No matter how much I cut, I can't keep up. The wall I hit one day after investing over 10 million yen in treatment technology [Series Part 2]

Table of Contents

1. Toward an Era Centered on Treatment

Hello everyone. This is Takaya, an MBA dentist.

In the first part of this series, I provided an overall digest of how my thinking shifted through four stages: "Treatment-centered → Preventive management-centered → Going out into the community → SDH → Regional revitalization."

From this second installment, I will write a bit more slowly, one step at a time.

The theme this time is the "Era of Treatment-Centered Care."

Why did I, as a newly minted dentist, become so obsessed with treatment technology? And why, after continuing to hone my skills, did I come to think, "This alone is meaningless"? I will write honestly about my journey from my third year after graduation through the next ten years.

I will state the conclusion first. I do not want to dismiss the study of treatment technology. In fact, I am still studying it today. It is just that at a certain point, I had to accept the fact that there are areas that technology cannot reach. That is what this story is about.

2. Third Year After Graduation, Standing at the Starting Line Without Knowing Anything

Just because you pass the national dental examination does not mean you can immediately treat patients. The clinical skills you possess at the time of graduation are truly the basics of the basics. In a sense, university is a "vocational training facility," and a national license is nothing more than a "qualification to stand at the starting line."

I realized, "Oh, I have to study this seriously," in 2014, my third year after graduation. After gaining experience in oral surgery at my first training site and being entrusted with general practice at a clinic in Kyoto, I realized my lack of ability painfully well. There were moments in front of patients where I didn't know what I was doing. That was truly exhausting.

So in 2014, I started studying at JIADS (a postgraduate training program for dentists). The following year, in 2015, I took the JIADS perio course and the prosthodontics course.

I would endlessly cut models, consult, cut again, and have them checked. "The shape here is wrong," "The occlusal height is off," "The margin (boundary) here should be a bit smoother." "The sutures are loose." It is a plain and endless world. But for the first time, I understood in my bones that the accumulation of such details determines the quality of treatment.

3. Ten Years of Diligently Learning Both Domestically and Abroad

From there, my days of what felt like clinical study abroad began.

I belonged to JSCO (a JIADS Osaka study group) and read research papers almost every month. Days were spent immersed in studying occlusal reconstruction (treatment to rebuild the entire bite) with overseas journals in hand. "What is ideal treatment?"—this was my question at the time. It was a period when I would open papers before going to sleep and think about cases while commuting.

In 2016, I went on a short-term study abroad program for 2-3 weeks at the University of Pennsylvania Department of Periodontics. The experience of having the authors of the papers I had been reading in Japan lecture right in front of me had a decisive influence on my clinical perspective.

I took the PHIJ (Perio Health Institute Japan) basic course in 2018 and...

In 2019, I went to Houston for training.

In the DSJ-affiliated study group, I repeatedly practiced implants, occlusal reconstruction, occlusal examination, and wax-ups (diagnostic work to create tooth shapes) with my own hands, and in another course, I assembled artificial teeth for complete dentures by myself from morning till night.

I still study evidence without fail.

4. Self-investment, easily exceeding 10 million yen

I will write this honestly, but the self-investment I have made up to this point is roughly over 10 million yen. Tuition, teaching materials, overseas travel expenses, equipment, books, journal subscription fees, and conference participation fees. It is not rare in this world for a single course to cost over 1 million yen, and overseas training can easily cost hundreds of thousands of yen. If you accumulate this over 10 years, you reach this kind of figure. I don't think this scale is particularly unusual in the dental world.

Thanks to that, the number of places where I can present cases has increased. In 2024, I also presented at the American Academy of Periodontology (AAP), and

In 2024, I also presented a case at the Getsurin-kai meeting held in Fukuoka. Other than that, I am given the opportunity to present at academic conferences and study groups almost every year. These are the modest results of 10 years of continuous study.

5. After 7 to 8 years, the treated oral cavity begins to break down

From here on, it becomes a bit of a painful story.

Using the techniques I learned, I provide patients with treatments ranging from hundreds of thousands to millions of yen. Full-mouth rehabilitation (treatment to rebuild the entire oral cavity), occlusal reconstruction, and full-arch prosthetics including implants. Patients are happy. I also feel a sense of accomplishment. Many of those patients still visit my clinic today.

However, around 7 to 8 years after treatment, things gradually start to break down. The margins of the crowns develop cavities. Bone resorption (a phenomenon where bone decreases) occurs around the implants. Periodontal pockets deepen. The occlusion shifts. Redoing one tooth, then redoing another. The bite that I thought I had created perfectly gradually collapses over the years.

