Expressive writing

Getting good ideas seems to be difficult especially in these day’s corona virus circumstance. The number of patients per day and the profit had gone down since the outbreak of the virus. They are recovering now, but far from those before corvid 19. It is painfully stressful, and seems to be difficult to get out of it.

Today only 2 patients will come in the afternoon, 14:00 to 14:30 and 18:00 to 18:30. The problem is how I can handle the time between them. It is nonsense to do net-surfing unintentionally, which means waste of time. How to deal with the vacant time? Our time is limited, so it is necessarily to be creative and have new ideas with limited resource.

Expressive writing, which is writing your negative feeling randomly for 8 to 10 minutes without pose after work or before going to bed, is said to be helpful to be creative and to reduce your stress as lots of psychologists recommend. You don’t have to have positive thinking. Honestly, I am introverted. Psychologists say an introvert should not apply positive thinking, because it will make your state of mind more miserable and devastated. Immerse your mind to something different from your present problems sometimes makes your stress less and you can be more creative and may get new ideas to get out of the suffocating feeling in daily life.

Forgetting the things before the turmoil and accepting current harsh situation and being creative, not positive, and hopefully improving imagination and finally getting some new good ideas to survive and thrive in this crisis is my desire. The ideas which will appear in my mind should be applied and tested lots of times. And we should evaluate them if they are effective or not, then do the same procedure one after another.

Learning psychology and applying it in daily life is what I have been cautious of these days.

GBR in a front tooth for incoming dental implant

Guided bone regeneration (GBR) is one of the most exciting topics of mine in dentistry. Istvan Urban is a Hungarian dentist who is the most famous in this field. I wonder if he can hold his seminar in Budapest now. Because of corona virus, Hungary seems to be shutting down people from other countries. My friends went to go there in Japanese dentist’s tour 2 years ago. I missed the chance.  His papers The amount of new bone by the surgery of Dr. Urban looks so huge. The key point to succeed is release incision, especially in back side of upper lip. Ordinary release incision cannot make good primary closure of gum. Horizontal and vertical ridge augmentation in upper front teeth area is the most challenging surgery. Some videos in YouTube are uploaded showing introduction the Urban institution, short lectures, and European osteointegration congress. The time of each congress video is 1 to 2 hours, which makes me have a little expectation of getting useful information for free. I could watch a few seconds of release incision in an upper frontal vertical and horizontal defect. However, I could not get a real key point of  the procedure in detail, which only dentists who attend his seminar can learn. The case above is my single tooth implant case which required GBR before inserting an implant. The membrane which covered bone graft was exposed after the GBR, which didn’t affect the result at all.

Like a decathlete

“Dentistry is work of love.” Kanzo Uchimura (evangelist 1861-1930)

“Life is too short to suffer.” Tony Robbins

 

Most of Japanese dentists are general practitioners unlike US dentists who are specialists, such as endodontists, periodontists, implantologists, orthodontologists, oral surgeon, etc. I heard a story of one of famous dentists of Japan. When he attended at a dental conference in US, he was asked by a US dentist, “What is your specialty?” and he replied “general practitioner”. The US dentist gave him a disdainful glance and went away. There may be a tendency where a specialist looks down on a general practitioner in other countries. I suppose it is not right or wrong, but just cultural difference.

As a general practitioner, I, like many Japanese dentists, am making effort to get overall skills including ones of root canal treatment, periodontal surgery like guided tissue regeneration, implant therapy including guided bone regeneration, bracing, extracting wisdom teeth, etc. And our final goal is making an ideal occlusion for effective chewing function. A general practitioner is like a decathlete, who may be in lower level in each field than a specialist. But, a general practitioner can make a total planning and execute it by himself, or sometimes with cooperation of specialists, which is rewarding. Brushing up each category is enjoyable, which takes time and money for learning in various seminars.

The case above was a female patient whose chief complaint was difficulty in chewing. She came to my clinic by an introduction of her friend who has been one of my long-term patients. When they had a party, the friend realized her mouth condition looked deteriorated and said she should go to my clinic. She swallows food, not bites. She had given up her teeth problem because she thought it’s too bad for a dentist to cure.

My imagination began to work. I was very excited to face the challenge. She did not accept an implant treatment plan. What I performed here were root canal treatments, minor tooth movement, the crowns covering natural teeth, and the removable dentures which were well accepted by her. She confessed she had depression before the treatment, but it almost disappeared because of this full mouth reconstruction, and made a great smile.

Continuing education is necessary because progress of technology is always happening. There is no final goal in learning.

