Contribution

How to contribute to other people? Being helpful to others is worthwhile for living. They say three forth of people hate their jobs. Luckily, I love my work. As a dentist, treatments for patients are contributions themselves. Clocks are ticking and my days as a dentist are numbered. That’s what I am thinking after birthday of 60.

I have been working at the biggest business town in Tokyo. Because of Corvid 19, the number of patients has decreased to 70 percent. Business person are working at home, not at office. They come to their office only once or twice a month. They changed their dentist near their home instead of coming here.

But I have a few patients who watched my clinical case reports and read my blogs and wanted my skills, saying “I want my devastated teeth fixed like your cases in the homepage”. That’s my big motivation to work. They come from countryside by train, contrary to the office workers around here. Consequently, I have lots of time for them, enough explanation, treatment planning, and of course treatments themselves.

A female patient came and rejected surgery which I proposed, at first. But, she gradually changed her mind and accepted my proposal through many time’s conversation. She will have the best quality of functional chewing by the surgery, I believe.

I am not sure what the future holds for me. However, I will keep learning and control what I can control, not focusing on uncontrollable things such as the coronavirus and the number of patients. Be patient for patients.

before and now

before and now
pink arrow indicates missing teeth area which needs sinus lift before implants

before and now

during sinus lift

before and just after sinus lift

Learning from failure

Trying to save a tooth which is strictly in a bad condition is occasionally a mission for a dentist depending on a patient’s character, dentist’s skill, etc. It is sometimes difficult to make a decision whether the tooth can be saved or is hopeless and should be extracted.

This case was the molar tooth astride the bone defect, only the tips of three roots were hemmed in by remaining bone, which caused loosening a little. It seemed to be challenging to get complete bone fill in this case, because of complexity in shape at the site, which means difficulties of complete debridement before applying bone graft and Emdogain which is medicine for tissue regeneration. During 5 years, it had kept in a better condition after the surgery. However, bone loss and loosening happened in the end. The partial bone fill may be just a happenstance and temporally. In a challenging case, being craven should be avoided, however, eternity of the tooth was delusional as a result. If I encountered the same case, I would apply deferent incision lines and materials. Learning from failure must be kept in mind.

The photos are ,during surgery, X-ray before surgery, 1 year after, 3 years after, 5 years after, 6 years after, respectively.

Checking effects of tissue regeneration surgery

This is a case of periodontal treatment. A 60 years old female had chief complaints which were missing teeth and periodontal problems in remaining teeth, where original bone which hemmed in the teeth had disappeared because of gum disease bacteria. Implants placement for missing teeth and tissue regeneration surgery for the teeth which lost their surrounding bone were carried out. In order to check the results of the surgery, after 6 month, CT scanning was taken, which showed new bone regeneration to some extent, not perfect recovery.  Incision, debridement, and suturing techniques must be more improved to get better results. Material choice may be also important. Growth mindset has to keep in mind and fixed mindset should be avoided in my learning curve.

A CT horizontal section of the lower premolar whose surrounding bone was partially lost (right) a bird’s eye view of the site during the surgery (left)

Vertical sections (left) and horizontal sections (right) of CT, before (above) and 6 months later (below)

Photos during the surgery in the upper front tooth. Incision (above right), exposing defect (below left), applying Emdogain (below middle) , placing bone material (below left), suturing (above right) , 3D image before surgery (above middle)

before (left) and 6 month (right) after surgery, horizontal (above) and vertical (below) sections

Intrusion of an upper molar

Leaving missing lower molars often makes upper molars extrude. Because of not enough space, making crowns on dental implants is impossible (far left photos). Applying mini-screw type implants for orthodontic treatment enables to push extruded tooth back (center photos). 5 months after the start of the intrusion treatment make the patient get enough space for the finishing crowns on the dental implants (far right photos).

Anti-aging?

Health span is more important than longevity. Nobody wants the time of suffering from unbearable symptoms by various kinds of disease and aging. The book shows how to slow down aging. The author said aging is a disease, not a natural phenomenon. Death is unavoidable, though. But, he said, aging is preventable. 300 years ago, no one believe we can fly. Now it’s natural to use airplanes. Aging is the same. Most of the people think they should accept getting old and do not make efforts for anti-aging. The author’s opinion mainly based on experiments on mice and including his subjective notion, is, for anti-aging, take 1g of NMN(nicotinamide mononucleotide), eat less (skipping breakfast and lunch which is called as intermittent fasting), exercise like HIIT(high intensive interval training such as Tabata protocol), and enough sleep (7-8 hours). The problem is taking 1g of NMN every day. It costs at least 6000 yen per day according to my research on Amazon. And NMN is effective for anti-aging in mice, but is not proved right in human experiments so far. Keio University issued a paper about the safety dose of NMN in human, not remarking effectiveness. I head Washington University issued the paper saying no clear scientific evidence of NMN. My English teacher gave the book and said he and his wife felt difference before and after taking NMN. He insisted that he felt more energetic than before. His wife said her eyesight became better only after 2 weeks of taking NMN. It sounds very intriguing, but my decision is not taking NMN, not only because scientifically not proven in human yet, but because not reasonable.

Emdgain vs Regrowth?

Emdgain and Regrowth are materials for regeneration of tissues including bone around teeth for patients who have gum disease. Emdgain was developed in Sweden and has been used for a long time, which provided lots of good results. Regrowth was developed in Japan a few years ago, which means having short history, where top leading periodontists are accumulating clinical data in their own clinics. What I was concern was if Regrowth would be really effective in my patients’ cases. 2 patients applied only Regrowth were failure, no bone regeneration in X-ray after 6 months. 4 patients were successful by applying not only Regrowth but also bone graft. According to a recent web seminar and articles in a dental magazine,  some top periodontists are getting good results with Emdgain and connective tissue graft, without bone graft. Other dentists said gaining bone by Regrowth at first and gaining attachment by Emdgain in second surgery has possibilities to have more ideal results. The number of subjects is still small, so further information is necessary to get the truth. Selection of materials and techniques in each case are not well discussed. Pursuing latest information all the time and thinking may provide my patients happy results.

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.