Minimally invasive adhesive dentistry.

I want to share a short case with everyone to show the possibilities in restorative dentistry today, and why it is so important to have trust in the care, skill, and judgment of your restorative dentist.

Much of the dentistry being performed continues to lag behind the current possibilities and technologies that are available today, and this almost always proves to result in a detriment to the patient. Granted, procedures of minimally invasive adhesive dentistry require intense planning and certain technical ability, but success can be predictably achieved in numerous clinical applications. Each case must be individualized and personalized based on someone's unique needs, circumstances, and objectives.

I have a great patient who came to me with the chief complaint of missing a tooth on her lower left side. The tooth had a history of needing root canal treatment and a full coverage crown, and eventually the tooth fractured. The dentist decided to remove the tooth without any consideration or discussion as to how he would replace it in the future.

Well, a few years later, this patient wanted her tooth back (understandably so). She is a young, attractive woman who will need many more years of using her teeth. However, things were now much more complex because of decisions that had been made (or not made) up to this point in time.

When the tooth was extracted, the dentist simply allowed the area to heal without anticipating the future replacement tooth. Subsequently, we lost plenty of healthy bone and soft tissue that could have been extremely helpful to make placing and restoring this area with a dental implant simple and predictable.

But, this was not the case. After obtaining a C.T. scan and consulting with our surgical colleagues, we determined that the ability to place a bone graft and implant would have an unpredictable outcome due to certain anatomical restrictions. Additionally, the time-frame to complete (not a factor in my decision-making) was significantly longer. 

Long story short, this particular patient was not interested in waiting. She had made up her mind that she did not want to go the route of a dental implant, and I had to respect that choice. She was fully informed of the pros and cons of both potential treatment options.

After adamantly telling me she was not going to have a dental implant placed, I had to figure out other viable options for her that I was comfortable with. The traditional option of a "bridge" (fixed partial denture) requires removing excessive amounts of healthy tooth structure from two teeth that were, for all intents and purposes in this case, perfect. This was the last thing I wanted to do. In fact, it is always a goal to do the most minimum amount of dentistry we can to achieve exceptional and predictable results.

So, we made a decision to fabricate an extremely thin glass-oxide ceramic restoration that would adhesively bond to this patient's healthy enamel. Thus, I was able to do very little dentistry on her adjacent teeth, and still create a restoration that is functional (chew whatever you want on it), and beautiful.

All of us were extremely happy with the result, and I could not be happier to have preserved the maximum amount of this patient's healthy tooth structure as possible instead of doing a traditional "bridge."

This was a fun and gratifying case to wrap up before the weekend. It continues to excite and amaze me what we can achieve when things are done in a meticulous and well-planned manner.

I have attached case documentation photographs below. I hope you agree that the result is pretty exceptional!

Note: Please understand that anything and everything I post to my blog or my website is entirely my restorative dental work and my digital dental photography that is done on my incredible patients. I thank them for their trust and their willingness to allow me to share their stories and experiences with others. 

You don't "have TMJ."

I was well aware that the biggest drawback to creating my blog was the fact that I would actually need to update it with new entries on a somewhat periodic basis. However, it's not everyday where I feel inspiration to share my thoughts with you (no offense, of course). That being said, it has been awhile, but I am glad to be back. I hope that everyone is having a safe, relaxing, and enjoyable start to their summer. I spent the first week of June in Lexington, Kentucky participating in the one and only Dr. Jeff Okeson’s mini-residency program on Orofacial Pain & Temporomandibular Joint Disorders. Dr. Okeson is the author of the “bible” of TMDs and Orofacial Pain, so learning from him was a true honor and incredible experience.

It is usually during these week-long explorations where I find time to reflect and discover potential inspiration to share my ideas with the world at-large. The program had approximately thirty participants (ranging from anesthesiologists to oral and maxillofacial surgeons) from all over the world (Norway, Australia, etc.), so I felt lucky to be just a short five hour drive away from the UK campus.

Anyway, enough of all that, let’s get straight into it. I am going to do my very best to stay focused on the topic at hand (I have a lot on my mind). But, before we begin, allow me to give a quick “shout-out” of inspiration to Mr. Mark Twain, who will be our tour guide for this entry.

How we learn.

