Optimal Oral Health and 80/20
It was a beautiful spring day this May when it was time to celebrate our third annual 80/20 club meeting. 80/20 club meetings are a celebration of the success of my 80 years and older patients who have maintained at least 20 of their teeth in there lifetime. I know, it may sound a bit silly, but it has become one of the most rewarding occasions of my dental career. Today, when the geriatric population has so little to grasp onto and celebrate when it comes to a health success, this specific elder population group of club members, have a positive dental health accomplishment to share with each other. This year’s theme at the 80/20 event was entitled “It takes more than one.” Though the years, I have come to realize that I cannot do it all myself, and the success of our patients has to be shared with my staff, the specialists I work with so closely, and most importantly, the patients themselves. It is this accumulative group effort that brings forth the success of 80/20. However, I cannot take full credit of this idea. Prior to our first 80/20 party, I had read about Dr. Yasuo Kawamura in Japan who had created the original idea of 80/20. In Japan, the tooth retention rate is much lower then it is here in the United States with the average 80 year old adult with a tooth retention rate of five. He had created the “Aishi” club consisting of patients who wanted to do what was necessary to never loose their dentition, ultimately reaching 80/20. This is a very high honor for an Aishi club member. In The Challenge of 80/20 Dr. Kawamura stated: “In order to carry out dental treatment, a dentist and a client need to have a interpersonal relationship. We must treat a client as an individual and tell them that we are interested in them as well as their teeth.” We could almost say that Dr. Kawamura is the Japanese version of L.D. Pankey due to their shared visions of relationship centered comprehensive care. Imagine, trying to accomplish dentistry in such a manner, that unless absolute necessity dictated it, you do not extract teeth that can be saved with the goal of optimal dental health.
To some in our profession, this may sound ridiculous. Often when I speak in front of groups I ask the simple question; “what is our primary role as dentists during our career?” I would have to say that unequivocally, the number one response is to treat, or keep patients out of pain. Now assuming I disagree with that response, which I do. I am going to ask all of you again; “What is our number one goal as dental professionals during our career?” The answer my dear friends is very simple. We need to help our patients keep their teeth a lifetime…period.
Keeping teeth may sound very simple and mundane, but since we inherit patients at all different stages of their dental journey, it really can be difficult to help someone accomplish optimal dental health as it applies to them. Imagine all of the aspects we need to consider with today’s knowledge. Periodontics, masticatory system function, decay, pathology, parafunctional habits, implantology, endodontics, and so on. However, notice I didn’t mention the aspects of dentistry of cosmetics or esthetics. Can one include this topic if our primary patient goal is to help them keep their teeth a lifetime? In reality, esthetics is a subset of dental function and even as important as most of you would feel it is for people, it has very little to do with the concept of helping people maintain their teeth a lifetime. Oh, but now I can hear a small group clamoring in the background; “but Dr. Myers, form follows function.” This statement would lead to the conclusion if the mouth functions correctly, form or esthetics will follow. I agree!
So now I hope we have come to the agreement that our goal as dentists is to help our patients obtain or maintain optimal oral health for their lifetime with as little tooth loss or iatrogenic disease as possible. Unfortunately, there are often barriers to this form of treatment as created by both the patient and or the dentist. I would say from my experience that the blame can be placed equally between the two. As dentists, how many of us take the time to first fully understand who the patient is as an individual or to do a comprehensive exam on our patients in order to fully understand their needs both personally and dentally. Is the educational level of the average dentist today at a level of proficiency in the two major forms of breakdown, bacterial and functional to evaluate the information obtained? Is the knowledge there to help restore our patients to a functional and maintainable level of optimal oral health?
