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Interview with A. Ryan Stanley, July 8, 2005 | UNCW Archives and Special Collections Online Database

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Title:
Interview with A. Ryan Stanley, July 8, 2005
Date:
July 8, 2005
Description:
In this interview, Dr. A. Ryan Stanley discusses his motivations for entering dentistry and gives a thorough overview of his dental education and training. He also speaks regarding care and concern for patients, how a dental practice is built, and changes and constants in dental procedures, equipment and techniques.
Phys. Desc:

Interviewee: Stanley, A. Ryan Interviewer: Zarbock, Paul Date of Interview: 7/8/2005 Series: SENC Health Services (Dentistry) Length 56 minutes

Zarbock: Good morning. My name is Paul Zarbock, a staff person with UNCW's Randall Library. Today is the 8th of July in the year 2005 and we're interviewing, for the health care delivery systems segment of special collections, Doctor A. Ryan Stanley, doctor of dental surgery. Good morning sir.

A. Ryan Stanley: Good morning.

Zarbock: Are you in good health and good spirits?

A. Ryan Stanley: I'm feeling good today, thank you.

Zarbock: Alright. Well, let's start off then. What individual or series of individuals or event or series or events led you into the selection of dentistry as your career choice?

A. Ryan Stanley: Well, I've always been interested in mechanical things and- and as a kid I used to take stuff apart and build things and- and junk like that, but uhm.. the- the one main person was my dentist when I was a kid. Uh.. his name was Burt Brennan, he practices in-- I think he's retired now, but he practiced in Greensboro, North Carolina. Uhm.. but he was just a really good guy, he took good care of his patients. And uh.. and as a five or six year old coming in and getting my first fillings done, uh.. he made me comfortable. Uh.. back in the good old days they had those big drawers uh.. cabinets with a zillion drawers in them, and he would let me go in and look at all this stuff and handle all the mechanical implements while he was uh.. working on my mom's teeth, and then when it was my turn, he would show me all the equipment and how it all worked, and I just found that very, very fascinating. Uh.. so it was always something that was interesting to me. Later on in life when I was uh.. I guess 12 or 13 years old I had braces, as most kids do, uhm.. and I went into the orthodontist's office and I was carrying a check for about 30 bucks as I recall, which uh.. back in the early 60s was a fairly significant sum of money, and I went in and I handed that to the secretary, and I sat down on a chair and I looked around in the big room and I saw that there were seven other kids that were sitting in the chairs, and uh.. figured they had also brought in checks with them, and I- I started doing the math and the guy in the lab coat, the dentist, uh.. was uh.. going around and tinkering in their mouths and going from one kid to the next, and I thought, "You know, this looks like something I could do. It looks like a pretty darn good deal." So right then and there I decided I wanted to be an orthodontist. Uh.. as it turns out uh.. I didn't have enough imagination to think of anything better to do as I got through college and- and school, so I...

Zarbock: Where did you go to college?

A. Ryan Stanley: Uh.. I was uh.. went to University of North Carolina, Chapel Hill. Uhm.. it was a- it was an interesting time there, we were right at the height of the Vietnam War so there was a lot of- of that sort of political stuff going on. Uhm.. I'm- was a chemistry major, so I'm uh.. I'm basically sort of a nerd, and I wasn't really deeply involved in all of that sort of thing, but it was uh.. formed an interesting background for what went on uh.. while I was going through college. But I- I proceeded on into uh.. the Dental School at Chapel Hill.

Zarbock: Let me ask about the application process in the Dental School. What did you have to do and what requirements were made of you?

A. Ryan Stanley: Uhm.. well of course there is an application that has to be filled out and all the paperwork and that sort of thing. There uhm.. is a dental aptitude test, uhm.. I think it's considerably different now then it was then, but uh.. there's uh.. similar to the SAT that you take when you get into college, it's a- it's a uh.. a scholastic aptitude and achievement test along with uhm.. a mechanical aptitude test. We- we had to carve a piece of chalk to a specification and uh.. go through some uh.. some testing on our ability to uhm.. to figure out spatial relations and- and stuff like that, which is something I've always thought was pretty fascinating.

Zarbock: Now other dentists have told me, when you mention carving something on a piece of chalk, that this wasn't just doodling, this had to be with great precision.

A. Ryan Stanley: Absolutely. Uh.. as I recall, we had a little round piece of chalk that looked like a- one of those oversized uh.. sidewalk chalks that you use uh.. and we had a specific, I think it was kind of like a uh.. an elongated pyramid that we were supposed to carve out of this chalk to a specific set of measurements. Uh.. it was a geometrical figure, it wasn't anything particularly artistic, uh.. but it was quite a challenge to get that chalk to behave and- and make it come out like you wanted it to.

Zarbock: Was this a take-home effort, or did you have to stay in the laboratory?

A. Ryan Stanley: No, it was in-- it was a laboratory test, right there. We did it right there on the spot.

Zarbock: Was it timed?

A. Ryan Stanley: Yes. Yeah, it-- I- I've always been fairly good at test-taking, uhm.. but I recall it being pretty uh.. pretty high-pressure situation. You know, you had to...

Zarbock: That's a lot of stress, isn't it?

A. Ryan Stanley: You had to think in terms of doing pretty well on that.

Zarbock: And again, to indicate the precision of this, other dentists have told me the evaluator even put a micrometer on it to make sure that you were within the certain variants.

A. Ryan Stanley: Uhm.. actually I don't remember that happening in my case, but it very well could have.

Zarbock: By the way, what year did you enter dental school, and how old are you?

