The Societal Bias For a Dental Appointment - An Editorial

The first appointment for you this damp and rainy Tuesday morning is at 8 a.m. as usual. The kids were late out the door to the bus stop for school. It is wet, damp, and you realize everything going forward will take longer until you reach the sanctuary of your beloved first treatment room of the day. 

It is indeed sanctuary, isn’t it?  It is where you are in complete control of the Universe: the people, the tone, the banter, the everything. You gather your things and get to the car. The rain pelts your windshield.  The wipers barely keep up as they sync with the beat of Eddie Rabbit’s “I Love a Rainy Night” on the radio, bringing a noticeably growing wry smile to your face. You navigate the morning buses and recycling collection in vain, knowing the morning is irrevocably altered. 

You arrive in time for your first patient, but not really, right?  The morning huddle is lost, and the choreography for Tuesday morning is off just a step, enough to make Bob Fosse stop and start all over – “From the top.” 

But you can’t do that, can you? You are a doctor. Worse, you are a dentist, and you better have “what it takes” (as they say on Broadway) to assuage the tenor in the office and be your usual charismatic self. Regardless, the day must go on. And the show must go on. We act genuine every day, but it is, indeed, a show. 

“Overture, curtains, lights...this is it, the night of nights...” 

The problem is, you’re 10 minutes behind. Better still, your first patient is the type to wait and ask specific questions without warning, thinking nothing of it... “it” being your time, which you are more than willing to give, just under different circumstances than the ones that exist this dreary Tuesday morning. Do you have systems in your practice for your staff to diffuse this, where they say specific words before you see the patient, ensuring a reasonable Q & A time?

Well, it is Tuesday morning, so that means double hygiene, two appointments needing two exams, staggered the usual 15 minutes apart. Still, you begin to feel it. “It” is your time and the 9:15 a.m. patient appointment is not far away. It is 8:45 am; what is your plan?

That is just but one scenario that may develop without fault of yourself or your practice. But others exist...such as this one:

Pandora's Box

There is a Pandora's Box in nearly everyone's mouth; some just need more time than others to cultivate an obscure problem. Ultimately, those boxes open sooner or later. That upper right first molar riddled with a large but leaking and deep MOD amalgam you observed with disdain and practically begged the asymptomatic patient to treat is now in your chair, finally appointed. 

Tragically, the patient attached to that tooth fits a certain personality description we refer to as a “Driver.” They are the type As, the “clock watchers,” those that are in your office five minutes...already looking at their watch five times. 

The subtle problem is this appointment was rescheduled a few times over a calendar year. The original time allotted may not serve as enough any longer. It was not enough at all. The plan for a core build up changed upon excavation of the leaking amalgam, only to encounter caries on the wall and on the floor of the old prep. One more step and you will engage the pulp chamber. 

Now what? Start the root canal therapy? Do you want to find the “MB2?” A sedative filling and refer to an endodontist? Regardless, whatever you decide, the outcome of treatment has changed. More so, chair time has changed. The Driver patient not so casually raises his wrist for all to see the not-so-discreet glance at his timepiece. 

It is as if you are not in the room and he’s assuming you are sipping coffee with your feet up. Yes, you did diligence and explained all that may occur upon treatment, but that was long ago, all the way back in the beginning of the appointment (sarcasm). It is amazing how soon a patient can forget an adult conversation between themselves and their Doctor.

Oh, wait, between themselves and their dentist. 

When my internist states my cholesterol is not where it usually is, he gets my full attention. The phrase “root canal” ought to garner the same attention. Instead, it is a nuisance affecting their schedule for the next two weeks. 

And that, colleagues, is where the problem may lie. In 23 years of practice, it is certainly true: There is a societal bias on appointments and procedures in dentistry, with the concept of time and importance, that medicine does not share.  

Now this may be empirically true only. It certainly is not true for all our patients. In fact, the relationships we share with our patients are likely our most prized possession. In them, dialogue exists so all parties included have a mutual respect and understanding of the journey. But within even the best patients exists that vacuum common with the other patients that you have not had the breakthrough with yet: The vacuum that sucks all the goodwill you earned, filled with forgetfulness, clocks, stopwatches, and personal organizers that suggest they have some place else to be and that this procedure is on par with a haircut or an oil change. 

