how it affects his health. Before you can do this you need to know the facts.

2. Learn the numbers and facts behind the risks of excessive alcohol consumption

The recommended low risk (of developing an alcohol related illnesses) daily units are:

healthy women 0-1 units
healthy men 0-2 units
65+ year-olds no more than 0-2 units (no more than 7 per week)

Learn these by heart or print them out (please note, that the recommendations can vary in different countries).

The oral cancer’s death rate is nearly 50%.

Alcohol is an aldehyde and it is metabolised by oral bacteria to acetaldehyde which is carcinogenic in humans.

This is very short but effective list. With this little information you can have a significant impact on patient’s alcohol consumption.

3. Be a therapist if needed

More than once I have been in a situation with a patient when the patient opens up about his life when we discuss about alcohol. There have been patients who have thought by themselves that they are drinking too much. Some tell the reasons behind them. All they need at this point is that someone listens.

But if you feel like the patient needs more advice and guidance, remember to ask
Do you mind me giving you an advice?

People generally respect you more if you don’t offer advice without asking. Especially when it is about alcohol. Have phone numbers at hand for local AA and offer them if needed.

4. If you didn’t ask about alcohol consumption

Do ask about alcohol every time when

  • there is no improvement on oral hygiene routine despite a great effort, especially if there is lot of plaque every time
  • the soft tissues are bright red and the patient is not using mouthwashes (and even if he is, mention also that alcohol can irritate the soft tissues no matter how it enters the mouth)
  • the mouth is very dry and no other reason is found for it

Reminder to All Dental Professionals

Do check the soft tissues and tongue every time you see the patient. It doesn’t take long and you might be saving somebody’s life. No matter if you are a nurse, hygienist or dentist. All of us can tell if something is normal or not and it doesn’t matter who points out the abnormality in the first place.

Have a dental camera or DSLR with macro lens at hand. Learn to use them so that when you see something suspicious, you are able to take a photo of it and compare it the next time.

This is an area in our profession that is too often neglected.

Information for the Patients

You are in good hands when you are interviewed thoroughly on your very first visit and  and every time when you have your check-up done. If you only needed to fill in a medical history form and no-one asks further questions, it’s not a very good sign. The professionals treating you are not looking after you very well.

Please do take our questions as they are. They are questions for your best interest and health and for good quality of treatment. We need to repeat these questions over and over again every time you come in for your regular check-up.

We will ask about subjects (like alcohol consumption) you would rather not discuss with anyone but please do not hide anything or lie. Most often we can see from the patient’s mouth if we were not told the truth about certain subjects like:

smoking
alcohol consumption
how often you clean between the teeth
do you brush your teeth regularly
certain illnesses

So be honest and don’t be afraid of a judgement. It is not our job to do.


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Repost with Forewords: Alcohol – The Feared Subject
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It’s ok to swallow, it’s only water… Or is it?

Sandbox-4950

You feel the water lever rising in your mouth while you are having a treatment done at the dentist. Your natural instinct raises an alarm in you mind.

I’m going to drown…

I’m choking…

Your eyes open wide and you raise your both hands to make a gesture that you want to get up to empty your mouth. The nurse quickly takes the suction to remove the water but there’s always some left, isn’t there? Your hands are still reaching the spittoon next to the dental chair but the nurse lays a hand on your shoulder and says gently

It’s ok to swallow, it’s only water.

Well is it?

Dental Unit (= the Chair) Waterlines Causing Infections?

The water in dental unit waterlines should match the same standards as safe drinking water. In short this means that the bacterial count (colony forming units, CFU) in the water should not exceed certain safe level (if interested to find out more in depth, please visit here). The standards vary in different countries. The countries I have worked the CFU/ml regulations vary from 100-500. Now here comes the nauseating fact:

In practice the CFU/ml levels can be as high as hundreds of thousands of all sorts of nasty bacteria, including the ones of human origin. Needless to say that it is enough to cause problems.

The problem with the dental units is that many of them are old and do not have the latest technology for waterline cleaning. Renewing the dental units is slow as they are expensive and practices want to use the existing ones as long as possible.

Dental units without waterline cleaning system have a slow flow in the waterlines, the water is warm and the water stands still during off-surgery hours (nights and weekends). Sounds like a very bad combination, eh? The old dental units do not have preventive valves in the waterlines to stop suck back of the patient’s saliva into the lines.

So as a result the waterlines in the dental units are lined with biofilm (a mass or layer of live micro-organisms attached to a surface) that should be removed regularly.

Who Is at Risk?

The healthy patients should not worry much. But to be honest, I do not like to swallow the water myself. It’s gross.

The patients whose immune system is impaired are most at risk. The elderly, the young children, medically compromised people and everyone with immunodeficiency. In worst case scenario the visit at the dentist can be lethal.

Of course us professionals are at risk as well. There are lots of aerosols in the air during the use of the dental unit. A bacterium to raise the biggest concern is the Legionella that causes Legionnaires’ disease. So do take care of the unit waterlines.

Advise for Professional to Improve the Water Quality

Use water source that meets the standards for drinking water.

Run the water from the unit waterlines (handpieces, ultrasonic scalers, air/water syringes):

10 minutes after the weekend
3 minutes in the morning
30 seconds after every patient

Use an efficient waterline treatment product recommended by the unit manufacturer. Use it regularly. Running the water as I advised will get rid of the free flowing bacteria but not the biofilm, it needs an effective disinfectant. The most effective product for getting rid of the biofilm are the ones containing:

hydrogen peroxide
hypochlorite
superoxidized water

Invest in new dental unit (do not go to the cheapest option – you only go from bad to worse) with the latest technology. It’s only humane thing to do.

Conclusion and Cause for Worry

In my experience the dental unit waterlines are not looked after as they should to maintain the good quality of the water.

I have seen that instead of cleaning the waterlines the dental professionals have stopped using the water e.g. when using the slow handpiece (the drill that feels like a street drill). Now I must mention that this happened only in the other country I worked at. I never found out why they actually do this (please enlighten me on comment box below!) but perhaps it was because of the water quality problem? When I used a slow handpiece there, I was naturally worried about overheating of the tooth and tried to get water flowing but it was made impossible.

I have seen a dentist performing implant surgery using a water from air/water syringe (it wasn’t the only thing that was wrong with that treatment – imagine dentist’s tie hanging loose and contaminating everything it touches. Sterile surgical coat was nowhere to be seen). Implant surgery if anything needs an absolute clean environment and wearing your personal clothes and using unit’s water supply simply is not up to the standards.

I know for a fact that many dental nurse neglect running the water as described above. It is appalling thing to do. Honestly.

What does this tell about us professionals? We should be the ones that are looking after the patient’s best interest and health. Doing all the fancy and immaculate maneuvers inside the mouth is not enough to fulfil our purpose.

Are we too busy making money and forgetting the basics?

Advise for the Patients

Seek out a modern dental practice with modern equipment. If you are unsure what modern dental unit looks like, here‘s one example (unfortunately I don’t get paid for advertising this site).

It is ok to ask the nurse or the dentist if the waterlines are regularly disinfected and if the nurse runs the water after each patient.


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