A. Ryan Stanley: Entered dental school-- I'm right now 56 years old, I entered dental school in 1970. Uhm.. I went through Chapel Hill undergraduate uhm.. working towards a chemistry degree (clears throat), but I was fortunate enough-- I- I knew in advance that I wanted to go to dental school. So I applied to dental school uh.. a year early. At that time, they had a program where you could get into dental school after three years of undergraduate college (clears throat) and uhm.. I was lucky enough to get in under that program, which sort of locks you into dental school because after your freshman year of dental school, assuming that you're successful, you're awarded an undergraduate degree of a BS in Dentistry, which, I can't imagine a more useless degree. But uh.. presuming that you're going to go on and finish dental school, it's a- it's kind of irrelevant. So I never actually got the chemistry degree I was pointing for, but uh.. I did make it and manage to get into dental school. Uhm.. I- I sincerely to this day believe what got me into dental school was the fact that I made an A in organic chemistry in undergraduate school. Uhm.. my grade point average wasn't all that great, uhm.. but they seemed to be very impressed (laughs) that I'd done well in organic uhm..

Zarbock: But a Bachelor's Degree in Dentistry.

A. Ryan Stanley: Bachelor of Science in Dentistry, that's the- that's the actual undergraduate college degree.

Zarbock: Do they still offer this degree do you know?

A. Ryan Stanley: I- I don't know if they do or not. I think they do still have an early entrance program, but I- I'm really not real sure.

Zarbock: But you must have been about 20, 21 years of age at that time?

A. Ryan Stanley: Uhm.. that's about right, yeah.

Zarbock: So off you go, you're now in dental school. You have a white coat.

A. Ryan Stanley: (clears throat) Yep, white coat. Those k- kind that come to the-- with the- with the preacher's collars that button up the side like uh.. like dentists and barbers used to wear, you know?

Zarbock: What ever happened to that style, by the way?

A. Ryan Stanley: I think it's kinda gone by the wayside. I was uh.. of course being in the era that I was, the late 60s, early 70s, things were changing a lot in our society at that time. Uhm.. the year that I started in dental school, uhm.. we were required to wear a- a necktie to class. Uhm.. I was told, although this was not something that was imposed on us, but I was told that prior to our entrance into dental school, they locked the doors at 8 am. So if you were late for class, you didn't get in. And they were pretty- they were pretty hardcore. Uhm.. the dental school a- at Chapel Hill has always had a tradition of- of a very high degree of excellence, and uhm.. and- and they're- they're very serious about what they do.

Zarbock: How many people in your class?

A. Ryan Stanley: A- as I recall there were 77 freshmen uh.. dental students in my starting class.

Zarbock: How many women?

A. Ryan Stanley: Uh.. we had- we had two women. Uh.. that has changed a lot since then. Uh.. a woman was a very unusual thing in dental school at that time. Uh.. there were a few, but- but a very few. Uh.. and now I think the- the class is a half or more female.

Zarbock: What about minority students?

A. Ryan Stanley: We did have uhm.. we had two minority students that I recall. One them was a- w- one of them was a- an African American woman who I- I think was probably the- the token female black at the time. Uh.. it was an era when we were undergoing that sort of a change as well. Uhm.. th- there are considerably more now. That's uh.. the opportunities are much more available to them now then they were then.

Zarbock: Did you enjoy dental school?

A. Ryan Stanley: I did. I did. It was- it was tough. Freshman year was really, really hard. Uh.. demanding academically, I will never as long as I live forget uhm.. spring of our freshman year uh.. final exams, we had 13 final exams, full major college level, graduate level three hour final exams in the space of about ten days. It was brutal (laughs). But uh.. and- and in- and in preparing for those exams, I set up a uh.. a study schedule, I was living by myself at the time, I had a mobile home outside of Chapel Hill. And uhm.. I would come home, our school day was 8 o'clock until 5 o'clock, all day long. Uh.. we had both academic and laboratory work uhm.. But I would come home, I would fix myself a little dinner, I'd watch the evening news, drink about nine cups of coffee, and at 8 pm I would go into my study room, I had a study room with a- with a desk and- and table and all that kind of stuff, and I would study from 8 'til midnight, every single night, six nights a week. I did that for about six weeks leading up to the exams just to make sure I had everything down as near cold as I could get it. Uhm.. once you get past freshman year the academic is uh.. is- is not quite as brutal 'cause you spend more time. Uh.. we started actually seeing live patients sophomore year in our dental school, which is a little bit unusual, that's earlier then a lot of schools, or at least it was then.

Zarbock: What about grading? Was it pass/fail? Or was it A, B, C, D?

A. Ryan Stanley: Oh no. It was A, B, C and we were uh.. we were informed in no uncertain terms at the beginning of our- of our uh.. dental school uh.. curriculum that uhm.. if you had below a C average you were out.

Zarbock: So it was strictly graduate school model, the grading.

A. Ryan Stanley: Yep. We were- yeah, we were graded- we were graded uh.. on everything. On everything. And I remember uh.. we were graded on our laboratory work of course as well, 'cause we had to learn how to carve teeth and learn how to make fillings and cut preparations, we worked on the dummy for the first year uh.. in our laboratory. And uh.. I had a friend in my class that was very compulsive about grades, and he would re-compute his grade point average every time he got a uh.. every time he got a uh.. a result on his grade, which I thought was kind of amusing. But uh.. we were all pretty conscious of that.

Zarbock: Take me back to that remark. You said you worked on a dummy?

