Dentistry is about people, not just teeth

 No, this entry is not about travel experience, it is about life experience while providing dental care.  People are more interesting than teeth.  Each person has their own story.  Feel free to skip this one.  We will get back to travel very soon.

Martha Caigambal:

While on an oral surgery rotation in my Comprehensive Dentistry Program, I encountered an especially interesting patient.  Martha Caigambal was an elderly lady with a very complicated medical history.  She was specifically accepted to our program as a challenging learning case and would not have otherwise been accepted.  Our normal mission was dental treatment for active-duty military only.  She was assigned as my patient.

Martha was a family member (mother or grandmother) of a US military member.  She was from the Philippines and a ‘reverse smoker’; that is, when smoking she would put the lit end of the cigarette inside her mouth.  Having spent time in the Philippines, my guess is that the habit originated due the rainy climate there.  The consequence is that the oral palatal tissue on such people is dry and scarred from being subjected to intense heat.  But that was a small part of her medical problems.  I remember that she had CHF, congestive heart failure, and diabetes, plus other issues beyond my memory.  She brought her medications to us in a shopping bag, from which she took pills sporadically.

Dentally, all her molars were beyond repair and needed extraction.  Internal medicine refused to be responsible for her admission; she was admitted by one of our board-certified oral surgeons.  Anesthesiology recommended that we use local anesthetics only; they were worried that if a deeper ‘numbing level’ were used, she may not recover consciousness.  Her heart condition plus bleeding problems were two Immediate concerns.

Nevertheless, they were present with their equipment and an IV started in the OR, operating room, in case of an emergency.  Martha was admitted to the hospital two days in advance, to ensure that her long list of medications were taken properly and that her laboratory values were stabilized and optimized.  Her anti-coagulant therapy was temporarily discontinued.

I am happy to report that her dental treatment was completed without further complication, and healing was uneventful.  I do remember her crying, “You are killing me!” during the surgery.  It wasn't from pain, but from the obvious trauma involved in removing multiple teeth.  Those multi-rooted molars with rotted crowns can be difficult to remove.  The fact that infection had spread to adjacent bone, with some abscess formation, reduced the quality of bone support and made tooth removal physically easier.

Did she subsequently improve her dental hygiene?  Removing those infected teeth had to help her general health status.  She was only accepted for this treatment for training purposes in our residency program.  I remember her name because of the complex medical problems to be evaluated and managed.

 

General Alexander Haig

When I oversaw the Walter Reed Hospital dental clinic in Washington, DC, 4-star retired General Alexander Haig had ‘his people’ request an appointment for dental care at our clinic.  He is a very senior guy, also the past US Secretary of State, and past Supreme Commander of NATO forces.  But you notice, he was “retired”, not on active duty.

Our major Army mission at the Walter Reed clinic was to treat active-duty soldiers (as well as any emergencies that occurred on hospital grounds).  We were also tasked with providing specialty care for US government employees involved in overseas terrorist attacks, i.e. Africa.  Occasionally, under special circumstances, we saw and treated heads of foreign countries who would come to the US for state-of-the-art care (very high security, on a weekend when the clinic was otherwise vacant.)

If a retired General is deserving of appointments, then why not lower-level enlisted soldiers?  What should a changed policy include?  My reply was that our dental clinic did not treat retirees, active duty only.  Haig’s ‘people’ then contacted the General in charge of Walter Reed, and he commanded that we provide an appointment for General Haig.  (Patient standards for medical care were more inclusive than prescribed for dental patients.  I believe they still are.)

My reaction was to contact the US Army General in charge of the entire Army Dental Corps to see what policy to follow.  I couldn’t countermand the hospital commander without the Dental Corps Commander’s backing.  Meanwhile General Haig was already scheduled for his initial appointment.

The awaited reply from the US Army Dental Corps commander, a man I knew personally, came only a few hours before the scheduled appointment.  I could not properly cancel that appointment at the last moment.  Instead, I saw General Haig at the appointed time, did a complete examination, and treated a simple defect in one of his restorations.

