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Interview with Douglas S. Fry, March 18, 2005 | UNCW Archives and Special Collections Online Database

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Interview with Douglas S. Fry, March 18, 2005
March 18, 2005
Dr. Douglas S. Fry, a pediatric dentist in Wilmington, discusses technological advancements in dentistry, HIPAA, and the treatment of and specific concerns regarding pediatric patients.
Phys. Desc:

Interviewee: Fry, Douglas S. Interviewer: Zarbock, Paul Date of Interview: 3/18/2005 Series: SENC Health Services (Dentistry) Length 57:30

Zarbock: Good morning. My name is Paul Zarbock. Today is the 19th of March in the year 2005 and we are videotaping for the special collections section in the health care delivery system effort that the University of North Carolina-Wilmington's library is assembling. We're going to meet Doctor Douglas Fry, a dentist here in practice in Wilmington. But Doctor Fry and I had a little conversation off-camera, so I'm going to start off like that. My initial question, Doctor Fry, was how did you get into dentistry, but I'm going to start even earlier. You were telling me that when you were small, really in grade school, activities began to center around you. What were those activities?

Douglas Fry: The uhm.. the activities we were talking about was my uhm.. inability to speak correctly and uh.. the term there is uh.. you know, improper speech phonetics. And uh.. it related to uh.. malocclusions of my jaws. And I didn't know that at the time, I just remember that when my classmates went out to uh.. recess that uh.. I had to go to see this teacher and we uh.. drew pictures and said phonetics, uh.. certain sounds that I couldn't say correctly. And uhm.. it worked, the therapy was successful. And uhm.. then as my uh.. ears developed a palate related to my own teeth and my jaws, uh.. wasn't until I was a teenager and uh.. I started noticing girls and I noticed that my smile uh.. wasn't pleasing. And so I talked to my folks about this and I said uh.. "What can we do about uhm.. my teeth?" And uh.. my dad being a National Park Service Ranger, uh.. most of our careers were in uh.. park areas that uh.. were far removed from good dental care and medical care. And so my parents had been informed about this years earlier, but uhm.. it wasn't until I was uh.. 15 and we moved to Omaha, Nebraska, where we had uh.. good medical care and dental care that I uh.. then began extensive treatment uh.. to correct my teeth uh.. with braces and orthodontics, and uhm.. that-- this had a great impact on my life. And I remember the day that my braces came off, you know, I was just like this-- a- a different person. Uhm.. my smile was pretty and, you know, I felt a lot of self-confident [sic] in myself. And uhm.. so those are things that I think have directed my attention to wanting to go into dentistry.

Zarbock: So really it was a very positive experience.

Douglas Fry: It was very, very positive. And uhm.. and I can relate to uh.. people uh.. especially like teenagers who are really hard to motivate to get their hygiene, their dental hygiene up and things like that. A lot of times I'll go get my original study models and I'll bring them in, I'll show them, "This is what my smile was like." You know, "This is what my teeth were like." You know, "And I can cor-- you can correct this uh.. today. And you can have as nice a smile as I have, you know. But it's gonna take your work and- and your efforts to- to do it."

Zarbock: So is it possible to say that you began to generate an interest in the profession of dentistry while in high school, or was it even earlier?

Douglas Fry: I think in the health care profession, it was definitely earlier. I believed since I was about eight years old that I was gonna go into the health care uh.. profession. Uhm.. no one in our family or particularly close friends were uhm.. in the health care profession, but it was just a call that I felt I had all my life. And uhm.. more directed as I got into school, and uhm.. and then when I graduated from college, I had a chance to go through an accelerated dental program at the University of Tennessee where I finished uh.. my dental training in 36 months. And then I've had a uh.. career since that time, a pretty varied career. And then finally at uh.. the ripe age of 39 uh.. I went back to do a residency in pediatric dentistry, and uhm.. and even in the years since that time, uhm.. you know, my p- practice has evolved and changed, and I think that's important, that you continue to recognize the changes in your life uhm.. and move on from one phase to another, so that today the practice that I'm doing is something I feel real comfortable in, uh.. I enjoy doing that provides a great service for children. Uh.. I make a nice living from it, and uhm.. and I- I enjoy what I do.

Zarbock: How long have you been in practice, Doctor?

Douglas Fry: I don't really want to tell everybody that (laughs), but uh.. actually I've been uhm.. I graduated dental school in 1971, and so I've been practicing 34 years.

Zarbock: Let me do a little probing about this 30 plus year span. What are some of the significant alternations in the practice of dentistry as observed by you from when you left the University of Tennessee until now?

Douglas Fry: Oh, there are lots of changes, lots of changes. And we're constantly seeing changes going on. I think you need to look at it from different standpoints. I think you need to look at it from uhm.. you know, the technical skills that we're now taught. Uh.. students today are- are learning how to do preparations of teeth with the use of microscopes, uh.. computer assisting- assistance. Uhm.. the whole...

Zarbock: What do you mean by computer assistance?

