In 2017 the American Dental Association adopted a policy encouraging dentists to screen patients for sleep-related breathing disorders (SRBD). This includes assessing a patient’s risk for SRBD as part of a comprehensive medical and dental history and referring affected patients to a physician as appropriate. When this happened, I called my friend Dr. Steve Carstensen, who is at the forefront of sleep dentistry and asked him what we should implement in our dental practice. One of the tools he suggested is a quick and easy visual assessment called a Mallampati score.

The Mallampati score is one of four things we now do in my practice as a four-part sleep screening. (In Dr. Kelly Brummet’s recent PankeyGram article, she wrote about what this score determines and how she uses it in her practice, so you will want to go back and read that article as well this one.)

We have laminated copies of the Mallampati visualization chart (see below), which we printed from the Internet. We used these for visual reference in both of my operatories and the hygienist’s operatory. To make a visual assessment of the back of the patient’s mouth, say to the patient, “Open wide.” You don’t depress the tongue. The patient doesn’t say “aah.” The patient just opens wide. Then you look to see which of the four Mallampati images most closely matches what you see and give the patient a 1 through 4 score based on the image.

This is just a simple way to see if we think anatomically the patient can move air past the base of the tongue. My hygienist and I do this in conjunction with the STOP BANG questionnaire, Epworth Sleepiness Scale and asking about nose breathing.

L.D. Pankey famously said, “People change but not very much,” and hearing this for the very first time represented an “aha moment,” as it put into proper context an important realization I had previously ignored.

As dentists, we know a lot, and we have worked very hard to acquire that knowledge. As a consequence, we naturally want to use it to help others. But there’s a problem. Often times others act like they don’t want to be helped. Often times others act like they don’t want to be better. Often times others act like they don’t want to map a course toward a higher level of health. So, we struggle to make sense of it and even judge others as a result of it.

Developmental psychologist Jean Piaget, PhD told us that the motivation to change comes from within the individual, from their perception that they’re in a state of “disequilibria,” wherein what they’ve been doing in the past (including what they believed to be true) isn’t producing the outcome they want. And as a consequence, the person is confronted with an uncomfortable truth. They can’t keep on doing what they have been doing and expect a different outcome. They’re going to have to suffer through some personal change if they sincerely desire to experience something different in their life. And executing the change is going to cost them something namely time, energy, and money. In other words, significant change can’t be done for them or to them. It’s an “inside-out” process that they will have to do for themselves.

Some people will look at their need to change and ignore it. They will say to themselves the cost is too high for them to pay, or they will simply rationalize away their need to change in an elaborate form of denial. Others will immediately confront the challenge, learn what they need to know, figure out a way to pay the price, and move on. So, what’s the difference between these people?

Perception… values… readiness.

What Can We Influence? 

In our world as dentists, we can build up a person’s understanding of their situation through CoDiscovery, and therefore we can facilitate how they frame, prioritize and think about what they have learned. But we can’t make them change. We can’t cause them to act. We can only honor where they are with it all and stand ready to assist them when they are ready to move forward.

Significant change often requires a change in a person’s value structures and the hierarchy of those structures. Piaget called changes of this type “accommodations. Piaget said that they are made at the person’s own pace after the person senses that he or she is in a state of disequilibria. And so, Dr. Pankey was right. Those who change do so not because we are highly skilled at “case presentations.” They do so because they want to, and it may occur only a little bit at a time.

Screening our patients for airway and breathing issues is becoming a standard in dentistry. One of the things we have started to do every day in our Hygiene rooms, with our patients from three years old to very elderly, is visually looking at the back of their mouth and assign a Mallampati score.

The Mallampati score was developed by anaesthesiologist Seshagiri Mallampati, in 1985, as a non-invasive way to assess the ease of endotracheal intubation. The test is simply a visual assessment of the distance between the base of the tongue and the roof of the mouth.

In our practice, we begin a conversation about airway with patients. The Mallampati diagram (see below) allows both us and our patient to visualize, on a score of 1 to 4, the patient’s anatomical airway. We laminated the Mallampati diagram off of Google Images, and we can give it to the patient to hold while we screen them, or we share it with them after screening to let them see why they received the score they did. We then continue the conversation with them about their airway and why it might be a good idea for them to observe sleep patterns or be referred to a sleep physician for further diagnosis.

When we have experienced a deeply traumatic event, such as an emotionally laden death, or the near-death of a family member, what is often left behind is emotional debris with the potential to follow us around indefinitely. Subsequently, we can become haunted by memories of what happened, or what we should have done to make things better. These kinds of recurring thought patterns can easily bleed over into our daily lives and negatively influence our behavior—and our future.

On a neurobiological level, this occurs as our brain is designed to keep self-preservation as its highest priority. Thus, possessing the ability to quickly recall traumatic events protects us from similar things happening in the future. But commonly, this constant re-remembering can lead us into a state of psychological paralysis, depression and/or chronic anxiety, and poor decision-making.

At the present time, many patients live in fear of going to the dentist, because they believe there is too high of an infection risk. Concurrently, they consider the process of addressing their dental needs as being a lower life risk. These shadows of fear can remain strong in their mind, particularly when they have a family member who is in a high-risk category. Simultaneously, some dental team members have made the decision to leave dentistry for similar reasons. However, both challenges are happening at significantly lower rates within relationship-based / health-centered dental practices, as these practices have already built strong, enduring bridges of communication within their patient pools.

The Shadow

A contagious virus is a concept most people understand. The level of anxiety this virus has generated world-wide is something many cannot successfully manage alone. We have all had patients whose past dental experiences were so negative and their thinking about it so distorted they cannot recall why certain situations trigger their dental PTSD. Carl Jung referred to the source of these recurring thoughts as “the shadow.” Buried memories and their emotional associations can be so strong that they take complete control over a person’s behavior.

Letting Go

The brain does not stop maintaining its focus on traumatic memories until it has come up with a rational explanation for why they happened and a plan for how to avoid them in the future. On this, Jung stated, “Until you make the unconscious conscious, it will direct your life and you will call it fate.”

CoDiscovery was designed to address the influence of the shadow’s influence on current behavior patterns, in much the same way as psychotherapy facilitates the exploration of the past and associates new meanings with those memories. It is intended to help patients associate new meanings with what they are learning about their dental past.

The “Rogerian” therapy model of unconditional positive regard, congruence, and non-judgementalism is an ideal format for patients to safely explore their fears, beliefs, values, and priorities. And that’s why Bob Barkley and Nate Kohn, Jr., Ph.D., leaned so heavily on Carl Rogers’ work. Bob Barkley put this re-experiencing process under an umbrella he called, “Three Phase Adult Education,” and the rest became history.

The Future

As optimistic as the future appears to be regarding the successful management and treatment of COVID-19, this pandemic experience has reshaped our thinking—our “shadows,” forever. How we manage these memories, conscious and subconscious, will have a lot of influence on our success going forward. If we demonstrate we are on the same side as our patients in preventing COVID-19’s negative impact, we create yet another strategic advantage we can leverage against our transaction-oriented competition. On the other hand, if we allow our patients’ fear-driven “shadows” to drive their decision-making, we will rue the day we allowed this proverbial cart to be placed in front of their psychological horse.

Bob and Nate had it right. CoDiscovery is the pathway to deeper understanding, hence better decision-making. And better decision-making is exactly what our profession needs right now.