"A full belly is little worth where the mind is starved." -Mark Twain

Certainly, I learned lots of invaluable information that continues to layer advanced, evidence-based science that I continue to incorporate in my practice in order to provide my patients with optimal, individualized, and personalized care. The residency taught elements of restorative dentistry, pain management and control, advanced sleep medicine, behavioral sciences, physical therapy, and interdisciplinary medicine from leaders in their respective fields to help professionals treat TMD and muscle pain patients most appropriately. But, Dr. Okeson, recognizing the abundance of perpetuating myths that fellow colleagues tell patients about TMDs when they simply do not understand, gave us a very interesting synopsis in “ways in which we learn.”

So, how do we learn?

Here are different ways in which we learn:

  1. Trial and error
  2. Sometimes we learn from our own personal experiences
  3. Sometimes we learn from others, but cannot remember why
  4. Sometimes we learn from others, and repeat the same mistakes
  5. Sometimes we learn from others, who then become our mentors

My experience is that many dental professionals make treatment decisions based off of a pre-conceived set of “beliefs” that are not supported by modern-day science (physiology, evidence-based research, methods of imaging, etc.). This is a major disappointment to me. Undoubtedly, I will have conversations with other dental professionals who tell me they are treating “Mrs. Jones for TMJ.” I simply cannot imagine a fellow orthopedic surgeon telling his or her colleague that they are treating “Mrs. Jones for knee.”

However, we have allowed this in our profession. If we speak this way, how can we expect our patients to understand their conditions? We have taken our sophisticated masticatory system that is controlled by our joint (and muscles) and over-simplified it because we do not want to take the time to understand (I will explain why I believe this is the case in a future entry).

So, what do I think causes the confusion?

Let’s draw a quick picture:

Surprisingly, many United States dental schools teach very little about the jaw-joint (TMJ) in their formal pre-doctoral programs. Therefore, it is left to those to explore and learn on their own journey after they have begun the clinical practice of dentistry.

In dental school, we learn diagnosis and treatment planning on a limited basis. We learn how to identify a cavity, remove it, and place an appropriate restoration. Most dentists are accomplished at this task to some degree of clinical acceptability. We learn how patients present with a conventional toothache, and form diagnostic boxes based upon this formal training. Ask any dentist about someone who has extreme throbbing in a tooth with prolonged thermal (cold) sensitivity keeping them awake at night, and I guarantee they respond that this patient "needs a root canal" (yes, they might need root canal therapy). By the way, the "toothache" is the 7th most common complaint of pain in the United States.

However, in dental programs, we also learn anatomy and physiology of other systems of the body in the medical sciences. We learn all of this information in order to be able to assist our physician colleagues in treating our patients comprehensively, and address any potential systemic issues that may exist. All of this information results in an incomplete and hazy picture of our complex head and neck systems.

So, we leave dental school, and things are simple. We “fill cavities” and treat periodontal disease. Patients come in with toothaches, and we treat them. We become narrow in our thinking, because things are "working." We are practicing dentistry of the past. Let’s face it, at this stage, we are unaware of sophisticated dentistry. Some people remain in this stage for their entire years of practice. It is a safe, easy place to practice (far left on the graph above). Patients are (unfortunately) accustomed to this, like giving your identification and credit card to the check-in staff in a hotel lobby.

But, if you are like me, you strive for more. You begin to know yourself and understand how you want to treat your patients. You need to learn more if you aspire to treat people appropriately. And you need to learn from the best. And it comes at a cost when you’re learning from the best, but it does not matter, because the strive for excellence trumps any other form of motivation.

We learn something new on an entirely different level than the majority of our colleagues understand it. We begin to isolate ourselves from the way the majority of our colleagues think. We view things as complex, and look at an entirely different set of risk factors and methods of treatment based upon sound science.

Patients (even some practitioners) may view us as “different,” even though we are incorporating data based upon the literature in our diagnosis and treatment planning decisions. Unfortunately, however, patients have been given misinformation for so long (many times from purported “experts”), that we become the practitioners who are almost hard to believe.

"Nothing so needs reforming as other people's habits." -Mark Twain

We are healthcare professionals. It is not appropriate to learn from trial and error. It is not appropriate to simply tell patients what they desire to hear, because they have been told for years by those who have not done their due diligence to read the literature and convey scientific evidence to them in fear of rejection. How can we fail to recognize, utilize, and incorporate the incredible advances we have made to treat people in maximum comfort and aesthetics using scientific principles?

