4.30.2017

bite me

I had what should have been a routine dentist's appointment a few days ago that ... wasn't. It took me a while to figure out why this bothered me so.

I live in an upscale suburb of a major metropolitan area. The area is rife with dentists, all of whom are trying to outdo each other in their luxe experience, starting with a fancy lobby with a nicely stocked refrigerator, continuing on to the offering of a wide array of cosmetic services (whitening, veneers, Invisalign) to creature comforts such as warm blankets and sedation.

Until this week, the practice I selected (which I shall not name) just cleaned and examined my teeth and otherwise more or less left me alone (they replaced an ancient filling last year to keep a tooth from falling apart). My teeth are straight enough, and they are as white as I can ask them to be given my love of coffee. My fading beauty is unlikely to be revived by any changes to my teeth, and no one there ever pushed cosmetic dentistry on me. I suppose this makes me a not particularly lucrative patient.

This week, I had my teeth cleaned by a dental hygienist who is new to my dentist's office. I will give her credit for two things: she was very personable, and she did not push cosmetic dental services on me.

But.

We began on a strange note. Although I arrived at the office when it opened, right on time for my 8 a.m. appointment, she asked if she could take a moment to brush her teeth before we got started. I said, "Sure," because I'm not a monster, but at the time I wondered why she couldn't have done this before work. My appointment began about ten minutes late because of this.

I needed to give her significant updates to my recent history, including my second round of orthopedic surgery after my last dental appointment in October, and my stellar current A1C.

The hygienist took one look at my mouth and we were off to the races. She told me that I should have the dentist replace all my "silver" (more properly called amalgam) fillings, because "we don't like to see people with more than one or two." She said that they "probably" had decay underneath them. Mind you, there was no sign of decay in my bitewings taken six months ago, and no mention of decay by the dentist, so it was unclear on what she was basing her conjecture. In looking at this babe's blog afterward, I confirmed that she recommends removal of amalgam restorations because she deems them to be "unsafe." The American Dental Association says that this is unethical.The research she was touting to "prove" the lack of safety was an associational study of mercury levels in people with more than eight amalgam restorations (from what I can tell through the paywall). Which is not me. But I digress.

At this point, I felt like saying, "Excuse me, I did not realize that today's quiz was going to be on amalgam restorations. I only studied the material on fluoride. This is not fair."

Then it got stranger.

After checking my tongue, which I naively assumed was for signs of oral cancer, she informed me that I had a "moderate tongue-tie" and recommended that I have a lingual frenectomy. As she rattled off the problems caused by ankyloglossia, I couldn't help but notice that they were largely moot, for example difficulty in nursing. I contented myself in telling her that my mom had not reported any difficulty in nursing me when I was an infant. Meanwhile, the clock was ticking, and she still had not touched my teeth.

Next, she took a sample of plaque from my mouth (finally! She picked up an instrument!) and put it on a slide to inspect with her phase contrast microscope. "Say," I said, "I have never seen one of these in a dentist's office before," thinking that this was a new practice. She proudly informed me that she had been using this microscope in her work since 1985. I have been in various dentists' offices frequently since 1985. If no one else is doing this, that tells me something about the value of this practice.

After cleaning my teeth, the hygienist showed me the "bugs" (her term) on the slide, and pointed out a spirochete, a few white blood cells, and a few red blood cells for me. Did she think I was still blissfully unaware, at the age of 58, that the human mouth has bacteria in it? What made me even more skeptical of this piece of dental theater was her followup that if I had a healthy mouth, we "wouldn't see any movement" on the slide. Huh, so my mouth will be a sterile field? Right. She didn't make any attempt to quantify the bacteria, identify them specifically or record her observations in my chart. Since then, I have tried to determine to what uses a phase contrast microscope is typically put in clinical dentistry. The most honest article I found came right out and called it a "highly useful motivational tool," which the other articles I found in places like Dental Economics also implied. Okay then. It's show-and-tell.

She dispensed with taking any actual measurements of my periodontal pockets with a probe, the tedious process with one person calling out numbers to another who records them, probably because the dentist was not there. She opined that there were "changes" in my gums since they were checked in "2005" (actually, it was 2016, oops!) and that I now had periodontal disease. This meant, she said, that I would have to come back for an hour-and-a-half appointment, which might not be covered by insurance, of course, we would then come up with a "plan" for "oral wellness" for me, and she would be my "oral health coach." Then she hustled me out the door. I never saw the dentist, who had "not arrived yet" by the time I left. In other words, a dental hygienist had just diagnosed me with a condition, which is beyond her scope of practice (she is allowed to inspect and measure my periodontal pockets, but not make a diagnosis).

At this point, I figured that my situation must be dire, and expected an immediate recall appointment with the actual dentist for the massive overhaul of my mouth that was apparently necessary. Imagine my surprise when the receptionist booked me six months out. Not a dire emergency after all. I have, of course, canceled that appointment already.

Now that I have had the opportunity to reflect, here is what bothers me about this dog's breakfast. It had surprised me to hear that my gums looked worse than the last appointment (assuming for the sake of argument that her perception was accurate). After surgery in December that put me on crutches, I started flossing a lot, because there wasn't much else I could do, so I had been expecting a glowing report. Rather than exploring possible causes of this condition with me further, however, I gather she assumed that I am just bad at oral hygiene. She quickly loaded me up with a ton of new tasks, some of which contradicted what the last one had told me, so she could get back to the important work of trying to upsell me on her "oral health coaching" using meaningless demonstrations.

What she didn't bother to understand about her own patient is that the cumulative complexity of my medical care is already high. It was arrogant in the extreme for her to presume that I would want to place her in the center of my medical care as my savior, when in fact I am already working with a health coach, dietician, physical therapist, surgeon, pharmacist, primary care physician, ophthalmologist and dentist as necessary. This hygienist is not going to become the star of my medical show.

I am grateful, though, to her, in the end, because in hate-reading her blog, I picked up on something that she could have realized if she'd just stopped blathering for a moment and listened to me more carefully.

From my history, she knew or should have known that I am on several medications, middle-aged, and have type 2 diabetes. I think I shrugged when she asked about dry mouth, which is very common in type 2 diabetes, although the research is lousy. I have been thinking about that question, however, and realized that I frequently do feel what I have been interpreting as slight thirst, but could just as easily be dry mouth (subjective) or hyposalivation (objective). Further research also tells me that hyposalivation can be present without the perception of dry mouth. Compared to my ongoing recovery from reconstructive surgery, it has been a trivial annoyance and easy to ignore, but it can have consequences.

All the flossing and water-Piking in the world can't be expected to address my gum problems if I don't address my hyposalivation as well (if in fact I have it). I, therefore, as the director of my own healthcare, have started simple, harmless treatments for my (possible) dry mouth, with only indirect thanks to the hygienist. We will see what the next dentist says.

And I can hardly wait to see what's on my EOB.


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