Keep digging

The more time I spend in clinical practice, the more I appreciate the idea that the more information we get off the patient, the better our treatment outcomes. As I begin to ask more questions, I begin to wonder how much I have been missing in the past. I am learning that dentistry alone can't win against an inhospitable oral environment.

I spent a good hour with a patient today just digging through their history and trying to uncover the puzzle of his dental disease. I think a good rule is, "Nothing happens for no reason" or to put it another way "If the story isn't adding up then you're probably missing something." I think at university, we were given the tools to uncover these details but weren't taught how to use them. I also think that if you can agree that it is of utmost importance to modify the oral environment prior, during and after treatment, you can agree that we all need to dig a little deeper as to what the patient is doing to themselves with or without their knowledge.

This topic has been on my mind for a while so I'm afraid it may turn out to be another long post. Enough apologies, let's put on our detective hats and start digging...

A few points to start:

• Ask broad, open ended questions first. I have found more success with "do you drink anything other than water?" than "Do you have soft drinks, energy drinks, tea, coffee, cordial, juices etc.?" With the latter, I will almost get a self righteous "Oh no, I never have soft drinks" or "or I've cut down of soft drinks" Only to find out later that they chug energy drinks all day long instead or have cut down from 15 cans of coke a day to 14. Asking specific questions distracts them from what you are really asks them and lets them go off on a tangent that you aren't interested in. Patients love to tell you what they don't do and allowing them to do this masks what they are doing.
• I have a particular dislike of sugary drinks. Personally, I think refined sugars are comparable to poison. They provide no nutritional value and have a role in virtually all chronic diseases that plague the west. However, I have to stop myself taking such a strong stance at work. Tactfully, we have to allow patients to do everything in moderation. For me, sugary drinks are best way to deliver caries into a patient. They are:
• Easily available (all shops and vending machines)
• Often combined with acid to dull the ridiculous sugar content (soft drinks)
• Are arguably "more snackable" (who eats a cake for an hour? it's easier to sip a soft drink for that time)
• Probably have a higher sugar load per "serving" than sweets and is therefore more addictive
• Are advertised as thirst quenching so are often consumed when the person is dehydrated and the caffeine in soft drinks and energy drinks will reinforce this and make them feel like another drink
• Are heavily advertised, when you start paying attention, you will notice the ubiquity of soft drink and energy drink ads.
• Ask follow up questions. I am astounded as to what some people consider reasonable and normal. What they do isn't the issue; how much and how often is the issue. When I have followed up and asked how often they do the thing we are discussing, I have gotten the following responses:
• Cigarettes:
• Just a few: 10-15 a day
• I smoke a bit: 20 a day
• 20 a day but it's okay because they're rollies
• Soft drinks: 
• A bit: 5 cans a day
•  Not that much: 4 bottles sipped over the day
• I only drink coke/I don't like the taste of water. Finishes a 24 pack every few days
• Energy drinks:
• None...well about 1L a day
• Coffee: 
• I live off coffee: I have 4 in the morning and 4 in the afternoon
• I drink a lot of tea: Can have up to 20 cups a day
• Alcohol: 
• A few rum and cokes occasionally (a 12 year old)
• 12 beers every night right before bed (couldn't figure out why he had dental issues)
• Keeps a whiskey next to the bed to help them sleep 
• They will distract you with irrelevant information, steer them back on track. It is handy to have a set list of risk factors that you would like to ask about so that when you get back on track you haven't missed any points.
•  I ask questions about diet, they bring up the fact that they have started to be healthier. Healthier than what? Well I've started putting 1 sugar in my coffee and tea instead of 2. How many do they have a day? 10-15 coffees a day and up to 30 cups of tea. That's still the equivalent of up to 45 teaspoons of sugar just from their drinks.
• Are you a smoker? No i've quit smoking, I started when I was young and have wanted to quit for a while. Oh congratulations, how long has it been since you quit? Oh it was just last week was it?
• (to the morbidly obese patient) You seem to have risk factors for snoring and obstructive sleep apnoea. NO I sleep fine, my fit bit says I get 8-9 hours a night. 
• Especially the males: What brings you in today? I just want a check up. "silence". But this tooth has been broken for a while, and my teeth get sensitive, and my jaw hurts in the morning and so on and so forth.