A. Ryan Stanley: Yes. Uh.. we had uhm.. a little mannequin that was a- that was a uh.. a head-shaped thing. And that we actually would use in the posture that- that you're supposed to use when you're working on a patient uh.. to practice working with the mirror. Dentists are the only people in the world that can look at something in a mirror and actually know what they're doing. Uh.. because we train on that specifically. Uhm.. at Chapel Hill one of the- one of the things that- that they do that's special at- at the Chapel Hill School of Dentistry is, we actually had a set of natural extracted teeth that were mounted in a model uh.. that were fit together like natural teeth do. Most schools work on plastic teeth. Uh.. we used a natural tooth dental form, so we were uh.. cutting on actual human teeth when we were learning how to do this. Uh.. so it's a-- it gives a little bit different feel, it gives you a much uh.. better uhm.. impression of the anatomy and the structure of the tooth that you're working on. But yes, we used these- we used these uh.. natural tooth dentoforms and mannequins uh.. to practice learning how to make our preparation (inaudible).

Zarbock: How are these technical skills taught? You want to drill a tooth. I assume that at one time in your life, you had never drilled a tooth.

A. Ryan Stanley: That's correct.

Zarbock: You're now going to drill a tooth. How were you taught how to drill a tooth?

A. Ryan Stanley: Well we- we have classroom instruction that shows us uhm.. the uh.. we- we spent a lot of time learning the anatomy and the internal anatomy and form of teeth. (clears throat) Uhm.. we spent a lot of time on mechanics and engineering on how the drills actually work, the- the mechanical, physical process of cutting and how that occurs, and grinding. Sometimes you use a cutting instrument like a machinist's lathe. Sometimes you use a grinding instrument like a diamond grit uh.. instrument. Uhm.. but we had diagrams and we had books and we had little maps that showed exactly what the ideal form for a particular preparation in a particular tooth should look like. And uh.. we would first practice it on uh.. something you could hold in your hand, and then you would practice it on your mannequin, and uh.. then ultimately we practiced it on uh.. live patients.

Zarbock: What about giving shots? Had you given any shots before you ended up in dental school?

A. Ryan Stanley: Uh.. no. That's- that's another one of my favorite anecdotes. Uh.. Doctor Jim Overton [Ph?] and I who worked together uh.. have been buddies for years, we were neighbors in the trailer park where we lived. And the day came along in uh.. about halfway through our freshman year I guess, came along where in our laboratory it said, "You're-- today you're gonna learn how to give a uh.. a dental anesthetic injection." We said, "Okay, that's nice." We've studied it in class and we learned all the biochemistry, and we've learned all the uh.. the pharmacology and all of that stuff, and we've learned the mechanics uh.. theoretically on how to give an injection and what you're supposed to do, but we've never actually done this. Uhm.. well our instructor said, "Find a buddy and pair up, and you're gonna give each other an injection of local anesthetic today." So Doctor Overton was on the other side of the laboratory and the guys on either side of you in the lab, we sat in alphabetical order in our little lab niches, uh.. but as soon as that announcement was made that we needed to find a buddy, he I and both looked up and pointed, because I wasn't gonna let anybody do that to me the first time except him, and he kind of felt the same way. Uhm.. they pointed out to us that whoever goes first had better be really, really careful because your partner is going to go second and he'll get even if you don't do a good job. Overton and I have been close friends ever since.

Zarbock: How have anesthetics, if they have, changed since the time that you gave your first shot until yesterday?

A. Ryan Stanley: They really haven't changed much at all. I am still using the same medicament that I used on that first day.

Zarbock: What was the word you used?

A. Ryan Stanley: It's Lidocaine, which is a- which is a uh.. anesthetic-- it's a -- all of our general anesthetics are based on the cocaine molecule. Cocaine is the very first dental anesthetic that was ever used. Uhm.. there are certain problems with cocaine uh.. and there are certain problems with direct derivatives of- of cocaine. Uhm.. I'm embarrassed to say I can't spout off all of the technical chemical uh.. names right now, 'cause it's been quite a long time. But uhm.. the uh.. the- the mole- the various molecules of- that are used pharmacologically as a uh.. anesthetic agents are all- are all derivatives of that uh.. of that cocaine molecule. Uhm.. the stuff that we use now is uh.. Lidocaine Hydrochloride, uh.. that's one of our main anesthetics. There are a whole slew of similar medications that are used for different- different types of purposes and different sorts of situations, but really they're all very, very similar, they have slightly different effects. There's one that uhm.. is uh.. a much smaller molecule that diffuses through the tissues a little bit faster so you can get uh.. a little bit quicker anesthetic action. Uh.. there's one that sits in the tissues a lot longer so that you- you can actually give an injection and expect it to stay numb for four to six hours, which for a general dentistry practice is not all that useful, 'cause you don't want to be walking around with a fat lip for the next uh.. the rest of the afternoon. But the oral surgeons use that anesthetic quite frequently because when you're taking out wisdom teeth, you want to keep that thing numb the whole rest of the day because it's much more comfortable for the patient that way. But uh.. other then, you know, the development of some slightly new derivatives of the same molecule, we're using the same stuff we always have.

Zarbock: What about techniques? The day in dental school versus yesterday in dental practice, how have techniques changed in your practice?

A. Ryan Stanley: The- the mechanics of it are changing slowly, uh.. they haven't really changed a whole lot. When I started in dental school the transition from the old belt-driven hand pieces that some of the gray-haired people remember, uhm.. to the compressed air, turbine-driven uh.. hand pieces that make that horrendous whine that everybody hates to hear so much uh.. had already happened. So the uh.. we've been using the air-driven hand pieces since the day I started. And uh.. and uh.. they're still in use widely. Uh.. other mechanisms for making a cavity in a tooth, taking out- taking decay out of a teeth uh.. have been developed; they're using lasers now. Uhm.. they're using uhm.. high-velocity, air-driven abrasive now, it's basically a- a uh.. a sandblaster. Uhm.. but none of these things in my opinion have really superceded the old air turbine hand piece yet. I think the lasers are ultimately probably going to do that, but it's not- we're not quite there yet.

Zarbock: How does the laser function?

