My Dinner With Andrea

…where we lament, grouse, bemoan the state of dentistry, dental education, night guards, seafood fettuccine, and proper tipping for waitresses.

 

Dr. Halligan
Dr. Halligan

A Thursday night in San Diego, California in February. Rain is falling, wind is blowing out of the south and the thermometer has dropped to about 40 degrees.

The restaurant is within walking distance of the house, and while we might normally be hearty outdoor souls who walked a hundred miles in snow in December, tonight we don’t choose to walk in the slanting rain. I drive. We’re shown to a nice quiet corner table. It’s early. The crowd has not descended.

The waitress, young, short haired, a sort of hip SoCal look, but with no visible piercings or tattoos, takes our order: Harvest salad for both of us (have you noticed a sort of farm-to-table motif almost everywhere lately?) beef Wellington for me—I have ordered it here before, the chef knows how to do it, so why puzzle over the menu? I don’t even think about it. A seafood fettuccine for Andrea. She had a similar dish at Santa Monica Seafood recently and enjoyed it.

“I’m sensitive to garlic,” she tells the waitress, “Just can’t digest it. So, is there any garlic in this?”

The waitress says she’ll find out; she disappears for quite a while but when she comes back tells Andrea she’s safe.

I order a glass of red wine.

The salad is great—strawberries, lettuce, a mild oil and vinegar dressing and the strawberries lightly sweetened.

“What about our last patient today?” Andrea starts the conversation. “When did we first see her? Was it four months?”

“Last October, yeah. Pretty good C.O. Ridiculous lateral interferences. Poor canine guidance. But healthy joints. No clicking. Nice looking TMJ images. I sent T-scan print-outs to her dentist. Thought that would make a good road map: Here, I told him. Just adjust these inclines.”

“Today she’s back and her pain is worse.” Andrea took a bite of salad.

“The same interferences are still there, centric occlusion is screwed up, her dentist must have adjusted holding cusps, and I never said to make a night guard, but he made one anyway and it sucks.”

“Sure. You showed me. Totally uneven. Only hitting on the right side. When you were out of the room, I asked her about it. Like, did they do upper and lower models? Make a bite record? She said, no. They just did an upper impression and sent it to the lab.”

“What do the kids say today? WTF?”

Andrea laughed and the waitress took our salad plates away. “How’s the wine?”

“Good. Really good. It’s from Sicily. I tried a California Malbec here once. Not good at all. I tried a Malbec from New Zealand once too. Marlboro region. Not good either. Seems Malbec has to be from Argentina. Mendoza. Only place that grape does well.”

“But, you’re a real wine snob after all.” This she said with a smirk. I can tell the difference between a good wine and a Michelob–blindfolded. Just like Nelson DeMille.

“Yep. Definitely.” The facetiousness of the interchange is lost if you weren’t there to see her grin.

“And what about Doctor D—‘s patient? What do you think went wrong there?”

She was referring to a local dentist who did a full upper arch of dental restorations recently and then the patient came to me for a TMJ exam because of pain. Another case of no TMJ problem but, oh Lord, what’s a polite way to put this? Occlusion that was so far off that he’s lucky the patient didn’t leave him.

“You know he did the upper left crowns first, then went on to do the right side a few weeks later. That was probably the first mistake. I’d just prep everything and have the lab fabricate it all together. Should be more predictable that way. Just my opinion. I talked with him on the phone before I saw her. ‘She’s real sensitive to minor bite problems,’ he told me. ‘Make sure she doesn’t have a TMJ problem, but I think her bite is real close. She’s just very sensitive.’ Well, damn it! No! She’s not that sensitive at all!”

Andrea took a sip of water. “Are you getting pissed off?”

“Yes, I am. I mean, what the hell? His patient is only touching on the left side. I tell her to close, and I can retract the cheek on the right side and see daylight between upper and lower teeth when she’s biting down. He never should have cemented those right-side crowns. They are completely out of occlusion. By my actual measurement, there’s a gap of seven tenths of a millimeter there.

“I talked with him later, you know. He knows he has to re-do the whole right side. Of course, he doesn’t want to. I know that will be damned costly, but I think he sees that there’s no choice now.”