Douglas Fry: Oh. The whole thing from looking at a tooth, uh.. and designing the cavity preparation to it, to then actually using your hand piece that uh.. cuts the tooth and prepares it, and in a distant site, the-- say for instance uh.. an- in a inlay or crown on a tooth uh.. in a distant site, there is a uh.. computer generated uh.. machine that's cutting uh.. on a dentaform type of tooth the exact structures that you're cutting in the patients mouth. And then that's being transferred uh.. you know, ideally, to a model from which the uh.. inlay or the crown can be made. And uhm.. it- it's just phenomenal, the areas of uhm.. of dental research in materials. Uhm.. you know, materials that were just being introduced in the 60s and the 70s uh.. particularly the uh.. cosmetic filling, uh.. fillings like uhm.. the porcelain fillings. Uhm.. we're now in like second and third and fourth generations of these same materials so that we're using materials today that were just dreams years ago. Uh.. the areas of lasers that are being used. Uh.. lasers are used uh.. an awful lot in dentistry and oral uhm.. actual facial surgery, particularly with regards to soft tissue uh.. lesions of the face or lesions inside the oral cavity. Uhm.. surgery uh.. inter-orally. Uh.. some early work being done on hard tooth structure, but uh.. that's still an area that's gonna break through uh.. and needs more work on.

Zarbock: I'm sorry, would you define that please?

Douglas Fry: Uh.. well some of the lasers are being used. Lasers are- are great for soft tissue, skin and gums. Uh.. but to replace a drill, like a dental hand piece drill, uh.. it's not there yet. Uh.. just some surface areas like through enamel, uh.. helping to clean out the uh.. grooves of the teeth in preparation for sealants, and some uh.. small uh.. cavity removal. But for deeper areas where the nerve endings are gonna be, you're still gonna need some local anesthesia and you'll need a little bit of, you know, uh.. better equipment.

Zarbock: And speaking of anesthetics, how have they changed in 30 years?

Douglas Fry: They- they have changed a lot and uh.. even the local uhm.. I mean the injectable uh.. anesthetics uh.. some of the newer ones today that are being used uh.. beginning to be used in the United States have been used in other countries, Canada and in Europe, uhm.. they're more rapidly effective. Uhm.. we always are having to deal with, you know, pain uh.. and avoidance of pain, which- which is one of the biggest fears, you know, that patients have. Uh.. people fear going to the dentist uh.. because of pain and maybe previous or bad experiences. Uhm.. so the local anesthetics uh.. that are being used are uhm.. are tremendous. There's also other types of uh.. preliminary anesthetics like patches to place inside the gums, also some electronic pads that you can place and help to give initial uh.. local or topical anesthetic is very good. Uh.. in my specialty of pediatrics, there- there's uh.. limited research on the effects on primary teeth in dealing with children, and one of the issues always has to do, you know, with the management of the child, and uhm.. trying to separate that child's anxiety or uh.. response to something that uh.. an adult might respond to uh.. in a different way. But uhm.. it's- it's uh.. one of the critical areas that we need to have so that we can give uh.. injections and we can do dental treatment without it hurting the patient.

Zarbock: I've been told that there's been an avalanche of change in the business end of a practice. The need for documentation, the concern about malpractice, the burden of insurance, etcetera. Am I correct that there's been a tremendous change?

Douglas Fry: Yes. This is correct. I think when you look at the administrative- administrative side of dentistry and the business management of dentistry, uhm.. that it is changing uh.. as we yet speak. Uhm.. you mention a couple areas, uh.. malpractice, uh.. liability uh.. that's a very, very big issue. Uhm.. in real estate, you know, they have the slogan, "Everything is uh.. location, location, location." And in- in health care, it's documentation, documentation, documentation. And uh.. one uhm.. a little rule that I try to practice by and share with my employees is to remember the- the smallest note will outlive or outlast the longest memory. So in a record it's very important that you make a note, an entry of a note, and for instance in pediatrics we always uh.. assess a child's behavior and we use some type of a rating scale for the child's behavior with a number system, which is universally understood, and also a comment. So we would always say "Behavior," and I would give a number, and then a word. It might be like, four is very good, and we'd say, "Four, great child." You know. "Three uh, good, cooperative, uh.. quiet." Uh.. two would be, "Negative. Child whined." One would be, "Screamed all the time they were in the chair." So uh.. documentation is very important. Uhm.. records are just- are just so important. And- and in this whole area of record keeping, electronic records, you know, digital records, digital x-rays, uh.. electronic transfer of records. I mean, this is just like everything else in the electronic field, it just it's, you can't keep up with it hardly. And uh.. I just read in the latest uh.. ADA uh.. newsletter, which came out this week, the efforts to uh.. improve uh.. instant electronic claims. You know. And so uhm.. we have uh.. we use electronic claims and uh.. at the end of the week, you know, our claims have all been submitted to the insurance companies for that week, and uhm.. that- and therefore you get instant turnaround with your payments and your- and your records.

Zarbock: In a professional school in which a clinical practice is the end result, it has been my experience that the professional schools de-emphasize, or perhaps don't even get into, the management of the practice. Am I correct?

Douglas Fry: Of a uh.. that's an area that we're very deficient in, and I think generally people who have tended to go into the health care field, you know, tend to be less business-oriented then uhm.. some other people. Uh.. we're very uh.. scientifically oriented. Theories, you know- you know, "Show it to me, I'll believe it." Uh.. you have to duplicate this. You know, we're- we're real clear-cut about that. And it's our- it's a downfall of a lot of our uh.. people in- in health care. And so the schools have begun to address that, you know, and you have c- certain courses in business management. But, you know, it's nothing like the real world that you get out there in.

