Issue #48, August 2015
Special Issue: On the Road Ahead
This issue, we’re stepping away from our usual format to share, in full, the latest installment in Dr. V’s ongoing series on the need for truly comprehensive biological dental care to support healing and optimal whole body health.
Dr. Verigin’s Comment
Dentistry Shouldn’t Be “Just Another Profession,” Part 3: On the Road Ahead
By Gary M. Verigin, DDS, CTN
We ended last time with a look ahead to some case histories that illustrate both the ravages of modern medicine and what is actually needed to stimulate healing. But the more I thought about it, the more I thought that we should first take some time to get clear on the matter of what biological dentistry actually is.
So often, patients come in for a second opinion, having been told that they need many thousands of dollars of dental work, including implants and root canals and unnecessary crowns. Sometimes it’s a conventional dentist who’s told them this; sometimes one who describes his or her practice as “biological.” In neither case has the relationship between their dental and medical ills been completely or successfully explored.
The very term “biological dentistry” didn’t even exist until 1985, when Dr. Ed Arana and I started the American Academy of Biological Dentistry (now called the International Academy of Biological Dentistry and Medicine). We felt it was the best term to describe the fusion of biological medicine and clinical dentistry we were learning from German researchers and practitioners like Reinhold Voll, Ralf Turk, Fritz Kramer and others. As we put it back then in our founding statement,
21st Century Medicine will be concerned with the depollution of the internal and external environments. It is time to correct our mistakes and become biologists of the mouth in addition to our technical expertise. Physicians and dentists must work together for the good of the whole person. The fragmentation caused by specialization must be rethought. An integrated and unified approach of mind, body and spirit in diagnosis and treatment must be instituted for all. [emphasis added]
The shift away from this ideal is one that we’ve seen before. So let’s take one more look back at the evolution to dollar-driven health care, only this time focusing on the dental aspect.
Out of Dental School
A certain amount of dissatisfaction may be inherent,
even necessary, to the practice of medicine.
– Abigail Zugar, NEJM (2004)
I entered the University of Washington Dental School in September 1961, where it was a well-established fact that every entering class would see its size cut nearly in half before graduation. It’s what the upperclassmen told us. It’s what the faculty told us, encouraging us to study hard and not be like the student sitting to our right or left.
For the next four years, I was constantly, feverishly working to make sure I would not be one of those cast aside. And in 1965, I graduated with forty-some others – half of our original, optimistic class plus several students who transferred into the school late. Diplomas in hand, we were eager to flee the establishment.
Of course, first we had to pass our boards, and these were extremely difficult. The Washington State Board came within a couple weeks of graduation and was all clinical. (We had already taken National Boards twice – once after our second year and again near the end of our fourth.) We each had to perform three procedures in the dental school clinic: 1) prepare a patient for a gold restoration, then cast, fit and cement it all in a single day; 2) prepare a gold foil restoration between an upper incisor (front tooth) and cuspid, solo, without an assistant; and 3) place an amalgam in a bicuspid or molar.
The California Boards were even more intense. First, there was a day-long written exam covering all the science we covered in the first two years of dental school and all the dentistry covered in the last two. Then there was the clinical portion, which involved doing both a gold foil and an amalgam placement. Our lab skills were tested, as well. We were challenged with waxing up a full crown on a set of articulated models and setting up a full set of false teeth on articulated models.
I was extremely pleased to have passed both the Washington and California Boards on my first attempt.
After learning I’d passed the Washington boards, I found a job working part time in a group clinic in downtown Seattle. I was to do dentistry on a commission basis in a multistory facility in a less than desirable location. Being low on the totem pole, I got all the patients who no one else wanted. All I did was place amalgam – first, just in young children but eventually in adults, as well. We used no protective gear of any kind – no gloves, no masks – save a dental dam for the patient, not out of any concerns about mercury but because that’s how we were taught to do it at UW.
But in all four years, the point of mercury’s toxicity was never discussed. We had two 10-week courses on dental materials, an hour a day, five days a week. Not once did anyone mention that mercury is neurotoxic. We were taught how to use it, and that was it. We all accepted the concept without question.
