Reality Check - aspiredental

Reality Check

Our work isn’t always easy. Sometimes it’s downright hard. But mostly, with experience and skill development and communicative puissance, it can be a wonderful career; and nearly every dentist I know is someone kindhearted, good and diligent. They are honest, clever and trying to make their way in the world like everyone else.

Nevertheless, a collective reality check – a parody based in reality – may be helpful. Let’s see.

Where do we work?

Somewhat uniquely, we work inside the human body on a fully conscious patient. Lots of them, every day.

Other healthcare professionals may have some crossover with this, but it is the exception to their daily practice. For us it’s each and every person that comes through the door. Every patient, every day, every week, every year until you can’t do it anymore.

Our patients are fully aware, they are supine and we ply our trade in one of their orifices. (Shared with ENT, Obs and Gynae, Colorectal and Urology).

Think about being supine. When do you do it? Would you do it on a bus? In a cinema? It is a position with Palaeolithic traits of submission and vulnerability. The poshest chair in the world doesn’t change that. Lying flat is for bedtime and sunbathing

What is unique about this location?

Unlike the other orifices, the mouth has multiple primary roles.

The other orifices typically have just one primary function with perhaps some secondaries tagged onto their CV. The nose is primarily a respiratory organ which can also smell. If you lose your sense of smell, it’s a shame; if you can’t breathe, you die. Primary and secondary roles.

We are far too British to discuss the hierarchy of function for all the others. You can work that out at home.

The mouth has multiple primary roles, the primacy of which can perhaps be debated. It probably relates to your lifestyle.

Here’s as stab in the dark:

Eating – chewing, swallowing and tasting. All separate processes which can be subjectively ranked by patients. To be pedantic, we can consider these to be under one primary role of consumption and digestion of essential nutrition, but that serves no purpose for us here.

When I meet a patient whose laryngeal tumour has been irradiated they are alive but sometimes cannot swallow. At all. Just imagine. Try it for an hour, you’ll fail.

(As an aside, such processes we take for granted and therefore don’t appreciate can be taken away in a heartbeat. My own mental wellbeing is helped no end by the continuous reminders of things for which I should be grateful; for every day. It’s the flip side of working in a big hospital with devastated, newly diagnosed cancer patients walking in every single day.)

Speaking – along with abstract thought and problem solving, it is our species’ power of communication which sets us apart from others. We are social creatures and to be isolated is understandably abhorrent to us. The power of spoken communication is how we ply our trade!

Sexual attractiveness – this orifice (I’m still talking dentistry and the mouth, BTW) is always on display. It is frequently decorated, enhanced, modified at the expense of its own health to be more attractive, and it forms part of your face. The power of beauty is beyond contestation and the mouth is a protagonist in that storyline. Lipstick is chosen carefully and often with expert advice from a Lipstick Jedi in a white tunic. Lips are filled, plumped, sculpted and glossed. They are optimised every day, and the teeth behind them increasingly need to follow suit. This does not aid eating or speech. It is to increase sexual market value. Nothing more, nothing less. Debate me, I welcome it.

What other factors can influence the management of this body part?

Firstly, teeth have a biologically inexplicable level of neural innervation. Most other body parts have a nerve supply and pain threshold commensurate with their vital function.

Your heart is bloody important, so issues like infarction (heart attacks) are indescribably painful.

Punches to the kidney can render you incapacitated; trauma to the eyes is immediately devastating and disabling.

Bruises to your thighs hurt, but not much, etc. Muscle is important but not vital.

Teeth are more innervated than any other body part, yet you lose a tooth or get decay….you’re probably not going to die, but the pain can be compared to the very worst of pains.

On pain scales the 10/10s can occur with:

Heart attack

Passing kidney stones

Childbirth – (interesting explanation for this one, if you ever want – not for a dental blog though!)

and…toothache. Irreversible pulpits is all-consuming and has put patients in ICU.

Who knew?

So, the pain stakes are high. As is the anticipation of pain during treatment. Heightened only by the most stupid teaching I ever received. Neural priming is real and powerful. Prime your patient to expect pain with the following phrase:

“If it hurts, just put your hand up.”

OMG, stop saying this – whoever taught you to, owes you an apology for being so wrong.

It translates as:

“Because your teeth are massively sensitive and I’m about to do something which may cause you screaming agony, I’m not sure if the agony is coming or not so be ready to jump and react – as, if you’re quick, I’ll stop causing the agony…ready…steady GOOOOOOO!!!’

Tell the patient a story that primes them for comfort, calm, and easy treatment.

Pain sensation from the teeth is carried by one of the twelve nerves which exit your brain and make your whole body work. Nerve number five in fact. The trigeminal nerve. T-Dawg.

Now, sadly, this lovely nerve splits into three and then into about a million. It has two types of fibres within itself – which makes early mild pain easy and predictable to locate, and severe longer-term pain more disseminated and confusing to locate.

This is a terrible news as late pains and severe pains will often be impossible for both patient and dentist to locate, with multiple false positives, and your treatment may be a best guess! They’re in agony, and all we can do is guess.

Patients often wait to seek help as they hope the problem will magically fix itself (so they can avoid supine orifice inspection).

The framing of the suggested treatment here is essential as you may get the wrong tooth despite your best intentions. The treatment needs to be discussed in terms of diagnostics rather than outcome. By that I mean you can guarantee to try and decipher the history, locate the cause, inspect and think hard, then suggest a most likely cause and treat that. That’s all you can guarantee, and they must know that’s the deal. Not a promise to be rid of pain, just a promise to really try.

Pain in the head is harder to tolerate for us all, too, as it is so close to the brain.

So, the pain is severe, been going for days, is hard to find, and lots of teeth could be causing it. Happy, happy.