Andrea forked some sea food out of a mollusk shell. “They did this better at Santa Monica Seafood. I didn’t know I’d just get a couple tiny pieces of shrimp and that I’d have to dig the meat out of all of these shells.” And then to the waitress when she came to check on us, “Can I get some bread to sop up a bit of my sauce?”

“Of course. I’ll be right back.”

“You know, Doctor D— is younger than I am,” Andrea said, putting another empty mollusk shell on an extra plate. “Maybe ten-twelve years younger than you are, but he looks older. I think dentistry is aging him.”

“Yeah, there were guys who went gray while they were in dental school—and they were in their twenties. Anyway, back to him and his patient, I just don’t know why we’re seeing this stuff so much. We did a chart audit a couple of years ago, and half the people sent to me for TMJ exam had no TMJ issue at all. Just screwed up occlusions. And the basics of occlusion are pretty simple. Every tooth should hit at the same time with about the same amount of force when a person closes—(I demonstrated by tapping my teeth together and the 28 little castanets sounded their solid perfect harmonious song, a sound that many people cannot make. When some people tap teeth together it’s more like a tin drum of  two or three teeth clanking and the rest following slightly out of time)—and when a person chews side to side, all the back teeth should immediately come apart. What’s so damn hard about that concept? I once heard someone say that there are more people who know how to build a rocket ship to the moon than can put a few upper and lower teeth together and make them work right. It’s probably true.”

“So, what do you think has gone wrong? And what influence can you have?”

“You know that I’m in the middle of that Charles Dickens’ biography, and it’s interesting that he was quite a social critic and reformer. He said in an interview, or maybe wrote in his journals, I forget which, that he always tried to be positive and humorous. When I think of Nicholas Nickleby and even Bleak House, I don’t think he was being particularly positive. He was downright scathing. And Nicholas Nickleby I think resulted in some meaningful reforms of some of those terrible English schools. But his point, I think, is that he tried to keep it light.

“And that reminds me of Omer Reed. Did you ever hear him denigrate anyone? I didn’t. He told an interesting story once about a new patient who came to him for exam, and this patient—a nice older lady—had some dentistry including a three-unit bridge that had leaking margins, recurrent decay and was simply failing. So, he asked her, ‘How long have you had this bridge, Mrs. Jones?’ ‘Oh, I’ve had it about a year-and-a half. My son, who’s a dentist down in Tucson, made it. But he’s been diagnosed with cancer and can’t practice anymore. I…I don’t think he’s going to make it.’ Do you think Omer said anything negative about that bridge? Not a chance. He told those of us in his lecture that day, that he was going to make that bridge last a very long time for her and not say anything.

“Remember the Tim Ferriss interview with Caterina Fake? She said that everybody she knows who is great at something was bad at it for a while. But they all wanted to become better, to master whatever it was they were doing. And that reminds me of something Omer Reed used to say: ‘Anything worth doing is worth doing badly for a while.’

“When I first got out of school, I thought I was awfully good. And I was hardly even a safe beginner. It took a good two or three years, maybe even more, of seeing failures, and my less than great results to really start learning. Pete Dawson was a big part of that. Really opened my eyes to what complete dentistry meant. Even after several trips to that big pink hotel in St. Petersburg, it still took time to sink in. Still, as a young graduate, I’m sure I knew more than most new graduates today. Gordon Christensen says that today’s dental school graduate is not prepared to practice dentistry, and from what I’ve seen, I think he’s right. Gee thanks for that three hundred-thousand-dollar education that hasn’t prepared me for the real world. Thanks very much. And worst of all, they don’t know that they don’t know.”

“What’s different?”

“I wish I knew. I have some ideas though. Today’s ceramic materials are better than we had. And bonding chemistry has come a long way. But we were exposed to real world-class detail and precision back then; at least to precision and excellence that goes beyond a lot of what we see today. I remember Peter K. Thomas. Did you know he was Marilyn Monroe’s dentist? Want to try some anterior restorations on that beautiful smile? Well, he did. Anyway, back when I knew him, I thought he was too detail oriented, too picayunish, too crazy about minor details. He said that a dentist should know the tops of the teeth, he meant the details of dental anatomy, as well as Arthur Rubinstein knows the keyboard of the piano. Rubinstein was still alive and performing back then. Anyway, does any dentist know the tops of the teeth as well as Rubinstein knew the keyboard of the piano? I don’t claim to, but I’m getting there. Do the top three percent of dentists possess that kind of detailed knowledge, the top one percent? And, it’s not a trifle thing. Who said it: perfection is in the details and perfection isn’t a detail?”

