All in a Day's Work: Brushing, Flossing, and Fatherhood

When I asked 16-year-old Victor about school, he was unengaged.  I received the same response when I attempted to discuss sports.  But when I asked him how his sister and 3-year-old nephew were doing, he was animated.  He talked easily and happily about his relationship with his nephew. Victor helps to share child-rearing responsibilities for his nephew.  I asked Victor when he planned to become a father.  Victor responded that he didn’t plan to become a father for a long time.  My question was a fair one.  His sister is a teen-age mom and occasionally I encounter sixteen-year-old fathers.  At this point, I could have pursued what precautions he planned in order to avoid fathering a child but I decided to save that conversation for another visit.  I reclined Victor’s chair and proceeded to evaluate his oral hygiene. I am Victor’s dentist. 

Even though my conversation with Victor about his nephew had no obvious relevance to the dental services I provided that day, my remarks were far from perfunctory.  They will provide a very important segue in the future when I discuss with him gingivitis, kissing, disease transmission and even planned parenthood with him.  Victor visits me more often than he visits any other health care provider.

Victor and I have enjoyed this level of rapport only recently. Although Victor has been my patient since he was a little boy, our visits were adversarial. At each visit, I provided the obligatory scolding that Victor’s mother promised him for not practicing good oral hygiene. Then I would remind his mother that if Victor didn’t brush his teeth, it was her responsibility to brush his teeth for him.  And then his mother would start fussing at him for being lazy.  Victor’s visits were always deprecating.

You would have thought that Victor would “get with the program” and start brushing his teeth if only to placate his mother and me.  But he didn’t.  As he got older, his oral hygiene continued to deteriorate and he developed chronic gingivitis.  Even my threats that the gingivitis would turn to periodontitis and that he would end up with dentures didn’t motivate him to change.  My oral hygiene demonstrations didn’t help either. 

I did not relish my visits with this noncompliant patient.  As he became older, he stopped protesting and maintained a flat affect.  Then one day, he just sobbed quietly. I was taken aback.  I didn’t know what to do.  I called Paul, one of our Spanish interpreters to come over to my exam room.  Since Victor spoke English, Paul didn’t need to speak Spanish with him but Paul understood Victor’s culture.  I needed someone who could assert the level of authority with Victor that I had lost—or actually, never really possessed.  But Paul didn’t assert authority.  He expressed concern, compassion and caring, which, despite my efforts, Victor never saw in me.  As I heard Victor repeat my remarks tearfully to Paul, I became so ashamed.  Victor said, “She told me that if I am going to be a success in life, I will need to have my natural teeth.  She said I am going to end up with dentures.”  He didn’t reference all the oral hygiene instructions I gave him to maintain his natural teeth.  He didn’t reference the condition that if he didn’t take care of his teeth, he would end up with dentures. No wonder Victor was defeated.  It was painfully cathartic to realize how counterproductive my manner was to achieving my goals. 

Today I can testify that, based on my experience, self-righteous zealots like me can change.  Sure, I wish Victor didn’t have gingivitis but I no longer judge his disease as his failure.  Victor is a normal 16 year old.  Gingivitis is the norm among 16 year olds.  I can be most helpful to Victor if he keeps coming to me for preventive visits so that I can manage his gingivitis.  And now that I have a teachable spirit, Victor is teaching me his learning style.  He breaks a task down into “baby steps” for his nephew because that is how Victor learns.  So, instead of directing Victor to floss all of his teeth, he is starting out just flossing the top 4 teeth because those are the teeth that people would notice if he developed cavities in them.  That makes sense to him.  

Now that Victor’s mother stays in the waiting room, we own our relationship. I don’t criticize Victor.  I find genuine reasons to affirm him.  I focus on what Victor is doing properly and I build upon it.  Moreover, now that Victor knows that I am there to help him and not scold him, he discusses his oral hygiene practices and divulges where he is having the most trouble.  I share with him ideas to improve compliance with home care recommendations. I recommend new oral hygiene products to assist him. 
 
I have learned that he will only make changes when brushing and flossing become important to him.    Perhaps when he tells me about his girlfriend, I will personalize the value of a healthy mouth for kissing.  Then, I’ll ask him when he plans to become a father and we’ll continue the conversation that is currently on-hold.    

Dr. Pamela Alston completed her DDS in 1982 at the University of California, San Francisco.  She then received a Masters of Public Policy from the University of California, Berkley.  Since 1990, Dr. Alston has worked with at-promise young people in her hometown, Oakland, California.  She is currently the Dental Director at the Alameda County Medical Center. 

Dr. Alston is committed to improving the world around her.  Her areas of special interest are early oral care, oral health care disparities, and access to oral care.  Her accomplishments in improving access to oral care in Alameda County were recognized with a Public Health Hero award by University of California, Berkeley, School of Public Health.