From the patient’s perspective, are they at a level of understanding of their own dental problems to fully grasp any solution we may try to give them? Most patients present to the dentist with the mentality of here are my teeth, if I could take them out of my head and hand them to you to repair I would be happier, so just fix them and let me go. And typically, this patient would fade away until the next crises arise for you to “repair” for them. How wonderful would it to be for a patient to “want” or “ask for” quality dental care. For this to happen, the patient needs to have ownership or stake in their own health for them to reach this level of seeking out care. In the 2003 report on ageism by our Surgeon General Dr. Richard Carmona, he states; “We can no longer afford to have Americans believe oral health is separate from their general well-being. Improving the health literacy of the public, including oral health literacy, is key.”
You see my friends; the concept of optimal dental health is a synergy between competent dentistry and patients who have understanding and ownership of their dental needs. Then through comprehensive care, we develop a doctor patient relationship with the same goal in mind, natural form and function of teeth for a lifetime. And this has become the hallmark of an 80/20 patient.
Now, how are we going to develop a path of creating this type of success? The starting point in the patient journey should be what many term the Preclinical interview. It is this time of general conversation that you begin to try to understand who your patient is as an individual. Why are they there, what are their wants and expectation for themselves and from you. Do they have an appreciation of what dentistry can do for them? How do they feel about their past dental experiences and how that may influence their thought processes? This can be a very difficult process for they typical introverted dentist. However, imagine the impact of reaching out and understanding the person behind the mouth we are going to treat. Dr. Irwin Becker at the Pankey Institute would explain this process as breaking through the outer shell many patients present with and reaching into the inner core and excepting this person as who they really are without any prejudices .
At this point to gain some trust from the patient we address or recognize their chief concern or complaint. Now notice, I didn’t say necessarily fix the problem. Jumping to this solution would be the first and most common cause of avoiding comprehensive care. This would be the quick, commodity type of care that after we complete the patient is excused until the next unit or commodity based repair is needed. The correct path would be beginning a process to help the patient understand what created the chief complaint in the first place. Therefore, we offer the patient to embark on a journey of co-discovery to help them understand what their dental needs may be. The term commonly used for this experience is the comprehensive exam. This is a time to gather information with the patient for us to study and learn their needs from. This evaluation is based on how the masticatory system functions and includes joint and muscle exam, a complete periodontal evaluation, a complete biomechanical evaluation, and a complete functional exam. More often then not, this cannot be completed without the aids of articulated models in centric relation, high quality radiographs and today’s standard of dental photography. When the effort is initiated to gather this information the simple concept must be kept in mind that you cannot fix a problem, until you understand what it is and how it was created.
From the gathered information, you must then develop the skills to present this information to the patient in a manner that is meaningful to them. They can take this knowledge and your advice to help them maintain or restore their dentition to optimal dental health. The ideal plan always has an optimal endpoint as decided for a particular patient’s circumstances and timeline for them to reach it. I never care how long it takes for me to repair a dentition as long as we never dentally regress. Too many of us feel we need to restore our patients immediately and that is just not true. This fix it quick approach can often overwhelm the patient or lead to poor dental care.
The journey of lifelong progression to 80/20 has to begin at an early age and it is our responsibility to promote life long optimal dental health. Many of my colleagues do not perform comprehensive evaluations on their “younger adult” patients because they do not have any perceived needs. Now we know that the most important need of the patient is education and early acceptance of their responsibility in taking care of their health. We also can use this time to develop relationships and trust so when dental needs develop, the patient will listen to our advice. The long term patients in all of our practices are those who accept treatment more readily because of the interpersonal relationship that has grown through the years. In my office today, the 80/20 club is well known and is now a motivator for many existing patients.
You now hopefully see the light of the success of 80/20 or lifelong optimal dental function is only possible when the patients take ownership of their health and oral conditions. From observing and getting to know my 80/20 club members, I have found that most of them have taken responsibility in most aspects of their lives. We have the responsibility to help them learn about how we can help them, but we also have the responsibility to not create situations that may under mind the success of our patient to reach 80/20. Remember, if you trust your knowledge, skill and experience, always ask yourself; “What would I do on this person if it were me?” With that, I hope all of you make it to the 80/20 club yourselves…will you?