A. Ryan Stanley: Uh.. the...

Zarbock: Couldn't you go all the way through the tooth, the jawbone and out into the chair?

A. Ryan Stanley: You could. There're- there're different sorts of laser uh.. instruments uhm.. that the mechanism that you use to produce the laser, a laser uh.. goes through a crystal of some sort, or some sort of medium that actually uh.. activates the laser action, and depending on what you use in that crystal, whether it be uh.. erbium or ruby or carbon dioxide, there're all sorts of different ways to do that, gives you a different type of laser pulse. Uh.. the ones that they're using in dentistry now, the one that's the most commonly used for preparing tooth structure, uhm.. is actually a heat-producing laser, and the way the thing works is it puts a tiny little droplet of water on the tooth, and then hits it with a very high intensity laser, short duration laser pulse, which causes that water to vaporize explosively, and it creates a little crater in the surface of the tooth. And it repeats this pulsing action at a very high rate of speed so that you're just basically pecking away at the tooth and producing a- a tiny little hole. Uhm.. it is so tiny and it happens so fast that this is uh.. it's controllable uh.. so you can m- manage the depth of it and manage the shape of it fairly well. I've never actually used one, so I can't really speak to that with any expertise or authority, but uh.. that's my understanding of the way it works. And there are several of these instruments that are in use here around town today. Uh.. the-- it- it's fairly expensive still because it's a new technology, I think the laser gadget costs about 40,000 bucks, as compared to a thousand or so for a really nice uh.. air-driven turbine hand piece. Uh.. and some of my colleagues who have used the laser say that it's not unusual for them to have to go back in with an air-driven hand piece to smooth up the edges and to refine the preparation. So I- I just sort of haven't bothered with that technology just yet. Uhm.. I enjoy watching the development of technology to see how it, you know, what's coming on, but I- I don't like to be the first one to use something new.

Zarbock: If you wouldn't mind, within this category, could you give me a tour of the intellectual horizon when it comes to what may take place in the techniques in dentistry in the future.

A. Ryan Stanley: Well I think- I think lasers are certainly something that's coming on very, very strong. Uh.. use of lasers on soft tissue as a scalpel, uh.. there are many procedures that we do where you need to cut the gums or where you need to remove a little bit of bone, or do something like that, those uh.. types of uses for uhm.. a different sort of laser uhm.. are coming on fairly strong. So I think we're going in that direction on a lot of things. Uhm.. (sniffs) as far as the preparation of teeth, one of the things that we are focusing on now is trying to keep those preparations as non-invasive as possible. Uh.. there are some technologies that help us to uh.. discover decay in a tooth at a very, very early stage. By discovering that decay early uh.. you can go in and make a very, very tiny cavity preparation, get rid of the decay, and seal it with a bonded resin uh.. type of filling material that does not require uh.. a mechanical dovetail or locking into the structure of the tooth the way the old silver fillings used to have to do. So the fillings can be much smaller, they can be less destructive to the tooth, and uhm.. and protect the tooth from additional decay.

Zarbock: This may be the time when I mention the M word, mercury.

A. Ryan Stanley: Mercury.

Zarbock: When you started off in practice, again let's date it as your student days.

A. Ryan Stanley: Yes.

Zarbock: How prevalent was the use of mercury then, how prevalent is the use of mercury now, and what is the consequences of then and now?

A. Ryan Stanley: Well, obviously this is a very highly charged and somewhat emotional issue with a lot of people. Uhm.. when I began in dentistry the silver amalgam fillings, which is a combination of mercury and silver and certain other alloys to help make it strengthen and- and make the working properties, well usually there's some copper and- and some other uhm.. trace elements that just help the material work well. Uhm.. but typically a silver amalgam filling is constructed- is- is formed by of about half mercury. What the mercury actually does is dissolve the silver and as it dissolves the silver it hardens and it becomes an alloy of mercury and silver. There's no free mercury in a silver filling, it's all alloyed and- and dissolved in the mercury. Uhm.. so it's all the solid, hard solid block. Now you can beat the mercury out of those fillings by either heating them or by grinding on them uh.. which- a- and actually just heats them, uh.. or by chemical means, but that mercury's locked into the silver filling uhm.. once it's hardened in place. Uh.. we used almost a- a 100% silver fillings uh.. back in those days. The plastic resin filling materials that we used on front teeth because you don't want to have a big silver filling in your front tooth, uh.. was just beginning to be developed successfully. There were several types of resin on the market, none of them worked very well, none of them were particularly durable and they didn't hold their color very well. So you'd put a filling in a front tooth and it would look okay for two or three years, and then it would begin to turn brown. Uhm.. that technology has improved amazingly over the last 30 years. Uhm.. so we are now able to use a strong, durable, well bonded resin filling almost anywhere that you would use a silver filling. So our use of silver and mercury has gone down dramatically. Uhm.. many of my patients uh.. question the safety of a silver filling because if you have sensitive enough instruments, and if you have silver fillings in your teeth, you can actually measure a minute amount of mercury being released just from chomping on those silver fillings and wearing them down over a period of time. Uhm.. it's such a minute amount that in my opinion it's of virtually no consequence. There have been repeated reputable scientific studies that have studied people that have had a lot of fillings for their entire lives, people that have never had any fillings, people that have various and sundry diseases and comparing which- w- whether they have a lot of fillings or not, and there's been no real solid scientific evidence to correlate a lot of fillings with any particular disease or problem. And there's also been some not so reputable science that can show all kinds of things. So as I said, this is a very controversial issue with some people, and in my opinion the most important thing about getting away from mercury because it is something that we're all trying to do as a profession, is when that old silver filling fails and you have to grind it out of somebody's tooth, then that silver amalgam, with the mercury still incorporated and locked in it by the way, that silver amalgam goes down your sewer system. So you have heavy metal silver and you also have a certain amount of mercury that is incorporated in that heavy metal alloy that goes into your s- sewer system, which could potentially go into your uh.. into your aquifer. That to me is a far greater problem then any problem that you might have with disease with actually having a filling in your mouth. Uh.. so I'm reducing the amount of silver that I use. Uhm.. there are situations where a silver filling is, in my opinion, still superior to and more durable then uh.. and more desirable then the direct placement plastic fillings.