And uhm.. what typically happens is that a doctor gets out of school and he practices- begins practice and he has time on his hand, and he can do a lot of things. But the busier he gets, the less he has to do with the business side of it. And uh.. several years ago uhm.. a very good friend of mine told me to, you know, always keep my pulse on my practice. Always keep aware of what was going on. Delve deeper into everything and try to keep on top of it. And uh.. you have to have uh.. good employees to help you do that. And uh.. one of the things that I found helped me in my practice is to uh.. have good employees and to compensate my employees well. And uhm.. you know, pay the employees well, offer good benefits to them, and keep them, you know. 'Cause longevity of employees is critical to any business. And typically there's been high turnover in the dental field, particularly among dental assistants, uhm.. you know, or hygienists, or office managers, or any- anybody that's working there. And uhm.. and that just will kill your practice. It'll just cause your business to go down, you can't be efficient and you have to spend time retraining people.

So what we've developed in- in our practice here uh.. with the help of uhm.. good management is uhm.. loyalty and faithfulness among my employees, and always try to help them to be a better person. And that's easy f- for me because I'm bakly- basically an exhorter, I like to encourage other people to do the best that they can do. And uh.. part of that I guess comes from my being uh.. raised by my father who uh.. was real involved with the Boy Scouts. And uh.. even as an adult, he would write a letter to me and he would draw a little finger of the Cub Scout and say "Do your best," you know. And so I always try to encourage our employees to do their best. And so a person who comes in at the entry level, say, and helps to uh.. begin sterilizing instruments and scrubbing instruments, you know, we will encourage them to get on in to continue education. Take the necessary courses that they need to do for their job. Look at them getting into uh.. dental radiola- ography. Uh.. of course all the requirements for uh.. emergency medical care, CPR, the OSHA requirements for sterilization. And so we have in our practice a number of people who are in the same family. We have mother/daughters, we've had brothers and sisters working, and it's made a real family, you know, organization. And that's, I think, been real important to me, and I think would help anybody.

Zarbock: I'm going to turn back to your clinical practice in a minute, but simply to point out the obvious that this digital tape will be held in a vault at UNCW until the planet Earth stops making electricity. But up until that point, it will be there and years from now, the advantage of what we're doing now will be felt years from now when people review this tape and say, "Wow. Way back there in the year 2005, these were the problems and this was the situation." So here it's 2005 and I'm going to ask a question about something called HIPAA. First of all, what is HIPAA, and how does it affect you, and how has it changed?

Douglas Fry: Health uh.. HIPAA is basically a program uhm.. that was uh.. enforced by the federal government to protect uh.. people's privacy and uhm.. it was like some other programs developed, I think, particularly the emphasis on uh.. occupational safety hazard. Uhm.. the- the primary reason for doing it was real good and has great intent, but how it was implemented and the uh.. far-reaching uh.. effects of that has just been more then I think people realize.

For instance, with the administration, HIPAA is uh.. again a health insurance personal protective act, it's to help uh.. guard people's privacy. But the implementation of that into our practice has been, you know, it- it's been far-reaching. And some of it isn't good. For instance it's made, in trying to protect patients' rights, has made it harder within the practice to uh.. deal with that patient. For instance, you can't expose a patient's record. You're not supposed to go out into the reception room and call for Johnny Jones. You're supposed to go out and call for Johnny, or little Jones, or Mrs- or Johnny's mother. You know, you can't go out and say, "Johnny Jones' mother." And uh.. when they started implementing the uh.. HIPAA requirements at the hospital I had a lot of fun, and even did this recently. I would go out with the patients chart and I would call out the patient's (laughing) medical record number. I'd say, "Would patient 790654 (laughing) please come up." And of course, nobody knew their medical records, you know. And the- the ladies at the desk all laughed and the ... and uh.. it was funny.

But here in our practice, you know, you have to do that. So instead of having like your patient schedule after the day, and in your opertories or your treatment room or on your counter where the doctor and all the staff can see it, you can't do that. You've got to have it covered. So you have to flip up a chart or turn over a chart or do something, because you can't expose a patient's name and what they're there for in an area where-- to- to the public, to somebody else that's walking by and seeing this. And one of the things that real important in our- in the practice is that when you walk into a room you have immediately some type of clues as to that patient's health, particularly allergies, latex allergies or drug allergies and things like that. Heart conditions. So what you would typically do is on the front of a chart uh.. you might have that written out. Well now you can't expose the chart for the patient's name. So it's- it's-- you can't walk in the room always easily and see who's there. But you can-- but it takes recoding your prac- your records. For instance you might have on the-- in a children's practice, this is a real common thing you do, you have the patient's chart with the name of the child in big letters, "Johnny," or "Carolyn." And you walk in the room you say "Hi Johnny, how you doing?" And typically they'll say "Hey, how'd you know my name?" You know, and you say "I'm smart, you know." And you've got Johnny's name behind Johnny on the wall in the chart rack.

