comprehensive dentistry figure 1Not long ago this pleasantly assertive lady came into the practice with her central incisor that had just chipped again for the third time in less than three years. Armed with her natural assertiveness and a healthy degree of skepticism, she told me that she came to us because she heard good things about us and that she was having continued problems chipping this tooth.

Now at Spear Education we put a lot of emphasis on discovery, in particular discovery about the patient and the patient's condition. We also encourage helping to engage patients in a process of ownership.

So what do you see? Because if all you see a chipped tooth, and your brain, like mine has done all too frequently, immediately goes to whether you should use composite or porcelain … well, anybody can see that and that doesn’t differentiate you or completely help your patient.

So how might you think about this differently, give this patient your best work and help them to get healthier in the process?  

comprehensive dentistry figure 2

You might guess my next question to her was, "Why do you think it keeps breaking?" She predictably replied, "Well, I don't know, but I think maybe my last dentist didn't use very strong material. What do you think?" Of course I predictably replied, "Well, I don't know either, but would you be open to finding out?"

After assuring her that most dentist use pretty much the same material and most any dentist could repair the edge of that tooth, she agreed to let me take some photographs – two of which I've shown you here. As it turns out I only needed two photos and, eventually, a hand-held mirror.

Of course, as her edges came together and she looked at the wear patterns and how they beautifully fit together, she immediately went into a pattern of denial: “Well, I don't do that!”

“Perhaps not,” I said, “but why don't we do this? How about if I bond some material to the edge of the tooth to rid you of the irritation that it presents and, if you're willing, just have you pay attention to how you position your teeth?”

She would later tell me that while she thought I was completely out of my mind, she decided to placate my admonitions and “just play along.”

Fast forward a week later to her follow-up appointment. The first words out of her mouth were, “You know, you're right; I do hold my teeth like that occasionally, but I don't find it happening that often.”

"Isn't that interesting?" I queried. “I wonder when and, more importantly, why you're doing that because apparently it may have been going on for some time.”

"Well, I'm not sure. What do you think?" she asked.

While this conversation seems like it was getting painfully monotonous, it was an important discovery process for this patient.

"So how do you sleep, tell me about your sleep patterns?” I asked.

“Now that you ask, not very well. Why?"

Now you know where this is going. I was able to open the door to tell her that sometimes people hold their teeth forward when they sleep to help open the airway if they can't breathe well. Of course she said, “Why, I don't think I do that!” However, in order to again get me to “to shut me up” – her words – she agreed to a home sleep test. And guess what? We evaluated the results, referred her for a PSG and found she had a moderate-to-severe case of obstructive sleep apnea.

One of my favorite teachers, Dr. Henry Gremillion, always used to say, “You only treat what you see, and you only see what you know." Sure getting to the bottom of this took time and a lot of patience, something I'm not necessarily blessed with. But I decided sometime ago that I'd rather hold out for the best interests of my patients. That just takes time.

Now this patient is sleeping comfortably with her CPAP. She has also accepted occlusal splint therapy to manage her degenerative joints and occlusion as well as allow us to determine a stable condylar position before orthodontic repositioning and prosthetic care. We could just fix the tooth. We could even use something stronger like a porcelain veneer, following our facially generated treatment plan guidelines. But if we hadn't gotten to the core diagnosis, the dentistry still likely could have failed. More importantly the patient's overall health may have failed as well.

This patient has become a raving fan now as her skepticism has morphed into trust and her profound assertiveness is directed toward being a missionary for our practice. That's what comprehensive care is all about.

So, take a look at the photo again. What do you see?


Comments

Commenter's Profile Image Howard G.
March 17th, 2016
Could you please elaborate on what you meant in this paragraph? “Perhaps not,” I said, “but why don't we do this? How about if I bond some material to the edge of the tooth to rid you of the irritation that it presents and, if you're willing, just have you pay attention to how you position your teeth?” What exactly did you do? Did you just make the incisal edge longer for her to see what you saw?
Commenter's Profile Image Rex B.
March 17th, 2016
The perhaps not comment is used to not make the patient wrong and thereby stopping the communication from proceeding. It allows the patient to own the problem.
Commenter's Profile Image James O.
March 17th, 2016
Thanks Howard and Rex for your comments! Yes I did lightly feather the worn and chipped edges and bond some composite to address her initial concern but also invited her into the process by, as Rex said, not making her wrong and asking for her to pay attention to what she does with her teeth. As is usually the case, once she realized this was in fact happening to her (not just a theory) she started to ask for solutions. Incidentally, she's in splint therapy now and has achieved a very good degree of condylar (and disc) stability. At her appointment the other day she asked "well what's next to get this situation stabilized" and "you know I'm not all that interested in moving teeth". I asked what she was interested in if not moving teeth and made sure she was holding a mirror as we talked. "Well, she said, I guess if we're going to make these teeth work correctly I need to keep an open mind." The story continues...... Jim
Commenter's Profile Image BK R.
March 19th, 2016
All too familiar story of patients denial about their bruxing habits. Dr. Brian Lesage says-"Eyes cannot see what the mind does not know". I will never forget that. Thanks for the enlightening article, BK
Commenter's Profile Image James O.
March 19th, 2016
Thanks for the feedback BK! Great quote from Brian as well, good words to live by. Jim
Commenter's Profile Image Sylvia C.
April 2nd, 2016
Really appreciate this thread! I have a new patient with the same concerns that I have a presentation for on Monday. This information gives me verbiage and confidence! Thank you Jim!
Commenter's Profile Image James O.
April 2nd, 2016
Hey Sylvia, so glad this has helped you gain confidence and I know you'll do well. As a very expressive personality I frequently have trouble "staying in the question" with my patients but as in this case if I can have that disciplined communication it really can result in a wonderful outcome. Let me now how it goes and feel free to contact me if I can help in any way. All the best, Jim