Zarbock: And that's clinical choice?

A. Ryan Stanley: It is. It is. And I- and I think uh.. on average most dentists in- in the United States agree with that. You know, there are places where silver is just still better. Uhm.. and so they use it. There are- there are other options to silver, uh.. there are uh.. cast gold alloy fillings, there are porcelain uhm.. laboratory manufactured fired porcelain uh.. fillings in restorations that can be done, but those options are considerably more expensive then the directly placed either silver or bonded resin fillings, so they're not used as much.

Zarbock: The discussion of mercury is generally within the rubric of hazards connected with the practice of dentistry, let alone being the patient of a dentist. Well one of the changes I'm sure that you could identify back to the days when you were a student to yesterday, is your dress. You said that when you were in dental school you had to wear a tie. A coat was obligatory?

A. Ryan Stanley: Well, no. No we just- we would wear shirt and tie to class.

Zarbock: Okay.

A. Ryan Stanley: When we were in clinic we would wear those uh.. we'd take our shirts off and wear those barber suits.

Zarbock: Okay. How has it changed now, your attire?

A. Ryan Stanley: We are actually much more careful about our clinical attire now then we were then. Uhm.. it's less formal uh.. in appearance because you don't have that high, tight collar, but these uh.. these long-sleeve lab jackets, we wear rubber gloves all the time, uhm.. we wear masks, we wear glasses with eye shields. Uhm.. many doctors uh.. will wear a surgical cap to cover their hair. Uhm.. or so-- and- and many of the- many of the dentists or their staff will wear some sort of mask uhm.. see-through mask that will cover their face and protect from splash. Uhm.. there the concern can trace back directly to the AIDS problem. Uhm.. we became, during the mid 80s, we became so acutely aware of the high risk and the uh.. the high consequences of the AIDS disease.

Zarbock: And alarm bells went off.

A. Ryan Stanley: Alarm bells went off.

Zarbock: Everyplace.

A. Ryan Stanley: There was a huge public outcry, and uhm.. it- it became obvious that we needed to make sure that we were doing everything that we could possibly do to ensure both the safety of ourselves and our staff and to protect the patients from possible cross-contamination from one patient to the next. So virtually everything that comes into contact with a patient is either thoroughly sanitized with a disinfectant spray, wipe and spray, or steam sterilized in a- in a hospital-grade autoclave. Uh.. all of the instruments that actually go in the patient's mouth, or penetrate tissue, the drills, the uh.. the hand pieces, the uhm.. suction tips, the little picks and probes and things go through a steam sterilizer.

Zarbock: It's a different world. AIDS introduced a different world.

A. Ryan Stanley: It- it very much changed the way we do things.

Zarbock: Have you treated, to your knowledge, a patient with AIDS?

A. Ryan Stanley: I have. Uh.. I- I-- we- we make the assumption from a clinical point of view that any patient could have AIDS. Uhm.. that's just standard uh.. protocol for any kind of a hospital uh.. or health care based uh.. delivery system. You have to assume that any patient might be infective. But I do know for a fact that I had a young man who was a patient of mine from the time he was a teenager uhm.. was homosexual, went up to New York uhm.. contracted AIDS, came home, needed some dental care, and this has been, oh probably 20 years ago, uhm.. and informed me that he was HIV positive and would I treat him. And I did. Uhm..

Zarbock: Did you have a choice?

A. Ryan Stanley: Uhm.. I think so, but I don't think I would have turned him away. He was a- he was a nice kid, I knew him, he was a patient of record, and I felt morally obligated to- to do what I could to take care of him. Uhm.. he subsequently passed away, uhm.. probably a year or two after I treated him.

Zarbock: You know, I'd never thought of that thought. Can a dentist refuse to treat a patient?

A. Ryan Stanley: Yes. There are certain guidelines. Uh.. the- the dentist/patient relationship, or any doctor/patient relationship, is a mutually optional one. If someone walks through the door and wants me to take care of them, I have the right to say, "No, I don't want to treat you." Now there are certain limitations on that right. I can't say, "No, I don't want to treat you because you're black." I can't say, "I don't want to treat you because of your country of origin." Uh.. th- that sort of thing.

Zarbock: Yeah.

A. Ryan Stanley: I can't say, "I don't want to treat you because you have AIDS," or because you have some other disability. Now there are certain situations where I have to make a clinical judgment and say "I, as a physician, or- or doctor in this facility don't have the proper equipment or training or knowledge or facility to take proper care of you." You know, "You're too sick for me to see, or you have a disease that I can't control." Uh.. and in that case, it becomes a clinical judgment where I would have to say to a patient, "You're going to have to seek care elsewhere."

Zarbock: But the gold standard measurement is quality of care.

A. Ryan Stanley: Absolutely.

Zarbock: If I cannot provide a quality of care.

A. Ryan Stanley: Then- then it's my-- i- it's encumbered upon me to help that patient find somebody who can.

Zarbock: Yeah. I was thinking there are other infectious diseases in addition to AIDS, TB comes to mind readily.

A. Ryan Stanley: TB is one that- that is making a comeback, unfortunately. And uhm.. TB is much, much more infe- contagious then uh.. then uh.. AIDS is. Uhm.. so personally I would be far more frightened of a patient that uh.. that had TB and was actively uh.. in- in uh.. affected with TB then I would uh.. somebody who was HIV positive.

