Sharing a fika*

Dr. Rohit Sachdeva discusses a 50-year orthodontic career with Dr. Larry White

*A little flavor on the Swedish word/ritual fika. (Definition by John Duxbury) Often translated as “a coffee-and-cake break,” in reality, a fika is a concept, a state of mind, an attitude, and an important part of Swedish culture. It means making time for friends and colleagues to share a beverage and snack. But even more important than the food, it’s all about companionship, socializing and catching up to share some time with the people we live and work with every day.

Kindly share with us your journey to becoming an orthodontist.

When I was 10 years old, I had a primary molar removed sans anesthesia. It hurt so much, I vowed I would never again visit a dentist, but of course, my mother had other ideas about that, and she heard about a new, young dentist in Lubbock, Texas, who had quickly developed a good reputation. That appointment with Dr. Jim Reynolds was so pleasant that on our way home to Hobbs, New Mexico, I told my mother that I thought I might enjoy being a dentist someday. That was the beginning of a lifelong friendship with Jim Reynolds that has benefited my life beyond measure.

Dr. Larry White

Dr. Larry White as consultant to an ortho company

Among the many individuals who you give credit for being influencers in your life, two names seem to stand out. Can you elaborate on those people? And what are the characteristics of a good mentor?

My mentors were certainly influential in special ways, but great parents who helped shape my behavior and gave me solid values and the necessary discipline prepared me to respond favorably to good mentors. But good mentors need to have authenticity and obviously good character, plus the willingness to share the whys that are behind the concepts they are trying to share with you.

My high school coach, Duane Fisher, knew his craft quite well, and he always wanted players to understand why he trained them to perform a certain task. He strongly believed if people understood why they did something, they would more readily endorse it. I find that applicable in training dental assistants as well. He also wanted his players to have the courage to do their best. Now, it is one thing to have the physical courage to stand In front of a large charging running back, but it also takes emotional courage to stay past 5:00 p.m. and replace some broken brackets and wires when the whole staff had rather be on their way home.

Jim Reynolds, on the other hand, shared with me the value of professional camaraderie. Because there will always be someone who knows something that you don’t, you need to cultivate friendships that allow you to access the special knowledge you need to grow professionally. Professional hubris prevents a lot of promising orthodontists from developing as fully as they could.

Throughout your career and currently, you are a mentor to many fortunate individuals. Can you tell me whether the mentee seeks the mentor, or is it the other way around?

In my professional life, it was the mentee that sought the mentor. For me, it began in the spring of 1968, when Dr. Tom Mulligan presented a paper for membership in the Angle Orthodontic Society. That meeting was in Dallas, and the residents at the Baylor Orthodontic Department were guests. I was just about to graduate, and Tom talked about moment-to-force ratios, lingual-arch activations, cantilever concepts, moments produced by forces, and static equilibrium. I didn’t understand a word he said, and neither did any of our faculty. I approached Tom and asked if he would consider mentoring me regarding Burstone Biomechanics, and he graciously agreed. I know I must have perplexed him on many occasions, but he stuck with me for 50 years, and he taught me biomechanical concepts that transcend bracket designs, philosophies of treatment, and therapeutic systems, etc., and I will forever be in his debt.

I suppose in other cases, it might be a mentor who discovers a student or player who displays unusual interest or talent and would motivate the mentor to seek the mentee, but professionally, people need to seek those who have information and skills they lack.

You were the first All-American footballer at the University of New Mexico and were inducted into the New Mexico Hall of Honor. Also, you were named by Sports Illustrated as one of the “50 Greatest Athletes of the Past Century” in New Mexico. By any measurable standards, these are noteworthy accomplishments. As a linebacker whose play was designed around a defensive strategy, are there any parallels that you can draw that have influenced your approach to orthodontic care?

The willingness to have the courage to do your best under trying circumstances and even play through injuries offer worthy lessons for any profession. Life offers a lot of worthy goals one might seek. But one needs to understand unmistakably that a certain amount of sacrifice is the price you need to pay to achieve those goals.