Then I explained his overall treatment needs to him.  He had some long-term needs which would require multiple appointments.  Using the most diplomatic words I could muster, I explained that the clinic was focused on active-duty military.  Fortunately, he took it well, stating that, of course, he had the means to afford dentistry wherever he chose.  His concern was for those military retirees who could not afford such options.  He made a parting joke about President Clinton.

I learned in my career (perhaps not soon enough) that politics are universal.  This situation ended amicably.  The next incident I will describe did not end so well.

 

The Retiree from New Jersey

The driving time from New Jersey to Washington, DC, is 3-4 hours, with the route passing by the major cities of Philadelphia and Baltimore.  Thus, I was surprised when a military retiree from New Jersey showed up at our reception desk demanding care for his “dental emergency”.  Our reception personnel, whom I had great faith in, explained our policy of care for active duty, but he was insistent.  In charge of the clinic, I was not going to let our trusted reception personnel take the brunt of his displeasure.  Fortuitously, we had records of a previous visit by this same person.  He had shown up almost a year prior, been seen for a different problem, and, on that visit, was told that he also had a tooth that needed to be extracted.

Now that tooth was hurting.  I explained to him that his situation did not qualify as an emergency.  He would not be seen here.  When a patient is told they need an extraction but then elects to wait until it becomes painful, the pain is the result of their planning.  How many other dental offices did he drive by on his 200-mile trip to DC?  He was unwilling to spend any of his money on his neglected dental needs.  Dental care was worth zero to him, but he wanted us to redirect our efforts away from our designated active-duty mission toward his schedule for his needs.

I was adamant.  I had seen the same thing happen with middle-of-the night patients who came in when it was convenient for them.  They didn’t want to pay, and they didn’t want to take time off from work and lose wages.  This could be true even if it was their children experiencing pain.  But they didn’t mind inconveniencing our dental staff with a night-time visit.

He cussed me out roundly in front of the reception personnel and scheduled patients awaiting care.  He loudly declared that he hoped I would “rot in hell.”  It did not bother me.  I wanted it to be known to our staff that I would support them, and I would support established policies.

A month or more later, I received a letter forwarded to me from President Clinton.  This same retiree vented his written displeasure with Walter Reed, and specifically with me, and sent it to the highest authority he could think of.  I received no reprimand or other unfavorable repercussions.  Just part of the job.

When determining dental care priorities, I never cared about military rank or cost.  I had three rules: 1) Will the patient appreciate and maintain good dental health after the care given?  2) Will the patient show up for needed appointments?  3) Will the patient be available long enough to complete all required steps in the procedure?

I have little regard for those who expect me to care more about their teeth than they do.   

When it was my turn for emergency call and I had come in late at night, often the patient was someone who did not see a dentist for routine care but only came in for ‘emergencies’.  If it was a tooth that needed to be extracted and they asked me to “pull it”, I would generally write them a script for pain medication and tell them to get an appointment.  If they asked me only for pain medication for the tooth, I would usually go ahead and extract the tooth.  I wanted to change their habits away from midnight visits and towards regular scheduled dental care.  Some of those encounters, when asking only for pain medication, were more interested in getting drugs that having their ‘problem’ treated.     

Rewards Beyond Money

 After writing "Careers and a Hobby", I kept remembering the special patients and unique situations that made my dental career so rewarding.  In the US military, dental/medical care is not determined by rank or cost, the question is whether the patient needs and deserves the treatment considered.  I asked three things of my patients: 1) Will you practice good hygiene to maintain the results?  2) Will you show up for all needed appointments?  3)  Will you be assigned at this base long enough to complete required treatment?

Question number one was most critical.  I will not waste my time or the taxpayer's money.  Number two could be impaired by frequent deployments.  Number three is important because partially completed treatment can leave a patient in worse condition than no treatment all.

What follows is a story of one of many patients for whom care provided was life changing, and I will never forget. 

When Dawn suggested that I apply to dental school, instead of medical school, her consideration was that it would allow more regular hours, more time available for family activities.  My reply was, “Dentistry sounds boring.”; I had very limited understanding of dental procedures at that time.