But, so what we had to do in our practice was devise a series of codes, color codes in our practice that mean certain things. So for any medical allergy we have a red sticker on that chart. So you see that chart, your red sticker, you immediately know there's some kind of medical alert that you've got to be involved with. Then we can use codes for other things, like the type of insurance or payment plan that they have. And then inside the chart you can still mark anywhere you want. So it's required a lot more documentation, and a lot of things I think are unnecessary and kind of foolish. But uhm.. it's the law, and so we're gonna abide by that. And as a result we've had to have training for the staff uh.. special training uh.. on a annual update, and uhm.. when-- and to keep with the standards and the changes, uhm.. HIPAA is the one we've been talking about now, but of course the other that preceded that was the OSHA requirements. And a lot of it is just common sense, you know, and it's things that people did in their practice all the time, good standard of care. But now it's the law.

Zarbock: Do you hospitalize patients?

Douglas Fry: I treat patients in the hospital. Yes I do, under a general anesthesia.

Zarbock: Now that also means that HIPAA again is involved am I correct? Unless the patient has specifically authorized certain individuals to know that he or she is in the hospital, that person is invisible. Am I correct?

Douglas Fry: Uh.. again with the area of uhm.. confidentiality. Uhm.. and the hospital has to exercise those same rules, I know at the outpatient uhm.. clinic, they have the list of all the patients, but it's not where the patients can see it. And if it happened to be on a desk uh.. where other people go by, then it's covered with a blank sheet. So then only the people who ha- are supposed to have access to their name can see that and pick it up. As- but as I mentioned uhm.. in the reception room to go out to see a patient, or the family of a patient, you know, you have to be uh.. very confident uh.. confidential about how you identify them and call their name. And then of course discussing the- the patient's uh.. health, you know. And so the hospital provides a room, you know, to do that. And- but see again, that's just uh.. common decency and I think uh.. courtesy to show the patient. In our practice, you know, we-- for years, you know, we didn't go out in the reception room and discuss the patient's uh.. treatment out there among other people, or discuss their finances. We always brought them back in a separate place and talked to them. But uh.. the new laws have just made it mandatory.

Zarbock: I'm going to steer back to you. You graduated from University of Tennessee College of Dentistry.

Douglas Fry: That's correct.

Zarbock: In what year?

Douglas Fry: Uh.. 1971.

Zarbock: And off-camera you mentioned that you went into public health at that time.

Douglas Fry: That's correct. Uh.. came to-'course I graduated from school and dad said, "What are you gonna do?" (laughs) And I said "I don't know. I hadn't thought about that." And uh.. he says, "Well, you've got to get a job." And so I said, "Okay." And uh.. I came to work at- in North Carolina with the Department of Public Health, which is one of the top public health programs uh.. in the country. And I was a public health dentist for two years, and uh.. I developed some rather unique programs during the time that I was uh.. with the state uh.. We developed some educational programs for schoolteachers to actually get credit for their recertification on dental health education. We had a whole program on uhm.. you know, the causes of dental disease uh.. plaque control, how to uh.. clean the teeth properly and bacterial plaque and diet. And then we had a session on how to implement these uh.. these ideas in the classroom. And so that was uhm.. a- a special thing that I did in my public health service. Also in public health at that time, uh.. was uh.. a lot of emphasis on school fluoridation systems. In the county rural schools uhm.. we put a number of fluoridaters into the school system. Of course that was based upon uhm.. a random sampling of the children's home water supplies to know if there was natural fluoride in the water and how much, because then we adjusted the school water supply to uh.. the optimal level for those children. And so I had a- a great career in public health. And then uhm.. I went on into uh.. to private practice after that.

Zarbock: But fluoridation, it is now an accepted practice. But there was some hostility in individual pockets in the United States against fluoridation on the basis that this was "corrupting" or "it could be a signal of governmental take-over"?

Douglas Fry: Right. Uh.. I think, you know, it came from a lot of areas. I think one was the issue of government controlling our lives. I think another was health issues uh.. the damage it might do to- to uh.. bone structures, and uhm.. and changing the environment from our natural water, you know, I think it's from c- from a lot of issues that are against it. But uh.. I think it's well-proven that, you know, fluoridation, particularly in the developing teeth, that's- that's critical in helping to prevent tooth decay. And uh.. recently I think as last year one time, there was a uhm.. a community in the United States that voted to take fluoride out of their drinking water, you know. And it's just hard to believe that people would- would do that because the benefits have been proven for, you know, well over a half a century to that. And uh.. and then all the uh.. studies that have been done since that time on the topical fluorides and supplements of fluorides and the benefit of fluorides. So uhm.. fluora- fluoridation as probably been one of the most significant things that helped reduce dental decay in the United States.

Zarbock: But after a number of years of practice, you decided to return to school, is that correct?

Douglas Fry: That's correct. I uhm.. was in general practice for uhm.. several years and then I went back and did a residency program in pediatric dentistry.

Zarbock: Why?

