Dr. Manu Dua by Arselia Gales, assistant editor

Young Canadian dentist overcomes adversity in his personal and professional life

by Arselia Gales, assistant editor

Dentists spend most of their working hours in their practices, so they usually don’t get many opportunities to see what it’s like inside another doctor’s office. Dentaltown magazine’s recurring Office Visit profile offers a chance for Townies to meet their peers, hear their stories and get a sense of their practice protocols.

In this issue, we introduce Dr. Manu Dua, who faced a lot of challenges when opening his practice three years ago. And more recently, he was diagnosed with oral cancer and underwent major surgery. With help from his friends and Townies, Dua has managed to maintain an upbeat demeanor despite these less-than-ideal circumstances. Read on and see how he manages his practice and how has life has changed since his diagnosis.

What inspired you to pursue a career in dentistry and to open your own practice shortly after graduating?

My sister, who’s about eight years older than I am, is a dentist and was a huge inf luence in my path to dentistry. At a young age, I was always interested in helping people and working with my hands, and dentistry seemed the most logical pathway to providing excellent care while doing what I loved. The relaxed lifestyle and flexibility in terms of ownership and having the ability to determine my own fate more than other professions was icing on the cake.

What obstacles did you experience when you first opened your practice in 2016? How did you overcome them?

I feel a better question would be: What didn’t go wrong? I started in 2016 amidst one of the worst recessions in our oil-driven economy and got into a bidding war for my space. Because it was two units and one was zoned medical and the other retail, I ended up having to fight City Hall with head city planners and the original architect to finally zone the place all medical. This took more than six months of negotiations with the city and lots of willpower.

When I finished construction, we went to get occupancy to start and it turns out my building didn’t get it, so I had to wait for more than a month with a full staff unable to work while the landlords got paperwork in order. Once we were open, someone broke into my practice in the first month. I went in on Saturday morning to work, but was greeted by smashed windows, police and some confused patients and staff.

Soon after, the clinic got flooded in our main ops and the server room. That was fun to take care of. Within a few months of opening, my vacuum wasn’t installed properly by one of the big three suppliers, so it shut down and took 12 hours to rebuild. Then, my brand-new sterilizer went down. I remember it went down Friday and we had patients on Saturday. So, I called a friend and took the instruments at 6 a.m. to his clinic, had them sterilized, then drove back to my clinic so we could work. It’s been a very
arduous journey, but the pride and joy of finally having my own space gave me the sheer will to overcome.

Wow! You definitely had to deal with a lot in a short period. What’s the dental market like now in Calgary? What are some of the pros and cons of the area?

Currently it’s very tough, because we are still in a bit of a recession with no end in sight. Competition is fierce with lots of nice new clinics coming up, and with corporate dentistry slowly moving in with economies of scale, it’s definitely not easy going right now.

A few years ago, Calgary was the “prom- ised land” for dentistry, with lots of oil money and many patients with insurance. But all good things come to an end, so we’re dealing with a bust economy, which requires a lot of creativity and excellent patient care to survive. The issue with being in a recession is that during the prime times, many clinics built were not only beautiful on the inside but also invested in a lot of technology and attractive features, which makes it easy for patients to shop for dentists.

Calgary itself is consistently ranked in one of the Top 6 places in the world to live in. We are close to the Rocky Mountains, Banff and Lake Louise, which are some of the most beautiful places on Earth.

You say you like to run a more traditional practice and focus less on all the bells and whistles of new and upcoming technologies. What exactly does that mean, and how do you achieve that?

I have found in my seven years of practice that some of the longest-lasting and most fundamentally sound dentistry has been from decades ago using more traditional materials and techniques. Don’t get me wrong, I appreciate the technology, but we have to stop and think that for most patients, especially when in a recession, they neither desire nor need all the bells and whistles. For example, a gold crown will outlast any Cerec crown. At the end of the day, what’s longer lasting, less expensive and more conservative for the patient is always the right answer. I find that over time, dentists get bored and they invest in technology—which is great, but then they get into the trap of making the patients fit the technology, as opposed to determining if the technology is right for the patient.