For example, it may seem out of sorts for a dentist to inquire to you about potential cervical spine issues when you show up in his or her chair with a toothache. But, what if science has proven that certain cervical spine issues refer pain to the chewing muscles that can present almost identically to a toothache? How often does a dentist inquire about Vitamin B12 levels when a patient presents with an unexplained burning feeling in their mouth? Are we helping our patients to the best of what modern day science offers? No longer does “no cavities” equate to “comprehensive” or a “healthy” oral cavity.

Eventually, we implement systems and acquire enough education and knowledge to make our decision making processes simpler, but at a highly proficient level. We strive to be at the furthest point to the right on the graph above. We become truly competent providers (so competent that we are again unaware of treating people any other way). And things are simple again.

Very few practices achieve this level of competence. Patients invited by others to a practice like this understand the systems well, and come to expect the level of thoroughness and intellectual integrity that is distinctly different from the “usual” routine.

Healthcare Marketing.

I am currently in the process of creating a website for my practice. This has been a few years in the making, and I realized I had to do it when one of my patients said to me: “You know, you really ought to at least be in the phone book.” Point well taken.

Honestly, I just cannot stand external “marketing” for healthcare. It pains me to see what much of our profession, which has the potential to be so extraordinary, puts on the internet for patients to read.

So, during this process, it physically saddens me when I browse different dentists websites explaining their practice and their “philosophy.” This is your page, and the public can view it at anytime! A 24/7 reflection of you, your values, and your philosophy.

  • “$50 cleaning! $100 whitening! $1,000 crown!”
  • “Free exam and x-rays!”

Really? How did we get here? ($100 whitening and we don’t even know each other yet…)

  • What about care, skill, and judgment?
  • What about maintaining our mouth in comfort, beauty, and aesthetics?
  • What about building relationships based on mutual trust and respect?

I went to this course with an exceptional restorative dentist, Dr. Ryan Mizumoto, who practices on the other side of town. He is a great colleague and friend, and sometimes the learning outside of the classroom proves to be more valuable than in the course itself (we literally listened to the 2014 American Equilibration Society’s annual meeting on the drive home). For more information, feel free to visit the AES here.

"To eat is human... to digest, divine." -Mark Twain

While in Lexington, we decided we needed a change in the normal cuisine we were having. We also decided that we needed a break from tasting authentic Kentucky bourbon, so we searched for a unique restaurant in Lexington. Finally, somebody told us about Yamaguchi’s. Yamaguchi’s has recently become my most respected restaurant for two reasons:

  1. Yamaguchi’s is in a strip-mall with no signage (see picture). You cannot find this place unless you know about Yamaguchi’s. It looks like a total dive.
  2. I need to quote the menu: “Our phone number is not listedand the phone is turned offall the time to provide a hideaway experience for our guests.”

Yamaguchi’s is not about advertising the quality of their food. Yamaguchi’s understands that the people who appreciate their quality will find their way to their restaurant and bring other like-minded folks with them. And, it works. It works really, really well.

The second you walk into Yamaguchi’s, you forget you are in a dingy, old, almost abandoned strip-mall. You surely forget you are in Lexington, Kentucky. We were not let down with the experience. The fish was delivered overnight, never frozen, and hand selected. Every single tapa dish was exceptional. The owner works diligently, solely concerned about the quality of his food and experience of his guests... not the volume of his customers. He knows that people will find his restaurant, somehow, someway, because of the excellent cuisine and ambience (enhanced by the fact that you never hear a phone ring while dining). Nobody accidentally leaves their cell phone ringer "on" in Yamaguchi’s.

Can you imagine telling a restaurant owner that it is a decent idea to never turn your business phone on? Sounds like a ridiculous idea, I know. But, Mr. Yamaguchi knows that his level of commitment provides cuisine so far superior to anyone else that people will come. And, people will know what to expect. They can expect an education in properly crafted tapas. His commitment to exceptional tapas and service is enough to drive success, despite what appears to be a difficult location for a high-end restaurant.

I want to try and (succinctly) bring all of this together.

Conclusion.