I haven't experienced a "complete redo" yet. But, when I think about what will happen in another 10 years, I am frankly scared. In particular, full-mouth prosthetics for patients who have entered old age can be cases where control becomes difficult. As cognitive function, saliva volume, hand dexterity, and frequency of clinic visits all gradually decline, maintaining the precise prosthetics created in their youth is a significant burden for both the patient and the medical professional.

I did my best at that time. The patient also chose the best option available at that moment. However, 'providing the best treatment' and 'protecting a patient's oral health for a lifetime' do not necessarily align—this fact has weighed more heavily on me with each passing year.

6. What on earth is 'ideal treatment'?

Here, I return to the question I had in my third year after graduation: 'What is ideal treatment?'

After 10 years of continuous learning, a sense of discomfort began to grow from a certain point.

Cases introduced at academic conferences and seminars are usually what are called champion cases. Miraculous long-term prognosis cases where function and aesthetics are maintained without change even after 10 or 20 years. As a young dentist, I honestly admired them, thinking, 'This is the kind of treatment I should aim for.'

Recently, social media has been added to this, further accelerating the situation. Instagram, TikTok, YouTube. Perfectly white, aligned front teeth, all-ceramic restorations that look like textbook illustrations, and cases with smiles that seem to have changed lives through Before/After photos flow by every single day.

There are many doctors who are amazing in terms of technical skill, and they are truly studying hard, including in photography and editing. I have no intention of denying that.

However, admiring those is a bit dangerous.

The reason is simple: cases posted on social media appear in a state with maximum production applied, including lighting, angles, saturation, contrast, and in some cases, retouching. Editing to slightly adjust the shape of front teeth is now commonplace. Furthermore, naturally, only successful cases are posted. Cases where the prognosis collapsed midway or cases where the patient dropped out never appear in Before/After videos.

The structure is exactly the same as social media influencers who upload photos every day holding brand bags, at picturesque travel destinations, taken at the best angles and with the best lighting. Days when they are struggling with living expenses, days when they fought with their family, or weekday afternoons when they have no plans at all are never uploaded to social media. The same trap is set for dentists as it is for people who look at those posts and feel depressed, thinking, 'My life is miserable.'

As social psychologist Festinger's social comparison theory suggests, humans are creatures who form self-evaluations by comparing themselves to others. If the object of comparison is only 'the best shots of others that have been maximally produced,' one's self-evaluation of their own clinical practice is structurally bound to be distorted. Multiple studies in the field of psychology have also reported on the negative correlation between social media use and self-esteem/depression (Vogel et al., 2014, etc.). In the field of plastic surgery, 'Snapchat dysmorphia,' where people believe their own face enhanced by editing apps is the ideal, has already become a problem, but I feel that something like a dental version of this is starting to happen not only to patients but also to dentists.

Thinking, 'Wow, that's amazing,' is healthy in itself. There is much to learn. However, feeling depressed by thinking, 'I'm no good because my clinical practice isn't at this level,' is a complete waste of time right now, and I want to write that clearly. You should have the same attitude as you would when not feeling down by comparing an influencer's brand photos with your own real life.

And, when you think about it, it's strange. Whether at academic conferences or on social media, only successful cases appear in the world. This is exactly what is known as **Survivorship Bias** in the business world. It is the same structure as in the consulting industry, where only collections of success stories become books, and collections of failure stories rarely see the light of day. In fact, many long-term prognosis papers on prosthetics are biased toward 'cooperative patient groups who can visit for regular maintenance,' and the legendary 30-year follow-up study by Axelsson & Lindhe in Sweden also looks at a specific group capable of continuous attendance. These are not results that apply to everyone in a general clinical setting.

And what was decisive was that I myself was seeing cases every day where teeth treated within the scope of insurance coverage were being used without any problems for decades.

A patient who had an insurance-covered metal crown placed 20 years ago still comes in for maintenance, and there is absolutely nothing wrong with that crown.

The ultimate example is the fact that there is a patient who is still using a crown placed by my grandfather (the second-generation Haruyo) 40 years ago using insurance-covered treatment.

A 40-year-old crown.

The material, the adhesive, and the preparation technique are all classic by today's standards. Even so, that tooth has been functioning in that person's mouth for 40 years. Conversely, there are cases where even after applying the most sophisticated, state-of-the-art prosthetics, they begin to break down in 7 to 8 years.

