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My View: Only you are you

December 10, 2019

By Stuart L. Segelnick, D.D.S.

Segelnick
Stuart L. Segelnick, D.D.S.
The ADA FDI World Dental Congress was held this year from Sept. 4-8 in San Francisco. At this event, the ADA House of Delegates meets to conduct the business of the ADA. Unknown to most dentists, yet renowned among dental editors, is a meeting conducted by the American Association of Dental Editors and Journalists, which traditionally precedes the annual ADA meeting. This two-day annual conference at the Marker Hotel San Francisco was well attended and had many fine speakers. Dr. Michael Glick, editor of The Journal of the American Dental Association, routinely lectures at this meeting, which also includes visits from ADA leadership. On the first day of the meeting, ADA Executive Director Kathleen O’Loughlin stopped by to give an update on what is happening at the ADA. During her conversation, she highlighted the problem of today’s young adults diagnosing themselves on the internet and shared that their main oral concern is having straight white teeth.

Sitting studiously in the audience, while speedily transcribing Dr. O’Loughlin’s ADA update, a part of my mind couldn’t help but recollect a recent upsetting patient interaction. Mr. D’identify (Mr. D.) was a middle-aged man who happened to find me on the internet.  My online presence isn’t as strong as it could be since I don’t advertise on the web or follow the myriad of recommendations website gurus suggest, which is why I was pleasantly surprised to greet him. His chief concern was to save his front teeth. He knew he had gum and bone loss and loose teeth, which was confirmed by several general dentists he recently visited. Mr. D. was not comfortable with any of the dentists and was currently seeking a new general dentist. Medically, Mr. D. said he was healthy; however, he hadn’t been to his physician in years and currently smokes a pack of cigarettes a day. When further prompted to relate exactly how many cigarettes, he admitted to smoking two to three packs a day. After my comprehensive examination and evaluation of his periodontal condition, along with a full set of X-rays he brought from his past general dentist, I diagnosed him with generalized stage IV grade C periodontitis. I requested he see his physician for an updated medical evaluation and consultation.   
 
Without getting into all the decisive details of his evaluation, Mr. D. presented with generalized severe attachment loss, especially on his anterior teeth, where he had deep pocket depths, two to three mobility coupled with occlusal trauma, and 90-95% radiographic bone loss. The obvious recommendation would be to remove them. I tried to explain with sincere empathy that the best long-term solution — and probably even short-term — would be extracting all his anterior teeth. I continued, “A full mouth reconstruction, including dental implants and the expertise of other specialists such as a prosthodontist, endodontist and…” when I was suddenly cut off by Mr. D. He told me his opinion, which was that his teeth were all salvageable, especially his front ones. He then described the hours of internet research he performed online. He did many Google searches and saw tons of YouTube videos that confirmed people in his situation saved their teeth with periodontal therapy. I appreciated all his internet research efforts though I felt they were not realistic in his specific situation. “Doc, I saw the pictures of their teeth and gum line and even their X-rays looked just like mine,” he insisted. I tried to counterpoint his insistence by utilizing his own list of treatments he viewed online and wanted me to perform on him, which he felt could save his hopeless teeth, such as nonsurgical local delivery antibiotics, noninvasive gingival grafting techniques and even laser-assisted periodontal therapy. After a lengthy discussion trying to educate Mr. D. by showing him numerous high-level scientific studies supporting my recommendations and refuting his, I believed I was making progress.  

However, Mr. D. refused to have any of his teeth extracted, and we agreed I would begin nonsurgical periodontal therapy. Many people I have encountered are not psychologically ready to lose their teeth, and for some, a slow transition is helpful. As dentists, I know we love to present expectable treatment because we strive for predictable results. I truly go all out to have happy patients who are satisfied with the work I’ve done and enjoy their teeth or implants for many years. He left the office and scheduled a scaling and root planing appointment.    

Mr. D. never showed up for his appointment. He never called to let me know and probably was well on his way to get other opinions from another periodontist. I called him up to see why he wasn’t returning. “Doc, I’m sorry I didn’t call. You told me the treatment you could do for me and the treatment I wanted you to do would not last, and I want to keep my teeth and for it to last, so I decided to go somewhere else,” he bluntly said. “I saw online that these treatments work on people just like me.” I couldn’t hold myself back, so I interrupted Mr. D. and said, “That’s impossible, since what you saw online did not show any of the measurements and medical and dental history I took on you, because only you are you.” I continued, “No one else you saw online or on YouTube is you; you are unique and the periodontal condition you have interacts with yourself in a way no one else could compare with; it’s personalized. Please, can’t you agree that only you are you?” I was slightly happier when he begrudgingly agreed. Yes, you may think, like I did, that Mr. D. would value the opinion of a board-certified periodontist with expert knowledge and 25 years of experience in treating periodontal disease. Then you too would have been wrong.

Mr. D. never returned. He was searching for someone to perform his self-proposed treatment. What would happen if I did listen to Mr. D. and we tried these procedures that I knew would be ineffective for the long term and most likely for the short term, without even tackling the ethical issues? Would he remember, after spending all the time, effort and money on his self-proposed treatment procedures, our conversations? Would Mr. D. be very upset if he wound up having to lose his teeth in a year, probably? I am waiting for some guidance from the ADA on how we can do a better job educating this new generation of internet self-diagnosing, treatment-planning, health-concerned browsers. Maybe the ADA can produce YouTube videos and updated online information, ranked high on Google searches, focused on this group. Unfortunately, the first thing they see online may more effectively persuade this new internet-savvy generation to have needed treatment than the hours they spend speaking with their dentist.     

This editorial, reprinted with permission, first appeared in the October issue of the Bulletin of the Second District Dental Society of New York. Dr. Segelnick is the editor of the publication, vice president of the American Association of Dental Editors and Journalists and an adjunct clinical professor in the department of periodontology and implant dentistry at the New York University College of Dentistry.