Well this sounds lovely. Who the hell would want to read more?

Sadly, there is more.

There are only a few biological tissues which have zero or negligible regenerative capacity.

Ocular tissues

Neural tissues

Hard dental tissues

If you damage these body parts, it’s hard or impossible to regrow and heal. Compare this to cutting your hair or scraping your knee.

The mouth is a wet and warm environment with regular visits from fingers, food and sugar. All of which makes it grow hostile bacteria and fungi quicker here than anywhere else in your whole body. It wins. Gold medal. The victor.

It’s the only visible petri dish you have, and if left unattended it stinks. Like a dead goat in the sun. For a month. OMG… Perio breath…how can they not know?

Oh my goodness, can this get any worse? 

Yes, it can!!

Just one more factor to consider…just one I promise!

Certain mammalian species clench and grind their teeth if in states of anxiety and stress. Often people don’t even know they’re stressed; and some who do, deny it.

Stress isn’t an illness, it’s a state of being and it affects every dynamic cell in your body. Headache, upset tummy, skin rash, disrupted sleep, tired, shaky, no appetite, raised heart rate, altered mood….I could go on and on. Every system you have is affected by stress.

Horses, chimps and humans (plus a few others) can react this way. These patterns of behaviour are called parafunctional, meaning they exist outside functional norms.

Functional chewing forces in a human are limited by the nerve sensitivity at the interface between the teeth and the bone – the magical periodontal ligament. It tells you that you are biting, with the slightest touch, a stone or a strawberry.

Typically, 70 to 150 Newtons is the maximum amount of force passed through your teeth. The gnashers meet very little during function and worryingly meet loads and loads during parafunction.

Parafuntion causes a few big changes:

Firstly, the numbers go up. Much more force: The increase can range from x 2.5 to x 7 the normal maximum. That is loads!!! Properly loads. I have seen patients fracture roots, and devitalise virgin teeth.

Longer and more frequent force: chewing muscles lack the cellular components to regulate against overuse, so do not tire (Golgi tendons, if you are interested). Chewing food means 7 minutes of actual tooth to tooth contact every 24 hrs. Parafunction may last 20 mins to 6 hours.

The last big change is the direction and localisation of force. The heightened and prolonged force is concentrated on one or two teeth rather than being disseminated.

What is its impact on the tooth you just crowned? Now the PDL is sore. So your shiny new crown is TTP. The patient is upset….you know the rest.

Oh …One More Thing…sorry!!!

We are expensive. Now if you’ve read some of the other blogs you will be an expert in understanding how people tend to think – or rather how they tend not to.

Cost is a relative term and one person’s loose change is another’s life savings.

What does the term ‘heavy’ mean? Or ‘tall’, or ‘blue’, or ‘bright’ or ‘slow or loud’?

A whisper in a library is loud. A 20kg weight may be described as heavy but so can an elephant or a house.

I’m 6’ 2”, so quite tall, until I stand next to the head of plastic surgery who is a 22st 6’9” South African who doesn’t realise when he’s accidentally walked through a door without opening it. Seriously, he makes me look like Frodo.

The point is, people tend to think in relative and comparative terms. Which is heavier, which is brighter?

So, what are we compared to?

Well, how much does a visit to the GP cost? What about A&E? What about a week on a trauma ward after theatre to fix your broken leg?

People perceive healthcare as free. Except at the dentist. We ‘feel’ expensive.

Obviously, the NHS is not free. It costs you about £365 million a day to run the NHS (70% goes on pay). 365-mill-a-day!!!

But, folk think it’s free. They’re wrong. And they think you’re not free. They’re right.

So we compare badly, and the money issue is one I expect you have had almost no help in learning to discuss during your training to date.

Oh, it’s fine, don’t worry, it’s only for food for your children and a roof for you all. It’s not like dentists are actually real bloody people and just want to make an honest living, and feel safe without being made to feel hated and like a card-trick conman for doing a half decent job.

Dear People who set the Curriculum for Undergraduate Dental /Nurse Training (CUDNTs for short)- yes you – you’re absolutely missing some vital stuff. Missing it out is bad news!

It’s why we talk about money to our delegates a lot. Guess what, when you practise these discussions you get better at them. Amazing isn’t it!?


Our patients are people. Mostly nice and mostly normal. Some feel scared, vulnerable, and whilst lying supine may demand painless processes to keep the bacterial and fungal armageddon at bay, all the while wanting an aesthetic, functional, fragrant result on the same day.

Their potential for criticism of our work has many potential avenues, as you have read above, and each patient has their very own subjective ranking or priority.

So, what can we do?

Remember patients never sue a dentist who they like. All of the technical excellence we obsess over is important, but being liked is much, much more important.

That’s why every scenario and treatment plan is made so much easier if you develop your social and emotional intelligence.

Remember, in the decades-long research on what makes a good dentist the list below is ranked and has never changed.

What makes a good dentist?

  1. They didn’t hurt me
  2. Personality
  3. Personality
  4. Personality
  5. Personality
  6. Personality
  7. Personality
  8. Personality
  9. They made it look nice
  10. Their work lasts a long time

We need to be:

Artists, biologists, psychotherapists, psychologists, sculptors, beauticians, leaders, paramedics, advisors, planners, critics, business gurus, counsellors, microbiologists, lawyers and a whole pile more.

Despite the above, our jobs can be awesome, and we can really excel at them. By committing to quality and honesty and personal development and helping your fellow man, you can be amazing. You probably already are. Let’s see how good we can make this.

We’re enjoying helping so many with this and hope to see you soon on our Advanced Operative Aesthetic and Restorative Dentistry (PgCERT).


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