Zarbock: And while I'm wallowing around in this semi-legal area, I assume it's also legal for me as the patient to not tell you that I have AIDS, or not tell you have I have TB. I'm not required by law to tell you, is that correct?

A. Ryan Stanley: I-- you know, honestly I don't know. Uhm.. in order for me to provide adequate care for any patient, I need to know their complete health history. So it's in- i- it's important for me to know these things. It's important for me to know if someone's using uh.. recreational drugs. It's important for me to know if they have uh.. medical problems that may not be obvious, because uh.. the- the classic example is someone that uses uh.. cocaine. If they're using cocaine and I inject them with a local anesthetic that has Epinephrine in it, which is a very common additive to local anesthetics, uhm.. it could cause their blood pressure to skyrocket and it could kill them. So it's important for me to know these things. Uhm.. obviously I have no way of twisting a patient's arm or putting them on truth serum and saying "You've got to tell me this stuff," but it is in our health history. "Do you use alcohol, tobacco, recreational drugs? Are you HIV positive? Do you have any other p- possible uhm.. are you on any other possible medications, or have any other diseases that may affect what we do?" So these things are important to know.

Zarbock: By the way, tobacco as an influence in the practice of dentistry. What is the relationship between tobacco and the practice of dentistry?

A. Ryan Stanley: Uh.. the-- actually it's a huge relationship. One of the most prevalent diseases in this country is gum disease, periodontal disease. A person that smokes is two or three times more likely to have severe gum disease then a person that doesn't smoke. It makes you much, much more susceptible to gum disease. Uhm.. a person that smokes or uses uhm.. smokeless tobacco of various types uhm.. is much, much more likely to have oral cancer. One of the scariest things about oral cancer is that the average five year survival f- for a diagnosed case of oral cancer is 50%. Half of the people that are diagnosed with oral cancer die within five years. People that smoke, drink regularly, or use smokeless tobacco are considerably more uh.. susceptible to oral cancer then people who don't. So it's something we're always on the look out for.

Zarbock: And oral cancer can be in any part of the orifice.

A. Ryan Stanley: That's right.

Zarbock: Tongue, under the tongue.

A. Ryan Stanley: Tongue, under the tongue, cheeks, gums, throat, soft palate, hard palate, and uh.. we- we normally do a uh.. screening examination for any lesions or- or suspicious uh.. spots on the tongue, under the tongue, on the gums, in the cheeks, throat, every place we can see.

Zarbock: This is a very poor choice of words, but is it relatively easy to diagnose?

A. Ryan Stanley: No. Uh.. one of the scariest things about examining a patient uh.. for oral cancer is that there are a gillion things that look exactly the same. Early- early oral cancer lesions can look like most anything, or look like nothing at all. And unfortunately up until just recently, a dentist has to make a clinical decision and say "Well, I see a little something there, but I don't think it's anything." And obviously we have some training on what things look like and how we're 'sposed to diagnose things, but it is a very, very vague diagnosis in those cases. Within the last four or five years, uh.. systems have been developed to take little skin samples without having-- the- the only way to really diagnose the cancer is to cut it, send a piece of it to a laboratory and in- inspect it microscopically. And that can be both a painful and costly and uh.. inconvenient experience for the patient.

Zarbock: Let alone scary.

A. Ryan Stanley: Yeah. A- and-- not to mention the fact that the vast majority of these lesions are nothing. And so you send the patient out for- for a biopsy which is a bother and an expense, uhm.. and it comes back, "Okay, there's not problem." Uh.. now we have a- a brush biopsy method that's been developed over the last few years where you can take a little stiff brush, break away some of the- some of the surface cells, put them on a microscope slide, send them off to a laboratory where they're scanned by a computer, and they can screen these things and say "Okay, some of these cells show signs of abnormality." At that point, then you go in and say "Look, this thing looks a- this thing came back from the- from the brush biopsy a little bit suspicious, so let's go send you to the oral surgeon to take a knife to it and get a piece of it." The vast majority of them, I think it's something like 60 or 70% come back, cells look completely normal, you can reassure your patient that there's nothing going on. And this has been a great boon to me, I- I do those frequently, did one last week as a matter of fact.

Zarbock: I want to focus in on the word that you just used, reassurance.

A. Ryan Stanley: Yeah.

Zarbock: I don't know of any dental jokes. Going to a dentist is not considered, I think normatively, to be a funny thing.

A. Ryan Stanley: That's true.

Zarbock: It's scary, can be painful. How do you go about eyeballing and sizing up a patient and doing some sort of, the word counseling is too strong, but how do you adjust the exchange between you and a new patient in order to provide some reassurance?

A. Ryan Stanley: That's a- that's a great question, and- and as far as exactly delineating how I would go about it, I- I don't think I could tell you. You do it completely by feel. Uh.. one of the things that I have made a conscious effort to do in my practice is to stay relatively informal, relatively low key, we joke with our patients, we kid with them, we- I use first names, I don't have them insist that they call me doctor. Uhm.. and we try to keep the anxiety level as- as low as possible, just by being informal with the whole uh.. with the whole situation. To me, and I- I spent a lot of time in the dentist's chair myself as a kid and a teenager, uhm.. the- the worst thing about going to the dentist is it's boring. That's one of the reasons why there are so few dental jokes, because dentists pretty much are boring (laughs). Uh.. there is a high level of anxiety for some people, and- and just I- I think probably the- the real key to that is an interpersonal relationship with your patient that you can reassure them that you're going to be aware of their comfort level, and that you're gonna do everything that you can do to keep them as comfortable as you possibly can. One of the things about dentistry that's uncomfortable for a lot of people is that you are in a very, very vulnerable position. You're laying there on your back, you have relative strangers invading your personal space in a very intimate and personal sort of way, and there's a real sense of loss of control for a lot of people. And one of things that I consciously try to do is reassure people that number one, I'm paying attention to their comfort level, and that I'll try to make them as comfortable as I can, and that if they show signs of discomfort, I'm gonna pick up on that and try to do something about it. Obviously there are certain things in dentistry that are uncomfortable, but we do everything we can do to ameliorate that.