No malice, ill-will, nor disrespect from them, but even the best-trained patient falls prey to the Human Condition, where decades and generations of societies’ views and values on our industry outweighs the present day. Even those who own their conditions and willingly and electively accept treatment can slip into that abyss – dismissing procedures and the purpose of the appointment.

Perception of medical vs. dental procedures

Time is precious. We all know this. Our greatest commodity. We are all ants marching, all on the same hamster wheel. But a dental appointment, a procedure, cannot be viewed as just another stop in one’s day. It certainly may not feel like the highlight. It often may be the lowlight. But it is, regardless, the most important stop in the day. Why? Because it is, by all counts, same-day surgery.

A two-surface filling with moderate caries on an upper premolar/bicuspid does not equate to preparing a full arch, correct? The latter will get the patient's attention on the gravity of the process. But the former is just a part of the day’s checklist.

Now, if a patient has a routine biopsy on their skin, it is the highlight of their day. They may even tell people. Their entire day revolves around that procedure. They will amend the day so nothing impinges on this.

That two-surface filling with moderate caries is far more invasive than the biopsy. They may even take the same 45 minutes. More tissue, hard, soft, or both, will be excised in our chair. 

To be fair, both procedures require significant skill. The “filling” may get rescheduled on a whim. The skin biopsy is a proactive procedure with questions of the presence of irregular cellular activity. However, the dental treatment is already reactive, has definitive caries, clinical and radiographic, and no grey areas. It requires attention.

But the biopsy may be thought of as being lifesaving, while the patient may view the “filling” as tooth fixing, not even tooth saving. And there is the societal bias again. Medicine gets the attention it deserves. Dentistry...​

Dental treatment timing

Back to those two opening scenarios. Things happen. Unintended consequences happen to patients every day that alter the course of their day. That is why it remains a mystery why patients ask for a definitive time frame when they present. It took years of experience and confidence (and finding Gary DeWood in 2003), to share with them my feelings;

“If you can honestly tell me you hold your other doctors to the same standards, then I can appreciate the question.”

“Well, no,” is mostly the answer. 

Often, to further the levity, I apologize for not yet having installed a drive-thru window for the office. That one always works. Or, “I’m sorry you can’t just drop off your teeth like the cleaners next door.”  Or, “you know...we have discussed sound methods to help prevent visits like this for years.”

The last is my loving reminder that this is their issue and they must own it. We arrived here because of their actions. We are doing dental surgery, technically, on an awake patient, with moving parts, in a very small oral cavity, where success and failure are judged in microns. Why shouldn’t we be on time and exact? Really?

We are not mechanics and this is not Jiffy Lube. It is a fluid environment between the doctor, the patient and the assistant. No one drops off their teeth and picks them up. In fact, there is no other type of doctor a patient will ever spend more personal, vulnerable, one on one time with than their dentists. 

That is the interesting part of this – they know how much energy goes in to even a simple procedure, yet they want to be done before they start. With all the moving parts, they still assume their car, their crown, will be “done” in 90 minutes. 

Many other industries are given leeway for time. In fact, they are ridiculed for it, yet the consumer finds it acceptable, or they just accept there is no other alternative. The airline industry and the “cable guy” lead the list of distinguished businesses that interrupt mankind more than any other services. Their intentions are always good, but things can happen. Hospitals schedule patients’ surgeries and line them up like planes on a tarmac. Should a surgeon ever rush through a surgery just to get clear the surgical suite? Surgeries run late ALL the time. Maybe it is not accepted but is expected by the patient. Hence, the bias.

The long walk from the hygiene room

It is but a 20 foot walk from any of our hygiene rooms to the front desk. There are no hills, bad weather, or hairpin turns for our patients to negotiate. There is no mystical force to confront. When we dismissed them from the treatment room after a pleasant recap of their conditions and continued treatment considerations, all three of us were definitively on the same page: where we are, where we have been, what is next, and the consequences of actions. By the time they reach their destination at the front desk, they morph into someone else. 

