Special Section for New Dentists: What Dental School Didn’t Teach You by Dr. Daniel T. Quevedo

Health-focused dentistry and the conversation that changes case acceptance

by Dr. Daniel T. Quevedo

When I began my journey in dentistry 41 years ago, the dental school experience was very different than it is now. Getting volunteers from the community to allow us to practice our craft on them was not as difficult then as it is today. At the University of Tennessee Center for the Health Sciences back in the mid-1980s, we had to complete 40 units of crown and bridge, along with several units of gold inlays and onlays, before we could graduate. Today, new grads are telling me they feel fortunate if they get 10 units by graduation. If you are a recent graduate, your experience may have been a little different, but for the majority, this is the case.

Instead of practicing on live patients, many dental schools are having their students use manikins or ivorine teeth to learn both operative and crown and bridge dentistry. As you have probably already experienced, no two patients are alike. Some are gaggers. Some have huge tongues that get in the way, some have a very limited opening, and some have so much crowding that it’s difficult to do a Class II restoration without cutting or scraping the neighboring tooth. Nothing on a manikin prepares you for that, and the gap between the two is where most new grads lose their confidence in the first year.

I have had the benefit of some great educators and mentors in my career, and my goal here is to share some of that knowledge with you. L.D. Pankey was a master dentist. He understood the complex interplay between communication, patient psychology, and the art of dentistry better than most. He advocated comprehensive, patient-centered dentistry, and he had a cadre of dentists with similar skills who worked with him for many years teaching thousands of dentists how to become better clinicians. Many of the dentists who taught alongside Pankey went out and started their own centers for teaching advanced dentistry. While I never met or studied directly under Pankey, I did have the privilege of studying under a few of his “lieutenants” who taught with him at the Pankey Institute, including Dr. Peter Dawson and Dr. Michael Schuster. Schuster founded The Schuster Center for Professional Development in Scottsdale, Arizona, and Dawson founded the Dawson Academy in St. Petersburg, Florida. When you attend the Schuster Center, you’re exposed to the teachings of not only Schuster but Pankey, Dawson, Dr. Bob Barkley, Dr. F. Harold Wirth, and other Pankey-associated dentists.

This article will expose you to a small part of the philosophy of all these men, but nowhere near enough to master it. To do that you really need to choose one of these schools of advanced dental education and attend the full program they offer.

In dental school, the major focus is on teaching each student how to restore areas that have broken down in our patients’ mouths. We were taught how to diagnose the problem and how to fix it, but very little time was spent teaching us how to communicate with our patients or how to overcome barriers to treatment. The cause-and-effect nature of dental disease, and how to teach that concept to a patient, was also insufficiently covered. Sure, we learned that caries is caused by Streptococcus mutans, which produces acids that demineralize the enamel and eventually culminate in a cavity, and that diet and home care play a large role as well. But invariably, for many graduates anyway, the main focus once they’re out of school is reactive repair rather than proactive prevention.

The medical model has traditionally been reactive repair. They see patients who are sick, run some diagnostic tests along with an examination, tell the patient what’s wrong, and prescribe some medicine, with little involvement by the patient beyond taking it as directed. Health-focused dentistry works differently. In this model, the patient is asked to become an active participant in their own health, and that typically begins at the new patient comprehensive exam. If you have a consultation room, this is a great place to start. The patient is less nervous in a nonclinical area and will share more with you as you review their medical and dental history. It’s also a great time to share your philosophy of practice with them, including the benefit of paying attention to the cause-and-effect nature of dental disease. I tell them, “If I fix what’s broken without regard for what caused it to happen in the first place, we’ll just have to fix it again down the road.”

Patients appreciate this, and they see more value in what you’re providing compared with previous offices, where they might have been ushered straight back to the clinical area so someone could began working on them. Once you’re done with the pre-clinical interview, ask their permission to take them back to the clinical area and begin your examination. Always include them in the process. The best way to do that is with a good-quality intraoral camera and a good screen in front of them so they can see what’s in their own mouth. We have to do a complete initial charting on a new patient anyway, including missing teeth, existing restorations, and any disease processes you see, so why not let the patient see what you’re seeing? When it’s time to discuss treatment needs, they won’t doubt you if they’ve already seen that crack, or the crumbling old amalgam, or the carious hole in their tooth. I can promise you that well over half of all the new patients I’ve seen over the years came to me because some other doctor told them they had a long list of things they needed and they didn’t believe him. They weren’t allowed to be active participants. Their old doc looked in their mouth, called out some findings to an assistant, and then handed them a long list of treatment. I cannot overstate this: Seeing is believing.

A big part of your success in explaining cause and effect will come down to your own grasp of complete dentistry, a concept I first learned from Schuster and one that took me years to really understand. The idea is easy to state and hard to practice. No restoration is truly finished if the mouth it sits in isn’t healthy and maintainable. Teeth, bone, joints, and muscles all function as one system, so a treatment plan that corrects one part while ignoring what’s damaging the rest isn’t a plan, it’s a repair. When I evaluate a new patient, I’m looking for whatever is accelerating the breakdown, and then asking what it would take to slow it down or stop it. Sometimes the answer is occlusal. Sometimes it’s diet, home care, or stress. Usually it’s more than one of those at once, and I would much rather find all of them at the first visit than discover them one at a time over the next 10 years.

If you’re a new graduate, you already have a big advantage over everyone who graduated more than 20 years ago: You have Dentaltown. As Howard Farran famously said, “No dentist will ever have to practice alone.” There was a time when many solo practitioners felt like they were on an island, disconnected from other dentists. Dentaltown gives you the benefit of a group practice, in that you can consult with other docs about difficult cases while still being a solo doctor. Take advantage of it.

Daniel T. Quevedo, DDS, is a 1984 graduate of the University of Tennessee Center for the Health Sciences. He practiced in the Nashville area, where he treated many Music City entertainers including Johnny Cash, before returning to his childhood home near Orlando, Florida. He was a Dentaltown moderator and administrator for 11 years and, with Dr. Rod Kurthy, helped organize the annual Dentaltown meeting dinner. He is the author of The Complete Dentist: Health-Focused Dentistry for Both New and Experienced Dental Professionals.