• Use logic and reason. The story they tell you has to match up to what you see in the mouth. They WILL claim they are taking are of themselves but this is as subjective as it gets. It is your job to unravel the true story. It is not your role to berate them, in fact this is what they expect but it is your responsibility to educate them and guide them. Cynicism is good but being an arsehole about it isn't. Take note of:
• I don't know why this is happening, I brush my teeth twice a day: The point here is that most people don't brush for long enough or effectively enough. Interdental cleaning is of paramount importance. Plaque disclosing dye can be helpful is visualising their hygiene and point out the fact that on their bitewings, all the decay and bone loss is interdentally and there is calculus everywhere that they cannot possibly clean off.
• I fell pregnant/got osteoporosis and all the calcium leeched out of my teeth: I mean it just doesn't make sense on a fundamental biological and cellular level. But let's draw the truth from the statement. Pregnant women will have cravings for certain foods and will experience gastric reflux often. However, these are exaggerations of the aetiology of the normal caries process rather than caries through some biological process unique to pregnancy. Hormonal fluctuations can lead to exaggerations in periodontal inflammation but this does not extend to caries as far as I know. Osteoporosis often accompanies advancing age and I often note in this age group that recession has led to food packing, frailty has led to a decline in oral hygiene and cumulative trauma through function has led to the breakdown of heavily restored teeth. Logically, enamel is acellular and avascular and so shouldn't be affected by body calcium balance and if anything, dentine should continue to become more sclerosed and highly mineralised with age. 
• I didn't have any problems until the previous dentist ground my teeth/did a filling I didn't need/tooth my tooth out: Don't judge your colleagues based on the patient's report. I don't think I can stress this enough. I feel there is a lack of collegiality these days in the name of business. I have never and hopefully never will talked trash about another dentist's work to a patient. To be fair I have only worked in rural and non competitive practices but it's more the principle behind it. You don't know what the conditions were like at the time. And patients lie. I would like to think my colleagues extend me the same courtesy when they are silently judging my work. I know that I have had off days in the past and off days lead to more off days. No one is perfect. Instead, hopefully you can approach the patient with a rational "Well I can't comment on their work because I wasn't there at the time, but what I do know is there is a problem now that needs addressing." Be sure to double down on your records because these are the patients that you may need to defend against one day. Memories can be sketchy, but hard copy evidence is rock solid. Your notes will trump their claims most days of the week.
• If you have questioned them and still haven't been able to match up the story to the situation, keep digging. There is always more to the story.
• Put the onus on them to improve themselves: You can work on them but it will fail if they dont change they have to choose between their vices and their teeth. you aren't their carer, you're their dentist. This is a point that I continue to struggle with. It's a fine line between delivering a lecture and encountering resistance and shying from the subject and having no effect. 
• The classic example is the long term, male smoker in his 50s. When you broach the subject of periodontal disease or smoking or the condition of his teeth the defences go straight up. He is used to being berated by health professionals about his smoking. He knows it's bad for his health but he's not going to stop because some hotshot doctor tells him to. You know just by looking at his eyes he's waiting for you to mention the smoking. Do you mention it and risk losing his attention for the rest of the appointment or do you let it slip and have fail to address the situation.
• Patients have to realise they are in charge of their own health. If they want to live the way they want without considering what it is doing to their body then they must be able to accept the consequences. Tell them that they have problems that you can address. Tell them that you'll do their fillings and take out their teeth as they need but the fillings will develop decay around them and they are likely to lose more teeth if they don't change the way they treat the environment in their mouth. At some point they are going to have to choose between their love of smoking/sugar/acid and their teeth.

The oral environment is an extremely harsh environment that is strongly affected by patient's decisions. When considering the treatment of these patients, we as responsible health practitioner must focus on modulating these environments by minimising the topical exposure of cariogenic substances, addressing systemic conditions e.g salivary dysfunction, gastric reflux and by the implementation of targeted, effective oral hygiene and remineralisation strategies. Along the way, there are roadblocks that may stem from the patient's inability to accept their role in their own health. The health practitioner needs to cut through this facade and make the patient realise that they need to pull their own weight if they want things to improve.