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.