"Always do right. This will gratify some people and astonish the rest." -Mark Twain

"The man with a new idea is a crank until the idea succeeds." -Mark Twain

Wrapping up, we covered two important issues. We discussed ways in which we learn, and that we must be careful to use sound principles of science as healthcare practitioners in our decisions while treating patients with complex problems. We also observed how certain types of marketing may be a distraction from the sophisticated services we are able to provide for our patients. We conclude that if we stay committed based solely on altruistic motives, people will find us.

It is our duty, as professionals, to approach our careers as a journey that lies along an infinite continuum of learning, growth, and personal development.

I believe that true commitment to being the very best one can be is enough to harbor trust, growth, and respect amongst colleagues, peers, and patients. I would advise anyone in any profession to simply immerse themselves in the highest level of professional growth they can, before their habits overtake their hunger for learning.

Be a life-long learner.

Learn from the masters.

And, aspire to surpass them.

Invictus

One of my favorite quotes is from the famous William Ernest Henley poem "Invictus." Invictus is a Victorian poem that was published in 1875, but what many people don't know about Henley is that he actually had one of his legs amputated just below his knee at the age of 17. Henley contracted tuberculosis of the bone at age 12, and when it progressed to his foot, physicians felt the only way to save his life was through amputation. Surprisingly, Henley remained active until the age of 53. I won't copy the entire poem here, but the quote that I'd like to elaborate upon (especially based on Henley's life circumstances) is:

"I am the master of my fate

I am the captain of my soul."

Let's put this in perspective. William Henley suffered a serious "life-event" that would normally result in complete immobility, compromised lifestyle, and self-pity. We must remember that, especially in this time period, we did not have efficient ways to mobilize and restore function to people that suffered amputation. However, Henley remained positive and took ownership of his problems. He knew that he was the only one who could choose his life direction, and did not blame others for his ailment.

So, what's your point?

In dentistry, as with many other professions and businesses, we as practitioners choose how we want to practice, and develop our own philosophies to create a practice that represents our true values. When I first graduated from dental school, I imagined that I would enter into the "real world" and be equipped to solve the most complex of issues that my patients faced. What I didn't expect to find over the first two years was a great lack of personal fulfillment when I would see (way) too many patients each day and try to solve all of their issues myself. I began to think that it was just my patients that weren't owning their own problems, and that if only they would change, then I would be happier. I couldn't be any further from the truth.

Like Henley, I had my first "ah-ha" moment of my professional life. I was failing as these patients dentist. I needed to change. That is not an easy thing to realize and admit, especially coming from someone who has always strived to do and be the very best. I wasn't failing because I was doing anything technically incorrect, but because I was not spending enough time with my patients. I was too busy, and I couldn't get to know them---the most fundamentally important thing that I should have been doing.

Enter: The Pankey Institute (http://www.pankey.org).

The Pankey Institute for Advanced Dental Education in Key Biscayne, Florida has provided a place for dentists to explore the meaning of excellence and renew their commitment to the kind of dentistry they want to be doing. L.D. Pankey's basic tenet to successful practice was: "Know yourself. Know your patient. Know your work. Apply the knowledge."

With the constantly changing healthcare system, many dentists tend to forget that we are the masters of our fate: not an insurance company or government mandate. It is our job to create an environment that harbors our own personal values. So, I felt it necessary to make a change.

I started to take more time---a lot more time---with each individual patient. I couldn't believe how much I got to know about so many interesting people. More importantly, I couldn't believe how much easier I could assist these patients in achieving their goals after thoroughly understanding their values, beliefs, and perspectives. I committed myself to an extraordinary amount of high level continuing education, and surrounded myself with some amazing practitioners in various study groups. I started to practice interdisciplinary dentistry utilizing extremely talented and knowledgeable specialists to help coordinate optimal patient care. But does all that really matter? No, of course not. We all know that people don't care about how much you know until they know how much you care.

Other dentists (often seasoned dentists who want to mentor "the kid") will often ask me why I spend so much time with each patient. They tend to mention that "time is money" and that my time would be better spent seeing more patients and therefore doing more "work."

I will hear comments such as:

  • "What do you do for an hour with a new patient?"
  • "Aren't people too busy to come and see you?"