“That would be Leonardo da Vinci.”

Leonardo da Vinci, Marilyn Monroe.

“Peter K. Thomas knew the teeth that well, but beyond that. When a person closes where exactly and how does the lingual cusp of the upper molar contact the central groove of the lower, and beyond that what apparent pathway does every upper cusp travel through as the lower jaw glides in its chewing journey? Which sluiceway exactly does the lingual cusp pass, how exactly are the buccal and lingual cusps missed by the passage of the upper lingual cusps? What pathways do the buccal cusps of the lower follow? He could sit down and draw the paths of that complex motion, he could duplicate it in wax, duplicate it again in gold. There weren’t many like him. I suppose the old Silver Fox of dentistry, Rex Ingram, came close. Do you remember, maybe twenty years ago now, we re-restored a quadrant of dentistry that was originally done by Rex Ingram? That elderly patient’s upper right crowns were all failing. But then they’d been there 40 years or more. Hell, I thought I was messing with something almost sacred, like touching up the Mona Lisa.”

The waitress came with a plate of bread, late it seemed, as Andrea was nearly done with dinner and there was no longer much sauce to dip her bread into. And just as the waitress was about to set down the bread she said, “Oh, I just realized, our house bread is a garlic bread. Would you like me to take it back and find some plain?” The look on Andrea’s face said Do you even have to ask? The waitress took the tray away.

“Attention to detail,” I said. “She just lost a few brownie points.”

“How many in dentistry actually want to become better? You know, they’re dealing with insurance plans, and ever higher overhead, and government employment regulations. Must be tough just to stay ahead of the curve these days. We could teach a seminar series but who would come?”

Seth Godin says we just need a minimum viable audience. I just don’t know how small the minimum viable is. And could I be as positive and fun as Omer Reed? That guy was—is—not only a friggin genius but had a way about him too. He was Peter Drucker with a dental degree. I think he knows the truth about dental practice from a business point of view. Howard Farran seems to have a clue. But there’s so much more. What did I read recently, it was about a media figure, some guy in the news, who suddenly became much less nice, less afraid to say what he really thinks? The quote was this: ‘It looks like the needle on his I Give a Damn Meter just broke off.’ I don’t think mine’s broken off yet, but I do get just plain pissed off sometimes by what I see. Still, Omer’s words come back to me: Anything worth doing is worth doing badly. For a while. Hell, it was true of me.”

The waitress brought some plain bread and Andrea broke a slice in two and we shared. The waitress didn’t appear again for a long time. The restaurant filled with diners; outside the rain kept falling. A fire truck rumbled passed and the room was briefly flooded with the glowing red of its flashing lights. At last she brought the bill and I put down my Visa card. Later, she brought it back for me to sign. What the hell, I thought. I tipped her ten percent and we walked back to the car in the rain.

 

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2 thoughts on “My Dinner With Andrea

  1. I remember having similar conversations with a few other dentists that were friends over the years. There was a very bad period at USC when Harold Slavkin was dean. Volunteer dentists working as clinical checkers were leaving because they felt students were not being taught right. An oral surgeon friend once told me, “What are our children going to do to find a dentist?” I called the Board several times to report incompetent dentists; I can remember at least three that were eventually shut down.

    The case you described with one side open nearly a mm is an extreme. Actually, doing one quadrant at a time should not lead to anything like that if done normally. But…you’re right. Doing both sides at once with a correct bite registration should get the best result.

    And so the world turns…….

    Jim

  2. Well written and I agree. As a USC grad in 76, we had a good basic understanding of occlusion. It took many years of practice and a pros residency to become really proficient. With all that is taught in dental school today, how can the young graduate really understand occlusion? Throw in the high debt from school and the increasing impact of PPOs and DMOs and young dentists are busy trying to make ends meet.

    Don’t have a solution and well done with your article.

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