So who would find it strange when my assistant at the clinic placed the mixed mass of amalgam on a circular piece of mesh and squeezed out the excess liquid mercury into a paper cup which she then tossed into the trash? Then she’d pass me the amalgam as I would condense it, layer by layer, into the tooth.
Towards Creating Harmony
If I have seen further…
it is by standing on the shoulders of giants.
– Sir Isaac Newton
As soon as I found out in late August that I had passed the California Boards, my wife, three children and I headed south, where I’d already been hired to work as an associate with an older, part-time dentist here in Escalon. About six months later, though I didn’t quite realize it at the time, another door opened.
One day, I was talking with a patient about some restorations they needed. I didn’t know I was being overheard by a rep from a company called Professional Budget Plan, who had been sitting in my boss’ private office, waiting to be introduced. His company, he said when we met, was a leader in all aspects of practice administration, including office forms, charts, visual patient education aids and classes.
It was certainly welcome information for a neophyte like me! All through dental school, I had never had to teach patients, let alone sell them on anything. Our patients were provided by our department, based on which requirements we needed to meet. Talking with this gentleman over lunch, it was obvious I needed a lot of training to learn how to talk with patients, how to listen and how to motivate them to proceed with necessary dental work. He spent considerable time teaching my assistant and me how and when to introduce concepts to patients, leaving us an educational device to try. It was a film strip with audio for helping patients learn about different aspects of dentistry: hygiene, amalgam, gold and porcelain fused to gold restorations, partials and dentures, fixed bridges, root canals, periodontal disease, children’s dentistry and orthodontics.
About a month later, he came back to see how we were doing and invite us to a day-long seminar they were hosting at the St. Francis Hotel in San Francisco. Their featured speaker was a Florida dentist by the name of Jesse Prather.
We went, and I was wowed by the kind of dentistry Prather was doing. He replaced mercury fillings with gold. He replaced missing teeth with fixed bridges. His work was absolutely gorgeous! “Where did you learn to do this kind of dentistry?” a fellow attendee asked.
Prather looked out to the 500-some of us sitting in the huge ballroom and asked how many of us had ever heard of a dentist named Peter K. Thomas. Seeing only a few hands go up, Prather asked again. “Raise your hand if you’ve heard of him.” Another hand or two went up, including one right in front of me.
“If you don’t take a class from him, “ Prather said, “you will really be missing the boat.”
During the break. I asked the dentist in front of me where Dr. Thomas practiced. Back at our office that Monday, my wife called Thomas’ Beverly Hills office and learned that he would be teaching a two and a half day course at USC in September, 1967.
That September weekend, we learned how teeth should articulate properly. We had to learn how to properly wax up teeth on the mounted stone models we each brought to the class. Several dentists from his study clubs were available to help out – one for every two attendees, which helped us scale the learning curve so much faster. It was an amazing – not to mention extremely helpful – experience!
Liking both my work and my work ethic, Dr. Thomas invited me to join him the next time he went to his favorite study club, which was held down in Fresno. After that meeting, he said he’d like to see me at his upcoming lecture at UCSF so he could introduce me to a few other dentists to start a Northern California study club. This happened, too.
Dr. Thomas became my first “giant” and mentor, teaching us to understand the tops of the teeth like Rubenstein knew the keys of a piano. Only with familiarity and understanding can a dentist help fit teeth together in a harmonic way. “Trifles make perfection,” he’d say, quoting Michaelangelo, “and perfection isn’t a trifle.”
The Rise of Preventive Dentistry
The next giant I met was Bob Barkley, a dentist from a small farming community west of Chicago who was teaching what was then a very new and radical paradigm: preventive dentistry. What made it radical was that dentistry was still considered mainly a matter of tactics and techniques, not a medical specialty. Dr. Barkley also introduced the importance of behavioral, educational, humanistic and philosophical aspects in creating and sustaining optimal oral health – factors pretty much ignored by dental schools all together.