I like to remind them that we are not treating a set of teeth, but people. We must address our expectations, goals, and desires. We must understand each others paradigms. Our goals for a patient may not be the same goals that the patient has for himself or herself. Arguably, an hour is often insufficient time for us to accomplish these tasks together. It is, however, a way to begin building a mutually beneficial relationship with each other based on trust and respect. Would you give up an hour of your time if it meant preventing losing teeth in the future? Taking a comprehensive approach also provides the baseline information that we need to do our work in the most predictable and optimal manner---with specific goals in mind. This, in my opinion, is the only way to create true value in the services we, as professionals, provide.

So, I remembered Henley, and that only I was the master of my fate. Do I take a chance and begin reflecting my values and philosophies into my work and my practice, or do I remain a technician of the mouth? If a patient called me on a holiday after breaking their front tooth, would I know who they were? Would I know what they expected of me as their dentist? In the beginning, probably not. However, now I have chosen to practice how I would like to be treated, and after a few years in, I can tell you that I am much happier both professionally and personally. I truly know my patients, and I don't need to scribble notes about their children, jobs, and hobbies on the front of their chart to remind me who I am treating. That in itself is personal fulfillment. I can now truly help my patients simply by understanding them as individual people living busy lives and dealing with unique and complex problems.

I fully recognize that we are living in the era of digital downloads, text messaging, fast food, and quick service, but there are many times when we need to rely on old-fashioned human relationships. It is important for us to get to know each other. It is important for the future of our journey together.

Embark upon your journey the same way, and remember, only you are the master of your fate.

Let's begin our journey together

Welcome to my blog, and let me be the first to say "thanks" for visiting. I have been debating for quite some time whether or not I want to expose my thoughts and ideas to the vast world wide web out there, but I've recently been inspired to do just that. So, before we go on this journey together, let me tell you what you can expect (or not expect) from this blog, and a bit about myself:

  1. I am a restorative dentist who practices in Lyndhurst, Ohio, and have committed myself to extensive post-graduate training. I practice relationship-based, comprehensive dentistry (much more on this later). What does this mean, for you, the reader? It means that I can't help but tell you that there will be many dental topics and philosophy to be discussed. I promise that I'll try to keep it interesting.
  2. Total health & well-being is of great importance to me. My life changed after reading Weston A. Price's Nutrition and Physical Degeneration: A Comparison of Primitive and Modern Diets and Their Effects. For anyone interested, I cannot recommend this book enough. Dr. Price was a Cleveland dentist known primarily for his theories on the relationship between nutrition, dental health, and physical health. This book was published in 1939, and the research is applicable to this very day. We will explore various aspects of Dr. Price's research in posts to come, but if you're interested, I would ask that you visit the Weston A. Price Foundation (http://www.westonaprice.org) for great resources on total wholeness and well-being. I should disclose that I receive absolutely no benefits for recommending this Foundation and/or book.
  3. I enjoy staying active. Outside of my practice and family, one of my greatest passions is CrossFit (http://www.crossfit.com). CrossFit is a strength & conditioning program that builds around community, nutrition, and mental strength and toughness. I am proud to say that I have been able to immerse myself in a great community of incredible people at CrossFit Distinction (http://www.crossfitdistinction.com) over the past two and a half years. It has been an incredible ride being surrounded by a community that knows exactly how to get the very best out of you at any given moment.
  4. I'm a Clevelander. Born and raised in Cleveland, Ohio, I enjoy all that this city has to offer. Despite our sports history, I am a passionate fan of the Browns, Indians, and Cavaliers. I have found this city a great place to stay and live. Cleveland (really) has it all.
  5. I went to college in Ann Arbor (yes, Michigan). Despite my loyalty to Ohio, when it comes to collegiate sports, my allegiance goes to my Michigan Wolverines. I attended the University of Michigan with a concentration in Cellular, Molecular, and Developmental Biology before attending the Case Western Reserve University School of Dental Medicine for professional school. Go Blue!
  6. I'm married to an (awesome) lawyer. You would think that wouldn't be easy, but surprisingly when you are the dentist in the relationship you learn to stop arguing with the attorney very quickly and succumb to defeat. I've thought about keeping a miniature white flag in my pocket at all times, but I don't think that is going to happen. Laura and I live happily with our favorite dog, Dylan, who also lives an all-natural lifestyle.

I know as we move forward you will get to know more about me, and what goes on inside my head. If you don't find this interesting, then please accept my apologies in advance. But, if you want to stick around for the ride, I'm glad to have you on board.

Thanks again for visiting.

Matt Kogan, DMD