Douglas Fry: The-- I think the reason that really motivated it- voted- motivated me was the change in my own life, my own personal life. Uhm.. my wife had complications in pregnancy with our child, and uhm.. was critically uh.. ill. And uhm.. both my son and my wife lived from this complication, she had Eclampsia, a severe case of Eclampsia and was in a coma for about three weeks. And uh.. my son uh.. was perfectly healthy outside of just delay getting started, but uhm.. it impacted me in lots of ways and immediately it impacted me because I was out of my practice for about a month. And it impacted me because of the financial debts that we occurred and the financial obligations that we occurred as a result of this. And uhm.. and so in the regrouping and getting back together I realized that, you know, I wasn't gonna be able to continue to do what I had been doing in the fashion in which I was doing it. Uh.. a general dentist in a community, and uhm.. and I really feel like that-- well I know, you know, one day I just got a uhm.. I opened up my journal uh.. came to the office, and I-- to my home, and I was looking at uh.. opportunities in the dental field. And I read about a program in pediatric dentistry and I said, "That's what I'm gonna be. I'm gonna go back to school and become a pediatric dentist." And uhm.. that's what I did.

Zarbock: How long was the program?

Douglas Fry: Uh.. the program was two years uh.. and I had a really unique program, I went to the University of Nebraska and our program at that time was uh.. divided between the uh.. dental school in a university setting uh.. in a nice Midwestern town, Lincoln, Nebraska, and the second half of my program was at a big metropolitan medical center at Omaha, Nebraska, at the medical school. And uhm.. we had, or I had a very diverse training with a strong emphasis upon the hospital-based training. And that was consistent with what I felt was the call for me to go back. I wanted to go back and work and train in a university or in a hospital setting. And so then when I came here to Wilmington, I was in private practice I-- and still am in private practice, but uh.. began to evolve my own practice into uh.. treating a lot of children in the operating room. And again, that's consistent with the demand that is out there today because in spite of all the advancements that we have made in dentistry, we are-- have rampant dental decay among infants.

Zarbock: Among infants?

Douglas Fry: Infants, yes. In fact uh.. you know, some things I think would be important to share here is that uh.. you know, it's estimated that 40% of children by the time they reach kindergarten have dental decay, and uh..

Zarbock: As a result of what?

Douglas Fry: The primary reason that children are having decay today is what we call uh.. bottle decay. Nursing bottle decay. There are several names that have been applied to, early childhood dental decay, uh.. previously it was called nursing bottle uh.. syndrome. We began to see children developing extensive decay as early as 15, 20 months of age. And this is because children are being put to sleep with a bottle, and again this is kind of reflective of the breakdown of- of family uh.. structure, uh.. good parenting, uh.. good mothering skills. Uh.. younger and younger women having children who aren't really prepared to take care of children. And uh.. but specifically with regards to dental disease, you are seeing children just being put to g- put to sleep with a bottle. Uh.. and it doesn't have to be Coca-Cola, which it often was, Coca-Cola and Pepsi, uh.. but just a bottle of milk. And uh.. sleeping with the bottle all night long, all day, every time they went to bed, having that milk in their mouth, the bacteria in the mouth is able to take the lactose and convert it into simple carbohydrates and sugars and consume it, and then of course throw off the waste products, which is acid. And the acid of course is what causes decay. So typically we'll see these children with decay uhm.. extensive decay behind their upper front teeth, but not their lower, because the tongue is laying over the lower incisors and kind of protecting that. And the saliva, which is a natural buffering solution of the mouth helps to protect that. So we're seeing extensive decay on these teeth, and then on the first primary molars which are developing in the arch. And the older the child gets and the more he does this, the more decay we see with that.

And studies have been shown also that this same phenomena can happen with children that sleep with their mother and breastfeed all night long. That the milk of the mother can also be used by the bacteria uh.. to make decay, and of course it goes on hours upon hours every day and every night. Now what we're seeing that's this-- continuing this phenomena on to the third and fourth and fifth year of-- five year old kids is the children walking around with the sippy-cups. And now these kids are walking around w- in a Wal-Mart and all over the place and going to church and school and home with the sippy-cup in their mouth. And they're keeping this, you know, substrate in their mouth, and it's causing decay. So let me give you a profile, the typical child that I treat, and I do about nine cases a week in the operating room under general anesthesia, is three years old and has extensive decay on 16 teeth that will require either extractions of four to six teeth and crowns and uh.. pulp treatment on four to eight teeth, and dental uh.. cavities that need fillings on the other teeth. In the average case it's going to take about two hours in the operating room to do all of this work.

Zarbock: Wow.

Douglas Fry: And I think that uh.. not only are we finding the amount of decay going on, but the-- a very, very big issue is access to care. And in North Carolina, which we- we're- we rank 47th in the country, out of 50 states uh.. with our health care, particularly dental care. W- we're that poor. We have that poor of health uh.. with our children. And in North Carolina alone we have, you know, 30% of the children in North Carolina are on some type of medical assistance program, which is going to further limit the access to care that these children have. You know, I think as a nation, as a whole, I mean, Am- United States of America is the wealthiest nation in the world, but we're nowhere near the top in health. You know, I think the highest I've seen us is 17th among western civilization uh.. western civilized nations and- and maybe lower then that in some studies. So although we have the means uh.. for the best care uh.. we're not the healthiest people and, you know, in a large part it's due to our- our lifestyle, we're- we're fat and lazy and we- we eat s- soft foods and high sugar content, and you just go back through the history of the world and you'll see, you know, where civilized nations came and where wealth came, then sugar came. And the more sugar and refined carbohydrates then the more dental disease that people have.