I truly believe that it is the carpenters and not the tools that determine the end results of good dentistry. Hand skill, proper isolation, patience and the ability to know one’s limits will always trump single-file endos, magical bonding systems or digital scanners. The foundations of good dentistry are and always will be timeless.

In addition, you like to maintain the balance between providing exceptional treatment at reasonable cost. How do you do this? Why is this one of your philosophies?

I worked hard to develop a supply-chain management system to keep inventory reasonably low. I researched extensively to find quality materials at reasonable prices to provide the best care without passing supplier markups to patients. Materials have advanced so much in our time that it’s not necessary to always shell out for big brand names when other manufacturers provide excellent products at more reasonable prices. I also built the clinic to be efficient in terms of carts for procedures, for us to set up quickly and do as much same-day dentistry as possible.

What’s an average day like at your practice? What does your patient population look like?

I wish I had some form of system and block scheduling but it’s more like the Wild Wild West, anything goes. We can start with an implant, bounce to a molar endo, then take out some “wizzies” all within a few hours. I have a lot of older patients; many have a lower income with lots of challenging restorative needs. In fact, I would say my restorative is more challenging than my endo, crowns, implants and extractions. I know most people glamorize the latter but good quality restorative in mouths with poor hygiene is very difficult in my opinion.

How is your practice laid out? How did you go about designing it to make it more inviting to patients?

I wanted it to be fresh and new but without intimidating the patients. I found teal to be a very soothing color and I really wanted it to transition throughout the clinic. One of the unique features in our clinic is a wave that goes down the hallways. It has texture, starts a light teal and transitions to a darker blue similar to the ocean. We get a lot of compliments, as not only is it unique, it really provides a great effect of distracting and soothing patients. All our cabinetry is custom, and we kept the clutter in the rooms minimal, coupled with 12-foot windows and multiple TVs. The ambience is quite unique and minimalistic.

How do you market to new patients?

When we first started, we did the traditional route of mailers, website and AdWords. But as we grew over the years, I’ve found Google on its own and word- of-mouth are the most effective. We have never advertised any promotions and we don’t do new patient offers. I figured my best and most cost-effective bet would be good ol’-fashioned word-of-mouth.

What gives you the most professional satisfaction?

I would probably say doing things that patients didn’t conceive as possible by saving teeth that had no business being saved and yet lasted for years. We call these “Hail Marys,” and by far they are my favorite procedures. I also love to get patients out of pain. I prefer the functional and pain management aspect to dentistry over the cosmetic. I find the appreciation of patients for the most part genuine and sincere and it warms my heart.

What’s something you’d like to see dentistry do differently, as a profession, within the next 10–15 years?

I would like us to shift back to a more pragmatic approach, and provide tools for newer dentists on how best to manage difficult restorative and save teeth as much as possible. I place implants, but I still think we are shifting far too fast toward not giving teeth a chance. I think with some tips and techniques, we can service patients’ teeth for much longer than we might even think possible.

What are some of your hobbies? What do you like to do in your spare time?

Usually, I would play sports, including rugby, squash and golf, badminton. I also like working out. We are surrounded by the gorgeous Rocky Mountains, so I take my kayak out to the lakes and have great little trips out there. It’s very serene and relaxing. Sometimes I like to cook and bake, and have been known to make the occasional cheesecake or brownies for my staff. A well-fed staff is a happy staff.

You were diagnosed with oral cancer in July. What support did you receive from the Townie community once you got your diagnosis? Was anybody particularly helpful as you worked through this difficult time?

I mostly kept quiet about my diagnosis, but a few close Townies who’ve become friends over the years were quick to give their support and offer any help they could.

I wanted to give a huge shout-out to my friend and oral surgeon in Calgary, Dr. Lee Darichuk (“IcedOMF”). He unfortunately was the person who had to give me my diagnosis, and since then he has been nothing but amazingly supportive and compassionate, even visiting me multiple times in the hospital. He will always be my brother for life. Also, I wanted to thank Dr. Fayette Williams (“toofache32”), who is famous on Dentaltown. Dr. Darichuk put me in contact with Dr. Williams, who was amazing in taking time out of his day to take my calls and address my fears and concerns and be supportive during the process.

How did you go about notifying your staff and instituting a plan while you’re out for recovery? What measures did you have to take?

