Jarrod Shapiro, DPM Practice Perfect Editor Assistant Professor Dept. of Podiatric Medicine Surgery & Biomechanics College of Podiatric Medicine Western University of Health Sciences St. Pomona, CA

Thoughts During a
Dental Appointment

Did you know I'm a TWO? I just found this out during my dental appointment a few days ago. One of the perks of being part of a university with a lot of colleges is the convenience of obtaining care (as long as you're OK with treatment by students). I have been going to the Western University College of Dentistry clinic for a little over one year now and have been very happy with their care. The students are friendly and sharp, and the faculty members are excellent. Going to this clinic for regular dental maintenance always provides me with interesting things to think about. I'd like to talk about a few seemingly disparate topics that actually blend together to form quality healthcare.

First, classifications. Let's think about my situation first. I'm a two, as I mentioned before. What does that mean? Apparently, there is a classification of gingival quality that is based on the depth of the pocket between the gum and the tooth and the amount of plaque. Zero is best, three is worst. It sounded reasonably good at the time that I was a two, and the students seemed very positive, but if you think about it, I'm on the lower half of gingival health. Too bad. Apparently no one is a zero, so perhaps it's not as bad as I think.

I'm generally not a giant fan of classifications. Most of them are just fodder for residency interview questions and for doctors to get their names into the medical literature. However, in some cases, classifications can be useful. One such classification is the International Working Group on the Diabetic Foot (IWGDF) system that categorizes risk in diabetic patients.¹ I like this classification for two simple reasons. The first is that it has been validated by legitimate research. Second, it's useful in predicting the risk of diabetic complications. Figure 1 shows the odds ratios of various diabetic foot complications as a result of each category. Validated, easy to use, descriptive, and perhaps even educational for our referring primary care doctors and patients. What more can we ask from a classification?

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Figure 1. IWGDF Foot Risk Categories and Associated Complications (PN = Peripheral neuropathy. PAD = Peripheral arterial disease).

While I was sitting there with my already big mouth open wide, I was privileged to listen to an interaction between my student dentist and her attending about proper sitting position. Understandably, dentists are going to have a very intimate relationship with their apparently expensive chairs. I listened while the attending discussed, demonstrated, and corrected my student's sitting position with a full explanation of the advantages to various sitting positions for optimal ergonomic and clinical effectiveness.

I found this highly detailed discussion very interesting for the very reason that I'm constantly harping on my students for their poor sitting and standing positions when in clinic and surgery. I can't count anymore the number of times my inexperienced students will slowly get closer and closer and closer to the surgical field while they're suturing. It's almost as if they're going to try suturing with their faces! It would be funny if they weren't going to contaminate my surgical field. In clinic, they lean over patients' feet, and a few times I've entered the room while they're working, I can swear my students are turning into Quasimodo, the hunchback of Notre Dame. Kyphosis here we come! One time, one of the students was so bent over the patient's feet that I thought one of his intervertebral disks was going to shoot out his back.

The one unfortunate part of my dental story is my student doctor didn't seem to appreciate the "sitting" discussion. I saw some eye rolling during and after the conversation. Beware to all of you who don't heed the warnings of your elders! Hunch and lean at your own risk. God only knows how much eye rolling my students do when I correct them!

When I think about these two issues, I realize how seemingly unrelated they are and yet how in reality they blend to form the basis for quality medical care. Here's how. The classifications topic is a metaphor for the mind, the thinking aspects of our medical science. Classifying allows us to better understand the implications of the diseases we treat and approach those diseases from an organized and rational standpoint.

On the other side of this coin is the physical aspect, the technique, of medicine and surgery. Proper technique takes time and experience to master (with a judicious sprinkling of wisdom from those who've come before to guide us). It's not always comfortable or easy, but mastering technique gives us the power to translate what is in the mind to the world of the physical, to actually "fix" our patients. 

It takes two sides of this coin – the mental yin to the physical yang - to make us effective patient care providers. Think of that the next time you sit down to treat a patient. It's amazing what the mind will think of when stuck in the dentist's chair.

Best wishes.

Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]

References:

Lavery L, et al. Diabetes Care. Jan 2008;31(1):154-156.

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