And in our country today we're not only faced with that, but w- we're seeing, you know, a tremendous problem with obesity in children. You know, these are all headline stories that are going on. And uh.. and it affects us right here in our own community. Uhm.. the access to care is very, very critical. And in- in North Carolina, uh.. it's been a major issue. There's recently been uh.. in just the last two years uh.. a lawsuit was filed against the State of North Carolina on behalf of Medicaid recipients which was successfully uh.. settled out of court in favor of the Medicaid recipients. And there were several uhm.. important key parts of that. And uh.. one was of course an increase in the fees uh.. payment schedule to the dentist, which has always been a- a uh.. reason why dentists uh.. weren't seeing the patients. Uhm.. another was to set up a uh.. a- an advisory group made up of different groups, the North Carolina Dental Society, the North American uh.. the North Carolina Academy of Pediatric Dentists, uh.. the uh.. North Carolina Chapter of Pediatricians, uh.. the Dental School, uh.. consumer groups, health advisory groups, you know, to help e- establish some guidelines to provide for uhm.. this program and implementing. The program has to continue to be boosted. For one, it could be cut in some funding uh.. if the federal government cuts back on Medicaid, and uh.. another of course would be just the cost of inflation. You know, we have to keep up with the cost of inflation. So uhm.. access to care for children and- is- is a critical issue in our community and in North Carolina.

Zarbock: Back to the infant situation, how do you go about dental education for a mother who has a child and breastfeeds the child on demand? Do you tell her to stop it?

Douglas Fry: Uhm.. let me just look at something right here a moment. Okay, uh.. well it's- it's, you know, first of all, I- I've developed what I call the hand of prevention, and I think there's five main components in the hand of prevention. And first is education and information, and that- that's critical. And again, in North Carolina this is becoming more difficult for us in dealing with children because of our increasing Hispanic population. So now we have a large number of Hispanic people, family, in our community who are gonna have a language barrier problem. So this is- this makes it difficult. And here, you know, I see a large number of patients who are Hispanic, and for us to properly, you know, examine the child and present a treatment plan, and make all the arrangements for them, we have to have an interpreter. We have to make sure we have someone there who can communicate to that person or that parent about it. And then of course, it- when all that's taken care of, I've still got to deal with a three year old who doesn't understand what I'm trying to do except in ways that I can communicate to them, and I've got a-- we have a language barrier. So that's why we're seeing an increasing number of children that I'm going to treat under general anesthesia. So education information is very important, and I'm gonna come back to the special program here in North Carolina in just a moment.

But then you need uh.. good plaque control or cleaning of the teeth. Bacteria plaque is the organized bacteria that builds up in everybody's mouth on a daily basis. And then we need good fluoride. Fluoride and sealants I'm gonna add to it. Sealants are a protective coating that's put on the molar teeth to help prevent decay. And then diet control. The average person in American consumes 125 pounds of sugar a year, and every time that you take some carbohydrate, refined carbohydrates into your mouth whether it be uhm.. sugar, easy dissolvable like in a Coca-Cola, or something real sticky like icing or peanut butter that clings to the teeth, you're going to have about an average of 30 minutes of acid production afterwards. So you're going to have this constantly acid production that's going on in the mouth. And that's how you get dental disease. It's not from a one time exposure, you know, it's a constant exposure. Back to the nursing bottle child. Uh.. that child is sitting there with that milk and that sugar being p- uh.. utilized to make an acid, hours every day and every night. And then the fifth component of this hand of prevention is good dentistry. You know, preventive dentistry, you know, fluoride, early dental detection, early dental treatment. You know, uh.. s- it's been said, you know, small problems require small solutions. Well small cavities require small fillings. Large cavities require larger fillings.

The program I wanted to mention was uh.. called "Into the Mouth of Babes," and it's a program that's been instituted here in North Carolina for several years. And it is a program available through physician's offices from the age of six months to three years. And uh.. a- a big driver behind this was uhm.. was a physician in Asheville, North Carolina, uhm.. I believe that that's where one of the primary sources for this guy started. But this program today is available through the uh.. physicians in North Carolina, and it requires the physician to go into a training class on dental education and dental prevention, and then the physician can go back to their office and train their staff. And so this is a program that's being used by pediatricians and family practitioners throughout the state of North Carolina. And uhm.. it involves education uh.. nutritional counseling with the parent, but-- which is a very important part, but the uhm.. the effective, immediately effective part of this is the application of a fluoride varnish on these children's teeth. And so the early child coming in, they get in the physician's office a fluoride varnish, and that's been proven to be very effective.

Zarbock: Would you discuss with us a little bit about.. you enter the life of a patient, let's say three or four years of age. The examination indicates that the more successful interdiction would be surgery in the hospital. How do you go about sharing this information with the parent and what do you tell the child who is three or four years of age?