However, I did take time to interview a dentist, with an engineering background, and was introduced to the broader span of dental procedures.  Certainly, the technical complexity and creativity needed in dental treatment, individualized for each patient, made dental practice seem interesting.  After working with patients for some time, the procedures became more routine (still challenging and tedious), and the personalities and experiences of my patients became the central aspect that made my practice rewarding.

The opportunity to apply for a military scholarship was attractive to us, both for financial support and a chance for future travel.  In dental school, some of my classmates derided the thought of practice in the US military, saying that such a practice would mainly consist of tooth extractions on patients with low appreciation for dental health, but that was the voice of ignorance.  I knew from previous enlisted military experience, that such patients could appreciate good care.

Our military service members come from a wide span of backgrounds, including hardship and foreign-born (mainly third world), but their commitment and necessary discipline come from a desire for achievement, improving their lot in life.  They have interesting stories from their personal backgrounds as well as military assignments worldwide.  When military recruitment is difficult, the US Army is forced to accept less qualified candidates for recruitment to meet quotas.

I was serving at Fort Drum, in northern New York State, when one of our dental hygienists called me over to meet a young, enlisted arrival, who had been treatment-planned for full dentures at his initial dental examination elsewhere.  I could easily see why he had been marked for such drastic treatment.

His hygiene was garbage; plaque, food debris, and inflamed gingival tissue everywhere, and every tooth had visible caries, the front teeth looking like apple cores, with the contacts between adjacent teeth rotted away.  The only reason he was scheduled to see a hygienist was that, even when surgery is planned, oral hygiene needs to be at an acceptable level to avoid surgical complications (i.e., excessive bleeding) and post-surgery infections.

Much of the bone in our jaws is there to support our teeth; once the teeth are gone, the surrounding bone atrophies.  Dentures at an early age may mean that later in life there will not be enough jawbone remaining to support dentures.  I have seen it happen.  He obviously came from a sad dysfunctional background.  Did I want to commit him to a toothless future?  Change is difficult.

I try never to judge a person by first impressions (although they are often accurate).  This was what his previous life had given him, but, now with his military life, he had a chance for a new future.  Would he be up to the challenge of changing his habits and accepting responsibility to achieve drastic improvement?

I sat with him and clearly explained why the previous dentist had recommended full dentures.  I explained that, with his absolute lack of effort toward hygiene, any attempt at restoration would be a waste of time.  (Something I had learned early in my career was that the patient must care as much as you, the provider, to achieve success.)  The treatment plan could change if his efforts toward dental health improved.  At this point, he had completely given up any attempt at hygiene.  He was in a world of ignorance, neglect, pain, and shame.  I left him with the hygienist for cleaning and instruction and told her to book his next appointment with me.

When I saw him next, his hygiene had improved little, if at all.  He was still stuck in a cycle of hopelessness.  He hadn’t fully comprehended the alternate future that I was offering.  Difficult oral conditions, copious debris and inflammation, were present, but I was able to isolate and restore a few of his front teeth comfortably, esthetically, and without exposing the pulp tissue while removing deep caries.  I handed him a mirror to view those few teeth which I had carefully restored to an original healthy form.  For the first time, he started to comprehend/believe what I was saying: “If you improve your oral hygiene, I can restore enough natural teeth to give you an acceptable smile.”

Every visit after that, his brushing and flossing efforts were greatly improved.  I had to improvise on many of the restorations because caries were more extensive than commonly encountered.  We had to extract (hopeless) all his molars and two lateral incisors (replaced by false teeth bonded in place), but to appearances, the result was a pleasing and healthy smile.  He told me, “Now for the first time I can go home, see my family and friends, and have a normal smile!”  Think of the significance of that…. Not just his smile, but his life had changed.

A year later I saw him again.  Excellent hygiene and not one defective restoration or new cavity.  He stated that the dental clinic was his favorite place to visit on our Army base.  What could be more professionally satisfying?  With dental treatment, I had been able to improve his entire outlook.

Encounters such as this were repeated throughout my career.  The military is a great place for encouraging change.  The goal was not just teeth but improving lives.  Dentistry is a very personal service.  I view my patients as good people who perhaps need some education, motivation, and treatment to correct faulty habits.  The satisfaction in doing that far outweighed any challenges involved in completing necessary procedures.