Zarbock: One of my observations over a lifetime has been that the emotional support of the patient entering a dental office starts at the front desk. And starts there, is picked up by the other staff, the aids and associates that you have, not certified in dentistry, but the attitude of a pleasant exchange.

A. Ryan Stanley: Absolutely.

Zarbock: And warmth, and personalizing you, "Well, how are you today? And by the way, blah, blah blah." The development of communication, it goes all the way through.

A. Ryan Stanley: Yeah, that...

Zarbock: In the good practice.

A. Ryan Stanley: That lady at the front desk is the face of your practice, and if it's a smiling, pleasant face that can- that can talk to people, that can work with people, that can uh.. diffuse people's anxiety, or their anger, there're- there're often times when problems occur that, you know, a patient's going to come in and they're unhappy about something. And if you're got a person who is uhm.. compassionate and sympathetic, that can- that can help that along and help resolve those problems, uh.. it just makes a world of difference in how the experience goes for everybody. Uhm.. and I think that- that plays into the personality of a practice. There are many people who are much more comfortable in a formal environment where the doctor is referred to as doctor, and everybody's wearing starched whites, and that's fine. One of the nice things about- about general dentistry in particular, is that it's a lot like a restaurant. Uh.. there are different styles of practice uh.. and there are different styles of people who are more comfortable in one practice or another. Uh.. so you uh.. i- in my practice I try not to be McDonalds, I try not to be the Ritz, I wanna be uh.. you know, on uh.. in a nice neighborhood, in a nice practice in some place that nice people would feel comfortable going to.

Zarbock: How do you get new patients?

A. Ryan Stanley: Uhm.. another interesting story. My architect got me an awful lot of patients. Doctor Overton and I were in practice together, we had separate practices, we're not really partners, but we share a space. Uhm.. we were over at- over at Plaza East Shopping Center in a store front uhm.. in- in a office-type structure over there, and uh.. for 13 years. And then developed a- a fairly good clientele, and fairly successful practices, but we knew we needed to get into a larger space, so we looked for- for property, and we happened to find this- this piece right here. And our architect designed just a very attractive nice building for us, and you wouldn't believe how many people have driven by here, looked a the building and said, "Oh, that's a dentist's office. I think I will go there." Uh.. just based on how the building looks. So I have to give major kudos to the architect that designed the building, he did a nice job for us. Location is important because people drive by here a lot, and they see us a lot. So our sign is out there and say "Oh yeah, there's a dentist and it's convenient to my house. It's convenient to where I go." Uhm.. the other primary way of getting patients is by word-of-mouth referral. I live or die by people telling their friends and their family that, "I have this dentist and I like him, and- and if you wanna go to a dentist, he's a good guy to go to." That's where we really get the vast majority of our patients, from satisfied customers. So we're under a lot of pressure to satisfy our customers.

Zarbock: Assume for the purpose of our discussion that 50 years from now, this videotape is being replayed. At that time, wherever it is that we are right now has disappeared. So where are we right now, thinking 50 years from now.

A. Ryan Stanley: All right. We are about halfway from- between Wilmington and Wrightsville Beach in North Carolina. We're on one of the main thoroughfares between Wilmington and Wrightsville Beach, on Oleander Drive, uh.. we're right on the corner where you can see us at a stoplight. Uhm..

Zarbock: And the address is?

A. Ryan Stanley: It's 6200 Oleander Drive. We're about a quarter of a mile from Bradley Creek.

Zarbock: After a very arduous and demanding educational process, and entering again a demanding field, you cannot practice in any health-related field and say, "Well, let's have a little easy time and take the casual way out," you're going to lose everything, including your house. From years of practice, what have you synthesized as the good things about practicing dentistry?