What is the reason for this difference?

I worried about this for a long time. Is it a difference in technical skill? A difference in materials? A difference in treatment planning?

The answer I finally arrived at is that it is not a difference in the quality of treatment, but perhaps a difference in whether the person is successfully managing their risks.

The patient who continues to use a 40-year-old crown has likely brushed their teeth carefully every day for these 40 years, visited the clinic regularly, paid attention to their eating habits, and maintained a stable lifestyle overall. My grandfather's skill certainly played a part, too. But what truly protected that tooth was the patient's own 40 years of self-care and the living environment that supported it.

Conversely, even if you apply state-of-the-art prosthetics, if the patient's lifestyle rhythm collapses, if the quality of their saliva drops, or if maintenance is interrupted, the prosthetic will break without mercy.

The moment of "treatment" where we dentists intervene is merely a single point in the long timeline of a patient's oral health. The rest of the time is dominated by the patient's own life and the environment surrounding it.

The moment I accepted this fact, something clicked inside me.

Instead of "aiming for perfect treatment", I shifted to "working together to create a state where the patient can control their own oral health".

From this point on, my interest clearly shifted from treatment techniques to preventive management.

7. The reality that less than 0.1% of people can afford full out-of-pocket treatment

There is one more thing I must write about.

A dentist who can hone their skills, accumulate cases, and provide treatment at a level that can be presented at academic conferences. This is certainly work that only top-tier dentists can do, both technically and in terms of business skills.

But how many patients do you think can accept full out-of-pocket treatment costing millions of yen?

Based on my gut feeling from practicing in a rural area,

• those who want to complete everything with insurance-covered treatment account for 99.9%

• those who can accept full out-of-pocket treatment in the millions account for less than 0.1%

• Focusing on insurance-covered treatment while combining it with some out-of-pocket expenses is the reality for the majority

While there are naturally regional and income disparities, this is the ratio I experience in a rural setting.

Even for a dentist who can provide the "best treatment," the opportunities to meet patients who both need it and are able to accept it are limited. This is not a problem of technical skill, but a problem of social structure.

By the way, the form of focusing on insurance-covered treatment while combining it with some out-of-pocket expenses is also a Win-Win structure in terms of negotiation theory. Since this is my area of expertise, I will write a proper article about it on another occasion.

8. There are areas that treatment technology alone cannot reach

Returning to the topic of "risk control."

Whether a patient can successfully control their own oral cavity—that is what ultimately determines the long-term prognosis of the treatment.

However, I later realized that the difference between those who can and cannot perform this risk control cannot be explained solely by the patient's own efforts.

The time and energy to brush teeth carefully every day. The financial leeway to prepare a balanced diet. The flexibility at work to continue regular visits. An environment where family and colleagues support self-care. The hope for tomorrow that makes one want to pay attention to health.

All of these depend heavily on the person's life background.

People who can continue visiting and those who cannot. People who can make self-care a habit and those who cannot. People who can choose out-of-pocket treatment and those who cannot. This is not a problem of technology or a lack of willpower on the part of the individual, but a problem of the social conditions in which that person is placed.

Once you reach this point, it becomes clear that "mastering treatment technology" alone cannot save every patient I meet. Unless I intervene further upstream, I cannot fully protect the oral cavity.

I would begin searching for what that "upstream" is in the next stage.

9. Conclusion—Next time: "Toward prevention-centered management"

For 10 years, I worked desperately on treatment technology. Over 10 million yen in self-investment, overseas training, academic presentations, and annual case studies. I don't think this was a mistake. Rather, I should say that it was precisely because of this experience that I saw the limits beyond it.

And, the insurance-covered crown that my grandfather treated 40 years ago is still functioning in the patient's mouth today—this fact rewrote something within me. It was not the difference in technology, but the patient's 40 years of risk control that protected that tooth.

Next time (Series Part 3), I will write about the shift toward prevention-centered management. It was my job after returning to introduce a systematic preventive management program (MTM) to our clinic, while building on the fluoride activities that had been rooted in the community since my father's generation. Several years of repeating discussions with my father and replacing the clinic's main focus from "treatment" to "prevention." **From "a clinic you come to after getting sick" to "a clinic that prevents you from getting sick."**

I will write about this in detail next time.

#SDH #SocialDeterminantsOfHealth #RegionalRevitalization #DentalCare #PreventiveDentistry #ClinicalDentistry #Prosthodontics #PeriodontalTreatment #100YearCompany #Kyoto #NantanCity