Considered the Pied Piper of this movement up until his tragic death in a plane crash in 1977, Barkley changed dentists’ perception of themselves – from “mouth mechanics” to health professionals. The old view of dentists as surgeons and engineers of the mouth was proving far too limiting. It really hindered dentists from applying many of the new discoveries being published then in scientific journals – discoveries that were casting new light on the relationship between oral and systemic health.
Now, you may think of the focus on oral-systemic health being quite new. In fact, the knowledge goes back at least to the 1960s. All the “new” discoveries of the links between periodontal disease and heart health, for instance? They were discussed in scientific literature as long as 60 years ago by the likes of Sumter Arnim, C.C. Bass and Harald Löe, illustrating how a preventive dental approach supports whole body health.
Consider, for instance, this passage from Bass’ 1965 paper “The Necessity for Effective Dental Health Service in Cardiology,” which was published in the American Heart Journal, cited by Dr. Lynn Carlisle in his excellent and invaluable series on preventive dentistry:
In almost all ailments of the heart caused by bacteria, the source of infection is known to be the pathologic and infected environment of the teeth … the health, welfare, and even life itself, of persons who have heart conditions which predispose to infection, may depend upon prevention and control of dental disease …. Caries is a source of bacteremia only, and then temporarily, from advanced-stage lesion involving infection of the pulp. Bacteria in the periodontal pocket and in the diseased periodontal tissues are the source of almost all bacteremia from the environment of the teeth …. I believe that at some time in the future, leading cardiologists will wonder, in retrospect, how information so needed by their patients could have been overlooked or neglected for so long.
This whole branch of research was never discussed in any of our periodontal courses in dental school. They were taught by pioneers such as Bob Barkley. Carlisle – himself a pioneer in the field and long-time practitioner – remarks that Barkley’s lectures
led to a paradigm shift in dentistry and enabled dentists to start implementing preventive dentistry in their practice immediately. The fundamental shift was that, because of the research by Bass, Armin and Loe now exposed to dentists by Barkley in his seminars, dentists became aware they could help save teeth for a lifetime instead of providing “fatalistic supervised neglect” as their patients lost most or all of their teeth from decay and gum disease. A common patient request during this time period was “pull ’em doc, I am going to lose ’em any way.”
Barkley was a “rock star,” says Carlisle, whose teachings spurred the formation of the American Society for Preventive Dentistry in 1968. According to its founders, the ASPD had two main goals: educate the profession and the public “on the prevention of dental caries and diseases of the gingiva and bone.”
Just three years later, more than 6000 dentists attended the society’s annual convention. Despite being offered no honoraria, 60 speakers presented to standing room only crowds. Membership soared to 8000. The 1971 meeting became known as “the Woodstock of Dentistry.”
“Preventive Dentistry,” says Carlisle,
hit like a tsunami. Dentists were “born again” because they could prevent the scourges of dental caries and the “red tide” of periodontal disease. The military “jumped all over the idea because they saw preventive dentistry as a problem solving vehicle in dental health delivery.” (Amenta, C., Brackett, R., Ross, P., 1976).
* * *
The ADA devoted an issue of the ADA Journal to preventive dentistry. Local dental societies had programs on preventive dentistry. The ADA changed most of their patient education materials to a preventive focus. Dental schools created Preventive Dentistry Departments. Preventive dentistry had a strong impact on national health programs. Public schools emphasized preventive dentistry programs.
Unfortunately, a number of factors arose to keep this new paradigm vital, including the simple tendency of dental schools and associations to move slowly and resist innovation, remaining focused on tactics and techniques. Carlisle suggests many additional factors, including Barkley’s untimely death, the lack of foundational support, rivaling egos, greed and a tendency by many dentists to be the distant expert to their patients rather than a facilitator of their health and well-being.
Indeed, many of these issues are issues all over again in the realms of holistic, integrative and biological dentistry.
The State of the (Biological Dental) Art
That’s not to say that some astounding achievements don’t continue to be made in both conventional and biological dentistry alike. They do. Modern dentistry – regardless of orientation – has made incredible strides since I was a young dental student.
But there are also some disturbing elements that are also obvious to many of the new patients who turn to us for help. As they get to know us, their statements about this are ever more candid and lucid.