 

Helped by system 2

According to the international bestseller “Thinking, Fast and Slow” by Daniel Kshneman, psychologists have been interested in the two modes of thinking evoked by multiplication problem. The two systems in the mind are referred to System 1 and System 2. System 1 operates automatically and quickly, with little or no effort and no sense of voluntary control. System 2 allocates attention to effortful mental activities that demand it, including complex computations. The operations of System 2 are often associated with the subjective experience of agency, choice, and concentration.

When I have a new patient, I sometimes am trapped by the first impression to him or her. And I judge character of the patient and decide if I will treat only the part he pointed, ignore other problems, and finish ASAP, or make a treatment plan of whole mouth after solving his initial chief complaint.

A guy, aging nearly 70, came to my clinic, showing a grimace with pain. He said he went to a dental college hospital because of an acute pain in his lower front tooth. The pain didn’t subside after the hospital’s treatment. By his wife’s introduction, he decided to come here. After all, the problematic tooth causing his pain was not one treated in the hospital. I treated a neighboring tooth which had pus at the edge of root. After the root canal treatment, eventually the pain subsided. He looked like a fastidious guy and my intuition, namely my system 1, worked dominantly in my mind, made me think I should finish and will not do further treatment to avoid emotional trouble.

But, a dental hygienist who is experienced and competent looked at his memo pad filled with lots of schedules, when she made his next appointment after the first visit. She told me that he must be a household name and I should research Wikipedia. She was right. My system 2 began to work and found that he worked in Ministry of Foreign Affairs, engaged in Scandinavian, became a professor of a private university, is an author of international relationship books, and is working as a commentator in TV news program.

After the root canal treatment and subsequent erase of the pain, he showed trust and asked full mouth treatment, and accepted my treatment plan which includes sinus lift, implants, and prosthesis for natural teeth, as you can see photos and X-ray. He was impressed and satisfied to see the before and after photos.

If I had not had the dental hygienist’s attentiveness, I would have missed a chance of full mouth reconstruction which inspires my imagination and creativity. Without her precious advice, I couldn’t have got the successful case.

The problem is when I must activate my system 2 in decision making, avoiding bias caused by system 1. I’m going to study psychology more to solve the problem, to make a better decision.

Passion to save my friend

In a national bestseller book “Awaken the giant within”, Tony Robbins said “I had a hard time giving credence to a doctor who was counseling patients about health but he, himself, was forty pounds overweight” and came across as a caricature where a fat doctor says “You need more exercise. Go and get me a cheeseburger with onions” to his patient. “Physician, heal thyself.” “It is a good doctor who follows his own prognosis.”

From a dentist view, I suppose many doctors, except for dentists, don’t care about their teeth. I wonder if it can be said for only Japanese medical doctors. My high school era’s friend was one of them. He is a handsome and smart guy who was a surgeon and now is working as an adviser dealing with medical law suits in an insurance company. He lost lower molars when he was late thirties. He came to my clinic for the first time 5 years ago. However, he did’t want an implant, but a removable denture which was not used in the end. Probably, he doubted the reliability of dental implant through some dental law suits. Then, he came once again last year. His chief complaint was smell caused by the fracture of upper front teeth. He wanted another removable denture after extraction of troubled teeth. Several days later, he said “This denture is awful, unbearable, I can’t talk clearly when giving lectures. Carry out implant treatment in the upper front teeth”.

I made Power Point slides explaining it’s necessary to have implants in the lower molars to save the upper front teeth implants and other natural teeth, showing force mechanism. I didn’t use any psychological persuasion skill described in a book “Influence: Science and Practice” by Cialdini, R.B. I just used my passion to save his dental condition. He looked impressed by my explanation and accepted my treatment plan.

He smiled and said, “I’m so happy to be able to enjoy eating” after the treatment. I was also happy to contribute to the quality of his life. Maintenance and periodical check-ups are necessary. However, I haven’t seen him since then, probably, because of the new coronavirus predicament. I must pull myself together and face up to the threat.

hardship

 

People all over the world except for some politicians and
bureaucrats are in predicament. We are surrounded by the virus hoax. When will
the state of emergency in Tokyo end? I’m getting cabin fever because of hunkering down. Will I forgo a pay for a while until then?
100,000 yen bounty for one person from the government is a drop in the bucket for almost people,
though it’s better than nothing.
I am despondent over the order I should not carry out dental implant
surgery in the current situation. She (my patient) missed her upper 6 front
teeth because of a traffic accident! For her, it is really the state of
emergency, losing esthetics. No brainer.
However, I admonish myself, saying in my mind, sort of incantation, “Pull
yourself together when the chips are down. Don’t be despondent over hardship. Your
focal point is analyzing past and present about your business, preparing for
the future, in order to mitigate obnoxious antsy feeling. Do not be tipsy. Don’t
waste your time, money, and opportunities.”