They become unaware of the very same conditions they have and the very same treatment they accepted, as if the dialogue never happened. “I need what?”, they squelch at the desk. 

Actually no one said need, as we try to never say “need.” Only the patient knows what they need. It is our job, your job, to empower them to make prudent choices so they feel they need treatment toward the path of least resistance for optimal oral health. Despite your and the hygienists’ skills, they forget everything at the end of that long walk.

These are not all reactive-type patients. That would make sense and not be worthy of discussion. It’s the proactive and regenerative-types that we at Spear Education talk about in the flagship workshop, Facially Generated Treatment Planning. 

If any other healthcare provider reviewed and reminded us of outstanding care, would you do it? Only you know. But would you be so disengaged to not remember what is at stake? You can begin to question the process, even the most seasoned of offices. 

Can you fix it, Doc?

In that question, they did not ask if you need more information other than the anecdote they shared, and the brief “ER” evaluation, to determine why their tooth broke. Your idea of fixed and their idea of fixed may be very different. 

Fixed can mean fill in what is missing and be done with it without further treatment. The bias here is that it is often assumed that what is wrong is obvious, when often it is not. 

Physicians get to diagnose and treat with a great deal of freedom and time: they may run test after test, titrate levels of a medication, combine medications, or change medications, because it is thought of as necessary and the accepted course. 

The bias is dentistry as a whole is not granted time to think. 

It became liberating when I was taught that it was OK not to know and to share that with patients. Saying the words, “I don’t know,” became easier and enjoyable because there was never any push back. 

Should any of us know definitively without some reasonable opportunity to study the subject? The follow-up statement to that was always something like, “but maybe we can find some things out together,” (the operative word being “together”). And they do not say no...almost never.

Etiology of the societal bias surrounding dentistry

The purpose of this article was to focus on this esoteric but almost innate mindset of how dentistry is viewed by the general public. Depending on your style of practice and level of post-graduate education, you may encounter this hourly, daily, weekly, monthly, or on small occasions throughout the year. But through your own journey, it was probably some of those intervals at some point. 

I write this because we are taught certain things in dental school that sway us to evaluate and treat patients. The central dogma of dental schools for so many decades is the complete inverse of the advanced education you receive here at Spear Education: those ivory pillars of academia preach biology, then structure, then function, then esthetics. 

It teaches lists and itemized treatment from troublesome to elective. We present estimates for the treatment with assigned fees for a “unit” of something: a filling, a crown, a denture. Patients ultimately view our work as a commodity: “this crown costs this much.” They place the fee on what you are placing on or in their tooth. 

Patients have asked if a gold crown was dependent on the market, as if they were ordering lobster for dinner...”market price.” That is how deep-seeded the thought process is. Dentistry just may have bestowed this bias on itself by the very methods and ideals we learned and those before us learned so many decades ago. 

The public only knows what they are accustomed to. The bias is our own, handed down from generation to generation. How do we get through to our society that they are not paying for the outcome, that filling, that crown, but they are paying for our care, skill and judgment?

Frank Spear turned the school model on its ear decades ago and created a linear, systematic approach to evaluating any one patient who is willing to break the cycle of the ghosts of treatment planning's past. It looks at the entire stomatognathic system, allowing us to create beautiful restorations that function better than what existed, maintaining a healthy periodontium. 

The cycle is, indeed, breaking slowly through amazing advanced education programs from Spear Education, The Pankey Institute and The Dawson Academy. More than ever, systemic health is linked to the oral cavity and the head and neck. Clues exist everywhere. You have to see what you are seeing. Further educate yourself, then your staff, then your patients. Be passionate and enthusiastic. Celebrate their awareness and their proactivity. Help them appreciate the consequences of their condition, but discover it together. 

Come join us at Spear Education and help break YOUR cycle. 

David St. Ledger, DDS is a Visiting Faculty Member, a Spear Moderator, and a Contributing Author