I basically had to have a staff meeting at the end of a normal workday and drop the bombshell. Some staff had noticed my lesion and knew something was wrong, but nobody was aware that it was oral cancer. I have a lot of local friends who were key in posting a locum position for me, and eventually I was lucky enough to find a great dentist I’d worked with before and trusted.

How will your practice run while you’re in recovery? How did you come to this decision?

Probably the only blessing of this whole ordeal is that it has taught me to let go, which is hard for most dentists. I was lucky in that not only do I trust my staff but also my locum is a friend and his work is exemplary, so that allows me to sleep at night. I tried to do the bookkeeping and payroll at the hospital and mostly just do a little admin work as I heal. I didn’t really have too many choices, so I did the best I could do and let fate take care of the rest.

What does the road to recovery look like? When do you plan to return to practicing full time?

The surgery was difficult. They took out half my tongue and transplanted skin and the radial artery from my left hand to my left tongue. They then grafted skin from my thigh to cover my arm. The good news is that I am recovering well, and I retained most of my speech. My left arm still gives me sharp pains and discomfort from the graft, but I am working through physical therapy for that. The biggest factor will be my ability to eat and get my range of motion in my neck back after the neck dissection. I am hoping to take about two months off and then slowly ease into things.

Doctor, Heal Thyself

The subject of this issue’s Office Visit, Dr. Manu Dua, was diagnosed with oral cancer in July 2019. Here, he shares his innermost thoughts about his journey: receiving his diagnosis, his extremely complicated surgery, and how he’s handling his road to recovery

We spend most of our professional lives diagnosing, treating and healing other people. However, sometimes in constantly treating others, we become immune to the fact that someday those conditions may affect us. When that day comes, we realize not only are we not immune but also that our lives are fragile and precious, and we need to stop and appreciate what we have, for soon it may be gone.

My oral cancer diagnosis

I had until this point convinced myself to live in constant fear—fear of failure, fear of rejection, fear of staff issues, fear of clinic issues and fear of life in general. The irony is, I didn’t understand what real fear was until I was faced with one of the most frightening prospects—my cancer diagnosis. I had just poured the best part of three years building a startup and surviving a recession and slow economy. Just when things were looking great for me, I got devastated in the worst possible way.

It started with an innocent sensation: I woke up feeling as though I had bit my tongue. I spoke to my colleague and best friend about it, because the feeling did not go away. Over the next few weeks I noticed an ulcer form, and eating had become painful the minute any food touched it. Concerned, I booked an appointment with an oral surgeon to look at it.

To add some context, I’m a healthy 33-year-old with no history of smoking or chewing tobacco, and I rarely drink alcohol. The first thing I asked my surgeon was if he thought it was malignant. Based on the symptoms and my great health history, we both thought it highly unlikely.

We tried a round of prednisone, because the symptoms were very close to erosive lichen planus, but that did not resolve. The lesion progressed, and I was getting earaches and constant pain in my lower jaw; I found it hard to sleep and focus at work. I tried my best to put on a brave face as we biopsied the lesion soon after the round of prednisone had no effect.

I won’t forget the Thursday afternoon in July when my friend and oral surgeon Dr. Lee Darichuk surprised me with an unexpected visit. He had come after work to personally give me the results of the biopsy. Until this point, I was very confident that it would be some form of autoimmune disease, because until this point, all of my training from dental school had heavily skewed my opinion toward a sense of arrogance that it couldn’t happen to me because I didn’t smoke, chew or drink. Also, the lesion was painful, and we’re taught malignancies are rarely painful. Imagine my surprise when he sadly informed me that I had squamous cell carcinoma of the left side of my tongue.

I would like to say that at this point I was completely devastated, but that wasn’t the case because I had watched one of my close friends battle a rare form of non-Hodgkin lymphoma for more than a year. Watching him go through multiple rounds of chemo and struggle with the effects of a bone marrow transplant really hardened me. I was there for his 30th birthday when he was in the hospital hooked up to IVs. There’s a sense of sadness that’s hard to explain in watching someone suffer for no fault of their own.

I had learned a long time ago that life was neither kind nor fair, but the unjust suffering of good people is hard to bear for even the strongest of people.