One of the main concerns is a continued emphasis on quick fixes without the dentist explaining any of the what or why, let alone fully inform them ofall available options – including the option for conventional treatment and the option of doing nothing at all. Neither are they told about risks, benefits or likely outcomes, medically or dentally.
This isn’t much different than a 9 minute appointment at Kaiser, where they just give you a prescription for antibiotics or cortisone-like drugs to control inflammation.
Now we begin to see the explosion of national chains of dental offices, as well, with their emphasis on things like efficiencies and through-put and, of course, sales. While the quality and goals of these corporations can vary even from site to site, most are dollar- and insurance-driven. They like to hire young graduates hungry to start paying off the hundreds of thousands of dollars of debt they accrued through dental school. Often unable to start practices of their own, they may find no choice but to work for one of these vulture-like organizations. And with more dental schools being started and new ones expanding, there is an ever-growing supply of new dentists they can tap into. The corporations get even bigger.
Too often, it’s ultimately insurance companies that are calling the shots – companies that exist to make profits, not support proper patient care. In a powerful article on major challenges facing the profession today, Dr. Gordon Christensen – a mentor of mine back at UW – outlines some of the main dentist complaints about third-party payment companies:
- Some payment plans do not even compensate enough to cover office expenses. [Some procedures – for instance, preventive dentistry and educational consults – aren’t compensated at all. – GMV]
- Often inexperienced and uneducated insurance-companies dictate treatment.
- Allegations of dentist dishonesty are leveled at dentists from third-party payers.
- Although quality of care varies considerably among dentists, it is not acknowledged by some companies.
- Dentists are frustrated with being told what they can charge patients regardless of the quality they produce or the difficulty of a procedure or difficulty of a patient.
Meantime, some of these companies have cut their payments for oral procedures even as dentists’ overhead expenses continue to rise. Some dentists may feel pressured to cut corners – and quality – themselves. And when the companies decide to change their policies, dentists have little choice but to adapt to those changes.
This is the environment in which a dentist today – conventional or biological – finds him or herself practicing. It’s brought precious little improvement in quality. It has brought an increase in overtreatment. Often, we’re asked to provide a second opinion by a patient new to the area, whose old, long-term dentist never said a thing about conditions their new dentist is now urging upon them.
At the same time, many general dentists attempt clinical tasks that could better be done by specialists, especially in oral surgery, in order to keep profits up. Yet as Christensen notes,
After decades of teaching “hands-on” courses for new graduates and dentists of all ages, I currently see a wide disparity in the clinical ability of the new graduates from schools in the USA. Some have god beginning clinical skills, while others appear to be woefully underprepared. In my clinical courses, I can easily identify the schools of the underprepared graduates.
As a previous full-time dental educator and administrator for many years, I fully understand the difficulty of elevating all graduating students to an acceptable beginning competency level. I also understand the need to include the many topics now necessary in dental curricula that were not previously necessary.
There are significant challenges that face any who consider their to be a truly holistic, biological dental practice in order to prosper and offer their patients/clients the best therapeutic care possible:
- Working together as teachers in the true sense of the word and, as a dental team, providing all patients with life-transforming learning moments.
- The creation of a relationship with the client that encourages self-discovery and behavioral change, ultimately working toward a preferred future, even in the face of resistance.
- Seeing clients not as a cluster of functions and subsystems, but as individuals – each, an experiencing, feeling, acting person.
- Recognizing that the gestalt of body, mind and spirit interacts synergistically to create a whole that is greater and transcends each of these as parts.
- Learning to listen deeply to ourselves and our clients, so we can listen to the divine and sacred spiritual source of our being.
- Embracing the concept of dental team and client as responsible partners in the healing relationship, who both are open to change and the effects of change in their lives to create a relationship in which each will take another step in the healing process.
When a client leaves your office and is able to explain to others your relationship and how they benefit from it, you know you’ve established the only sound basis for the growth of your business, your patient/client and your holistic, biological practice.
Aspen Dental image by Faolin42, via Wikimedia Commons