A. Ryan Stanley: One of the most surprising things about being a general family dentist uh.. over the years, uhm.. surprising to me at least, is how much fun I have watching other people's kids grow up. Uhm.. we get to see children from the time they're three or four years old, watch them go through their teenage years, watch them grow up and get married and have kids, and even in a lot of cases, bring their three and four year old kids in uh.. to have their teeth taken care of. Uhm.. when I f- first was going into dentistry as a teenager, I was in college, and- and decided I wanted to be a dentist, uhm.. my primary focus was on making a good living because I knew professionals made a pretty good living, uh.. and on doing something that I enjoyed. Uhm.. and that has turned out to be the case. Uhm.. a dentist in a good practice, if he works hard, can make a good living uh.. most anywhere in the country. We've been particularly fortunate to be right here in Wilmington uhm.. so things have turned out quite well that way. Uh.. but also doing something I enjoy, I enjoy making things, working with my hands, and I would do dentistry as a hobby if I didn't have to make a living at something. I just- I- I think it's fun. Uhm.. but surprisingly, (audio glitch) I've been on uh.. the third row seat of a whole lot of weddings, uhm.. a whole lot of new babies being born, and we are forever bringing baby pictures in, and their patients are bringing their new babies in with them. As a matter of fact, we have a requirement here uh.. when we have a patient that's pregnant and getting her teeth cleaned, uhm.. frequently they'll be due for another cleaning sometime within a few months after the baby is born, and we tell them straight up, "You don't get your teeth cleaned if you don't bring your baby with you when she's born." Uhm.. so we enjoy seeing that aspect of things. Uhm.. I, at one point, had four generations of the same family coming to me as active patients. I had great grandma, I had grandma, I had mom and dad and I had the kids coming in on a regular basis, which I- I just thought was really, really neat. Uh.. we see patients of all ages here, uh.. everywhere from three or four years old on up to, I have quite a few patients that are up in their 90s. Uhm.. And it's just interesting. One of the other things that I really enjoy is uh.. is meeting people. Uh.. people like Paul here that are just fun to talk to. Uh.. people from all walks of life. Uhm.. I've got a fellow that's a- a retired neurosurgeon who's probably one of the brightest guys I've ever run into in my life, and he's just fun to talk to. Uhm.. I've got people that are commercial fisherman that can tell you stories about what goes on out on- out at sea, and where to fish, and where to find flounder. I had a fellow tell me yesterday that, "You give me 48 hours and I'll give you 500 pounds of flounder if you want them." Uhm.. and just that interaction with people, and- and getting to know people over the years has- has really been great fun. Uhm.. dentistry is a directly productive kind of process. I can go in, have a patient come in with a broken tooth, and I can sit 'em down and I can fix 'em and I can walk 'em out the door with a smile on their face knowing that, "Hey, this alright again now." And- and that to me is one of my greatest pleasures. Uh.. to just be able to take somebody uhm.. that's got a problem and solve that problem for them in a concrete way. Uhm.. one of the other things I love to do uh.. and a patient I'll tell you about, that uhm.. is- is to take a- an attractive young lady and make her even prettier. Uhm.. had a gal who had just gotten out of braces, and this has been probably 20 years ago, and uh.. two of her front teeth where- where little peg teeth, they didn't just-- were o- undersized, and they didn't look right, and we were able through a, just a routine bonded resin procedure, able to build those teeth up and sculpt them into teeth that looked uh.. looked normal. And she had a beautiful smile, and she's still a beautiful young lady, she teaches school up in uh.. Brunswick County, and those fillings are still there after 20 years, it never ceases to amaze me uh.. they've uh.. they've lasted this long, which is way longer then they normally would. But uh.. to be able to see that smile on her face and to be able to see her now I think three or four year old child come in to take care of their teeth uh.. i- it's just been great fun over the years.

Zarbock: You're a very optimistic and warm-hearted guy, and it shows in your staff. Really, the person in charge of sets the tone.

A. Ryan Stanley: I think that's true. And- and I try to set a tone like that, I'm- I- I can be pretty crabby sometimes, but I guess we all do. Uhm.. but I try to keep uh.. the tone in the office collegial, uhm.. I don't really have employees, I wanna have co-workers. Uhm.. you have to be the boss sometimes, and- and that's just one of those uh.. what I consider a peripheral responsibility that I'd be just as happy without, but if you're gonna run a business, you have to do that. But we all work well together. Uh.. my staff, most of my staff has been with me for uh.. in excess of a decade. Uhm.. we get along well, we have a very friendly congenial environment here, so it makes it more fun.

Zarbock: That raises another issue. When you graduated from dental school who taught you the business of dentistry?

A. Ryan Stanley: (sighs) That's a- that's a good one, and it's a sore point with a lot of dentists. We don't learn a lot about operating a business in dental school. Uhm.. you- you have to learn it by the seat of your pants. Uhm.. I read a lot, I went to a lot of courses, I've had business consultants come into my office and look at things and say, "Okay, you should be doing this or that or something else a little bit differently or a little bit better." Uh.. you- you learn from other dentists. Uhm.. we have a- a very good community of dentists here that uh.. that cooperate and support each other. Uhm.. and, you know, you ask the guy that's been around for a few years, you say, "Yeah, what do I-- how do I do this? What do I do about this?" And uhm.. you basically just have to figure it out on your own, which is a little bit hard sometimes, it's a little bit stressful sometimes, but uhm.. in any- in any business, to be successful from a- from a business point of view, you have to provide a good service for your customers at a fair fee. Uh.. you have to charge enough to make enough money to keep your business going, you have to provide a quality of service that your uh.. clients are gonna wanna say, "I got my money's worth," and then be willing to come back for more. Uh.. it- it basically comes down to those simple things. I think if you uh.. w- if you boil it down.

Zarbock: We're just about at the end of the tape, and I wonder is there some message that you'd care to make? Since you get a copy of this, is there some message that you would like to make to your children or possibly grandchildren? Reflections.

A. Ryan Stanley: Children, grandchildren, or anybody else who uh.. who might wind up looking at dentistry as a profession and a way of life, because it is a way of life. Uhm.. there was a cartoon in a uh.. in a dental magazine somewhere years ago that I've never forgotten it. It was a picture of a tombstone that said uh.. "Born a man, died a dentist." Uh.. which was kind of a negative view of things, but if you're a dentist you're always a dentist. People are gonna walk up to you and uh.. and people are always going to say "Oh wow. Nothing personal doc, but I hate the dentist." Uhm.. but the other side of that coins is all those other pleasures that I mentioned before. You- you know you're doing somebody some good. Uh.. you can- you can provide a service for somebody that- that really and truly helps them and uh.. and make a good living doing it. And if you enjoy doing what you do, which if you don't enjoy doing what's involved in being a dentist you should be something else. Uhm.. you can take pleasure from the actual work that you do. Uh.. in making a contributions to- to helping people out. So uh.. it's been a good life for me, and I hope to keep doing it for a- for a while longer. My staff uh.. is constantly reminding me that uh.. I'll probably retire feet first when they wheel me out of here on a gurney after I've dropped dead at the chair side (laughs).

Zarbock: Well I hope that's a long time from now.

A. Ryan Stanley: I hope so too (laughs).

Zarbock: Thank you very much Doctor Stanley.

A. Ryan Stanley: You're welcome.

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