I scrambled to find a locum to bail me out, because I was a single dentist in a growing clinic with six staff members. I was living the nightmare every single owner dentist has, especially younger dentists with big bank loans and fledgling startups to take care of. My concern was also for my staff, many of whom depend on the clinic for their livelihoods, and for my patients who have been kind enough to honor me with their trust, which is hard to replace. The ENT surgeon had rushed my case, so I had less than two weeks to find a locum to entrust my life’s work with while I was recovering.

With the help of a friend who’s involved in the local dental community, I posted a locum position and soon I was blessed with a response from a dentist who had recently sold his clinic and was looking to locum. Turns out I had worked with him before, and not only was he a great and kind person, he was an excellent dentist. During this whole process, my locum, Dr. Jeff Bilodeau, has been amazing in keeping the clinic going and taking great care of my patients and staff. Most importantly, he has provided me with a huge sense of relief because I could focus on recovery and not worry about my clinic.

The next steps

My surgery was booked for eight hours. They had to remove about half my tongue and send each specimen to a pathologist for examination. They then removed a flap from my left arm and transplanted that to replace the removed tongue section. To keep the flap healthy, they transplanted the radial artery from my left hand to the tongue area to provide vasculature, then removed a section of skin from my left thigh to cover the left-hand area.

Because of a suspicious CT scan, they suspected lymph node involvement. They completed a neck dissection and removed the lymph nodes from the entire left side of my neck. To prevent the swelling from affecting my breathing, they performed a tracheostomy, an insertion in my neck to allow me to breathe. However, I was unable to speak while it was inserted. It took two ENT surgeons, two plastic surgeons and one vascular surgeon to take care of me, and I am eternally grateful to them all.

The (difficult) road to recovery

The entire hospital stay was a roller coaster of emotions and scares. They woke me up every hour for the first five days and every two hours for the remaining six days, so I basically didn’t sleep for more than a week.

On the fourth day, I developed a severe facial infection. My face was so swollen I couldn’t close my mouth for three days. They did an immediate CT scan, put me on IV antibiotics and rushed me back to the OR to drain the area, but because it was so spread out, all they could do was wait for the antibiotics to kick in.

At this point, I was unsure if I’d come out of the hospital alive. I hadn’t slept in days and I had a respiratory tract infection from the trach and a fever, and had somehow developed asthma. These were some of the darkest days I have ever experienced.

As the antibiotics kicked in, my condition started to improve and I made a promise to myself to come out stronger than ever. As I sat there sleep-deprived in a hospital bed unable to speak, I learned that the greatest wealth in life is the love and care of our loved ones. My friends and family stood by strong and gave me the courage and will to heal. No amount of money could have saved me from this predicament; no amount of practices, houses or cars would have rescued me. It was the skill and dedication of a team of surgeons and nurses and the love and strength of my family and close friends that gave me the will to survive.

Not being able to speak for two weeks teaches a person many things about the value and importance of words. I learned how to listen, how to appreciate things far more. Often we are too busy trying to get the last word in before even listening to our fellow humans. We need to speak more kindly to each other.

The first month after the surgery was the toughest for me, because I had to learn how to speak again, practice swallowing and eating, and learn to use my left hand again. Despite all the pain and nerve issues from my hand, I was focused on making the best of my second chance in life. Often we take what we have for granted until it is cruelly taken from us. I have taken this opportunity to slowly heal and work on myself.

Looking forward

Despite all the pain, emotional turmoil, and the cruel and unnecessary nature of cancer, I have come out of this experience strong and extremely thankful and grateful for all that I have and all those around me. It has given me a sense of perspective I would never have had, and has given me the strength and fortitude to live in the best possible way—full of kindness and without fear.

I wish this experience upon no one, and the most positive thing I can say is that it has given me the ability to truly appreciate what I have and a burning desire to make the best of my second chance in life.

My sincere hope, if someone has taken the time to read all of this, is that you shouldn’t have to face death to understand the meaning of life. No matter what circumstances you have in life, stay strong and embrace all that life throws your way, because living in fear is no way to live.

Refuse to let your life be defined by your circumstances; rather, find the inner strength and courage to respond and thrive amidst the most difficult of times, because we are all much stronger than we could possibly begin to imagine.