Douglas Fry: Right. Well, I think you're looking at uhm.. a component part of what pediatric dentistry is all about, so let's- let's start with that. And basically, uh.. pediatric dentistry is one of the recognized specialties uhm.. by uh.. the American Dental Association, and it has a uh.. a board certification program like the other specialties, and I am a board-certified pediatric dentist. Uh.. it makes me a diplomat of the American Board of Dentistry and a fellow in the American Academy of Pediatric Dentistry. I believe in uhm.. you know, membership of the professional organizations, uhm.. and so that's the correct channel I think through which, you know, I'm going to operate. Okay. And as a specialist, our- our field primarily deals with three areas; number one is prevention and we've heard a lot about that here today. Prevention to me is from the gradle to the- from the cradle to the grave. Prevention is all the way through. Fluoride alone, we've talked about uh.. fluoride's importance in the developing of the tooth structure, but fluoride topical applications, particularly brushing with fluoride paste, tooth paste, two to three times a day, fluoride supplements, you know, there's hardly any substitute for that. So uh.. prevention is one of our things.

We talked about sealants, trying to prevent decay before it even started. Uh.. even in the area of orthodontics, you know, crooked teeth, you know, preventing problems is important. And that you- we primarily do by preventing the loss of the tooth. Okay, so prevention is one of our foundations, the second area in our foundation i- is growth and development because you can look at a child, and uhm.. you can see the pattern that's going to be there. All of us have patterns in life, well we- we don't know what they are, we don't know how tall we're gonna be or how short we're gonna be, you know, if we're gonna have blue eyes, brown eyes or we're gonna be bald or what. But you know, the patterns are there, and you know, it's been sh- shown for years we've got uh.. pictures of uh.. the fetus, the unborn child in the mother's womb sucking their thumb. And that child comes into the world sucking their thumb. Okay, now like with some- thumb sucking, sometimes it's just a passive thing, the thumb's just held there, there's no oral musculature activity that's going on. And those kids won't develop malocclusions, but the ch-- then there're other children that suck their thumb with lots of oral muscle activities, and they're going to change the shape of their bite and their teeth, and they're gonna develop orthodontic problems.

And then there're children who may have really nice s- straight teeth, but you know, they don't have two jaws that go together. They've got, you know, grandpa's forward jaw and aunt Milly's lower jaw, and the jaws don't line up. And that's similar to my case. Now we didn't have a family history of what I had, Mandibular Prognathism, but uhm.. you know, I had it. And uh.. and I would have been a great candidate for jaw surgery when I was a teenager, but at that time it- it wasn't done the norm. Today it's- it's done all the time. You know, and I've even as an adult, as a dentist, you know, considered this Orthognathic surgery done to correct my bite because I'm still fighting my own malocclusions. My teeth have a certain place they wanna be. And uh.. all the orthodontics in the world, you know, is not gonna overcome what nature is trying to do right there. So uhm.. that- that's the thing I'm personally experienced with, and that's why I can relate to kids, as I mentioned earlier, teenagers about that. So growth and development is very important. So when we see the young child, we can begin to tell the parent, "You're gonna have-- your child's gonna have certain problems." And I kind of say, "Open up a savings account and put $5 a week in it." You know, "By the time they get old enough to need their braces, you'll have it paid for."

And then the third area that we as a specialist with children deal with is behavior management and modification, okay? So that involves a whole realm of things. We've mentioned earlier about us writing in the child's record about their behavior, and you were asking me specifically about getting to the hospital. Okay, that is the- sort of like the extreme. You know, on the scheme, or the timeframe of a child's needs and behavior management is gonna be nothing to everything. You know, the child doesn't have problems, they- they don't have dental disease, they don't need any treatment. The child has extensive dental problems and they need a whole lot of work. So in assess- in getting to this point, one my instructors in school had a little phrase, he liked to talk about behavior management, and it was said in this fashion, uhm.. "Hugs, tugs and drugs." You know, and so I-- that's a simple way of looking at it.

You've got children who they don't need any coaxing at all. My grandson was here the other day and he just hopped up in the chair and he opened his mouth, he put on his sunglasses and he's not yet two years old, he'll be two years old this month, you know. And that's- that's the ideal patient, you know, and it wasn't necessarily because he was my grandson, it's because that's the way that child is raised, he's in a loving, caring environment and he- he's open to new situations and new people and things like that. But we see so many children who, you know, like socially they're- they're handicapped, they just don't have the social experiences, they don't know how to deal with people, new environments, new situations.

So anyway, you're initially gonna treat the child. You come in and say hi to 'em, you talk to 'em, understanding their mental development and emotional development. And when I had my own son I began to realize how fast and- that changes. You know, it wasn't like one year, three years, five years, seven-year milestones. It's 12 months, it's 18 months, it's 20 months, 24, 30 months. And so, and that's the population children I'm dealing with primarily. And so these children come in and you've got to get them, you know, and we use a lot of techniques. You know, of course distraction techniques, and tell, show and do, and just being friendly to them and trying to coax them along. And the parents usually are pretty good, "Point at that," you know, a- a good help at that time. Then you've got the child you've got to kind of nurture. You've got to tug, you've got to get them in, you've got to coax them along, take constant attention. You know, you've got to assure them all the time. You know, voice control and a manner that's sometimes voice control, there's "Ding," very firm "No." Sometimes voice control is, "Come on, you can do it. Sure. You're doing- you're doing a great job. Now I'd be real quiet now." You know, so your voice controls a lot of things.