 

Checking a result of tissue regeneration surgery

 

There is no cure for corvid19. You just have to let run its course, which makes us antsy. If I don’t get out of this situation, I’ll go stir crazy. After this ceases, I should be raring to go.
2 weeks ago, the government declared the state of emergency in Tokyo. This morning, a patient, for whom I have been treating gum disease,
came to my clinic.  I carried out tissue regeneration surgery for her 5 months ago. The
surgery needs a substance called “Emdogain” which was developed in Scandinavian countries for
recovering lost tissues around a tooth. It is applied on the root surface of
the tooth. After the surgery, it is required strict plaque control.
I was worried about the level of her plaque control becomes worse, while she
doesn’t come to our clinic for fear of the corvid 19 turmoil. Fortunately, I found out her plaque control was better than I thought, so healing condition was good. Today’s X-ray shows recovery of lost bone, meaning successful regeneration
of bones between the premolar teeth, though it’s only 5 months after the surgery (In order to get full recovery, they say it takes 6-12 months). X-ray is
just a 2-D image, so I am going to check 3-D structure by CT scan a while
later. When I learned and started tissue regeneration therapy 9 years ago, in each time, I checked if new bone generation was achieved by another open flap surgery 1 year after the operation, meaning directly watched new tissues.
Recently, considering the reopening flap surgery gives some discomfort to the patients,
I check the results only by CT.
 In this case, the patient had missing molar
teeth which caused excessive load to the existing neighboring premolars. The major reason of
lost supporting bone is infection by plaque. In addition to this, the increased
loading may cause the phenomenon. For missing molars, I carried out implants
treatment. The premolars, to which I performed tissue regeneration surgery, are
covered by plastic temporary crowns now. Fundamental rule is final crows should be
applied at least 6 months after the surgery, so I am waiting for the time.
It may be a trivial successful experience,
though I can’t say it is complete success yet, I felt excited and a sense of
fulfillment, because my character may be simple. However, I may forget it
tomorrow and will pursue another success.
 In this case, I performed minor orthodontic
treatment, which was intrusion of an upper molar using mini-implants to create
space for lower molars’ implants (2 pieces), the opposite side in mandible (2
pieces of implant), an upper front tooth implant, and tissue regeneration
surgery in other 2 parts. The treatments which still are not carried out are final
crowns and micro tissue regeneration surgery in 2 other parts, which requires microscope, micro scalpels and delicate skill. The process to the goal is enjoyable, however, it
will be delayed because of corvid-19 turmoil.  

 

Challenging case

Recently, I had a patient who had trouble with dental implants which his former dentist had embedded. At first, I rejected to treat him. Because, the implants were different from ones which our clinic dealt with. I use implants produced by Straumman co. which has been used worldwide. I did not know the product maker of the patients’ implants through the appearance and X ray images of them. It is said that there are over 50 implant makers in the world. Some new companies aim niche in the market, struggling to keep up with the technology of the companies already having big share. Sometimes, some companies’ implants have kinks though they say their product are fool proof. I wanted to pull out the patient’s implants with counter clockwise strength, because they were poorly positioned. Of course, considering patient’s agony, I can’t carry out it. He asked me to treat many times, and finally, I gave in. Now, I am enjoying the process of reconstruction of his occlusion.

 before

 

 halfway
(It’s like night and day, isn’t it?)

 

 X-ray at the first visit

Pontsuku, Kokura’s sweets

 

 

 

Kokura is a smaller than Hakata (the capital
city of Fukuoka) but growing town in Fukuoka prefecture Kyushu Japan. Since
last September, I have attended a dental seminar held in Kokura, every second
weekend in each month. Last week, before going there from Tokyo, a dental hygienist turned to
me, “Doctor? Please buy souvenir for our staff”.
She is
called as a sweets commentator in my office. She gave me a list of sweets made in
Kokura. It seems that she researched all day long on the Internet. Considering expiring date of the sweets, I chose Pontsuku (photo) which an old
established store has made. It is a sponge cake including custard cream. There
are other versions of cream, such as powdered green tea, chocolate, and
strawberry. It was amazing, fluffy, fabulous and yummy. All our staff turned cartwheels. When you have a chance to visit Kokura, try
Pontsuku, the awesome sweets!

 

 

10 years after sinus floor augmentation

 

I sometimes encounter patients who don’t have enough bone in upper molar teeth missing area for placing dental implants. I learned skills of sinus floor augmentation, surgery of growing new bone in sinus for upcoming dental implants surgery, at University of Michigan in 2002. The reason for going abroad was that I could practice the skills using cadavers in US, which has been prohibited in Japan. Since then, I have overcome the difficulties in placing implants in upper molar. This is one of such cases, CT scan images after 10 years showing stable condition. The more I learn, the more I can contribute.