And then of course, drugs. So you've then got-- and when I'm talking about drugs, I'm talking about techniques other then, you know, simple tell, show and do, passive restraints, or holding the hands down, active restraints or whatever, and need some type of pharmacology, some type of drug intervention. It could be as simple as nitrous oxide. Nitrous oxide inhalation sedation. Nitrous oxide's very great, but you have to have a child that's willing to hold the nose piece on their nose, they have to (deep inhale, deep exhale) they have to breathe through their nose, they can't be whimpering, crying. A crying child's not breathing through their nose, you know. So nitrous oxide, sometimes a little mild tranquilizers you can use, a little, you know, uh.. sedative, something over-the-counter almost. You could use Valium, you could use a light, light alteration. But when you go past that, you get into what's called conscious sedation, and for conscious sedation where the child, or the adult in either case, has a compromised airway protective mechanism. That is gonna be all regulated by our State statutes, you have to have a certain license, you have to have certain drugs on- in your office to counteract uh.. adverse reactions. You have to be monitoring the patient, you know, you just can't indiscriminately go about it. And of course it's for the welfare of the patient, you know.

And uh.. so from that point on, whether it be an oral drug, or an injectable drug, whether it be an injection that we give in- can give in the oral cavity, or whether you have to do IV sedation, you know, you have to have- you have to meet certain guidelines. There's regulations about that. And that's pretty universal, universal precautions. And then that could be anything from drugs that are given orally to IV sedation or a general anesthetic. And in my practice I just see so many children that are so young to have so much problems, that I'm concentrating on a pool of patients that are going to require general anesthesia. I have done in-office sedation before, uhm.. I can do in-office sedations, but I prefer not to, I think it's the s- the safest environment is in that operating room where you've got trained anesthesiologists and nurses and everybody to pre-op the patient, manage the patient, and post-op the patient. So that helps me concentrate on my dentistry. And you got to go back and look at what got me here in the first place, that's what I wanted to do. I w- I wanted to go into that office- that hospital environment, I wanted to work with a team of people like that. But it took me years to get to that point. But as a pediatric dentist, we're all trained to do that, and here in our town we actually have uh.. five pediatric dentists that do work in the operating room on a daily basis. So much that we're doing about 48 hours a week uh.. approximately in the operating room. And I have patients that don't need to go under general anesthesia. I have patients that, you know, uhm.. might need-- that I think they'd be great candidates for just in-office conscious sedation, and when I see those patients, I will tell the parent. 'Cause that was a question you asked me. If-- I'll say to the parent, you know, "Your child needs to have work with some type of sedation and I think they'd be a good candidate for in-office conscious sedation, but I don't do that and I'd be glad to refer you to one of the other dentists that does." Or I might have a case that I can say "This child needs to have general anesthesia and, you know, I can do that." You have- you have other types of techniques like, you know, I mentioned, or some type of restraint maybe for a minimal amount of work, you know, and things like that. But a- and sometimes you don't know the- the clear choice of treatment, you know, but uh.. most of the times you do.

And so then how do you relate that to the child? Well again, if it's just something we're gonna do in the office, I mention we're gonna u- use good chair side manners, we're gonna tell show and do, we're gonna use- use a little distraction techniques, we're gonna try and so some, you know, nitrous oxide sedation. And then of course the child- and I don't try to talk to the child about "We're taking you to the hospital. We're gonna pull your teeth out," or something like that. We really try to avoid those because those do imprint on the child's mind what they're gonna do. The nice thing about some of the drugs that they use in general anesthesia is there is an amnesia affect, and so children don't really remember all those things that went on. Which is a problem you have when you treat the child in the office that is a cooperative child, and you start doing procedures, and they cooperate with you and they do everything that you ask them to do, but they don't like it. They don't like leaving with their lips numb and drooling and sometimes they bite themselves, and- and they don't like the sounds of the hand pieces, and so that child starts becoming leery about coming to the dentist, and then we've created that problem. So the reasons to go under general anesthesia, which is I think an important question, is because of the child's health. We have- we see a lot of children that are medically compromised, they're severe asthmatics, they uh.. they have health issues, uh.. they're risky children. And we see children here that we don't treat in Wilmington, we refer them to Chapel Hill to a medical institution where they can be followed along. Th- this happens frequently, they're high-risk children and- and they're not gonna be treated in a community like ours. But the- the health compromised child, we see a lot of the medically compromised child, children with Down Syndrome, Cerebral Palsy, problems like that. So they're gonna go for medical reasons, they're gonna go because they have extensive work, they've got to have major surgery, they've got to have a lot of teeth extracted, they've got to have a lot of crowns, they're- they're two and three years of age, they don't understand it. You know, and uh.. we don't- we want to preserve their psyche, we don't want to cause problems.

Zarbock: Doctor Fry, it's been said so often it's becoming a trite statement, so I'm going to add to the triteness by repeating it. The phrase goes something along the line that, if you really, really enjoy whatever it is that you're doing for a fee, that you never work a day in your life. If you don't like it, you've got to work every day in your life. You strike me as being somebody that in this context has never worked a day in his life. Am I correct?

Douglas Fry: I- I appreciate you saying that. I do feel like I enjoy my work. I get out of bed in the morning and I- I'm ready to come to work. I enjoy what I do.

Zarbock: You know what? It shows. Doctor Fry, thank you for your time.

Douglas Fry: Thank you.

Zarbock: This is a wonderful, wonderful interview.

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