College days | Dr. White dressed for the concert

You play the oboe, and as you jokingly say, “People on the football team remember me as a great oboist, and people in the orchestra remember me as a great football player.” It is also said that “the oboe picks the student rather than the student picking the oboe.” So what made the oboe pick you, and how has playing the oboe enriched your life?

I began playing the clarinet in grade school, and by the time I entered junior high school, the band didn’t have an oboe player, and the director encouraged me to switch to the oboe. I never regretted it. Musical training helped me develop an appreciation of music and have enormous respect for musicians who study and train so hard to perfect their crafts. I continued to play during my college days, and for 2 years played in the Albuquerque Symphony (which at the time was a amateur organization, and I still have the distinction of being the absolute worst oboist that symphony has ever had). I also played in the University of New Mexico (UNM) symphonic band.

You speak Spanish fluently, and I know you dedicated yourself to learning this second language much later in life. Why did you pursue this?

Most of my life was spent in New Mexico, which had and still has a rich Hispanic influence and culture. Our particular city had very few Mexican people in the 1940s and 1950s, but by the 1970s and 1980s, I could see how the demographics were changing and felt I needed to have the ability to communicate with patients and families that might not be comfortable speaking English. The Mexican population of that small town in New Mexico is now 60%. So I think I forecast that correctly. Currently in Dallas, Mexicans comprise 85% of my practice, so speaking to them in their native language seems to put some parents and patients at ease.

I understand John Rassias at Dartmouth College was your Spanish instructor. Can you share with us his unique teaching methods and your personal learning habits that helped you gain fluency in Spanish so rapidly?

Among other efforts to learn Spanish, I did spend part of a summer at Dartmouth under the teaching of John Rassias. He used a version of the Socratic Method sharing a sentence and suddenly pointing to a particular person to supply the correct verb. You couldn’t let your mind wander. Unfortunately, they taught a Castilian form of Spanish, which differs from the Mexican version, which I really wanted to learn.

As a bibliophile, with a voracious appetite for both fiction and nonfiction, can you recommend “must reads” for the orthodontist?

Professionally, of course, my go-to book is Dr. Tom Mulligan’s Common Sense Mechanics, which unfortunately is no longer available. Tom doesn’t plan to republish this and intends to donate it to some school that agrees to put it online for free distribution. Drs. Melsen and Fiorelli have an online publication on Biomechanics that offers sound fundamentals, and I also often consult Dr. Proffit’s book on orthodontics. The book by Graber, et al., offers readers a cornucopia of techniques.

Personally, several books have influenced me and continue to do so:

• Gift from the Sea
  Anne Morrow Lindbergh
• In the Shadow of Man
  Jane Goodall
• The True Believer, The Ordeal of Change, and others
  Eric Hoffer
• Games People Play
  Eric Berne
• Adventures of a Bystander
  Peter Drucker
• Know Your Child
  Stella Chess and Alexander Thomas
• The Social Contract
  Robert Ardrey
• The Cost of Discipleship
  Dietrich Bonhoeffer
• 12 Rules for Life
  Jordan Peterson

What is the takeaway message from the books you have recommended?

Life offers so much complexity; people need all the information and advice they can gather from those whose experiences differ from our own narrow interests, and I find that an eclectic selection makes life more interesting and offers me some of those aha moments of clarity.

Books authored by Dr. Larry White

You have run many parallel lives in professional orthodontics — a clinician, an editor of a widely read clinical journal, and an academic. What do you believe is the role of an editor?

Editors need to have less provinciality in their selection of articles and need to be open to the ideas of others. I particularly dislike the tendency of many editors to reject good clinical advice from clinicians with no affiliation to universities. In the current climate, I seriously doubt people like Drs. Schudy, Tweed, Steiner, Holdaway, etc., could find many outlets for their ideas. Also, I would like to see editors pay more attention to proper grammar. For example, we “retract” molars not “distalize” them. We don’t “mesialize” teeth, “lingualize” teeth or “buccalize” teeth. Editors should insist on professional language in articles such as “maxillary” and “mandibular” not “upper” and “lower.” Nor should they use “decimate” for “destroy.” Decimate refers to a tenth not a total. One final caveat — editors should stop allowing six authors to publish a 2-page article. I believe that is nonsense and simply padding the authorship.

I would like to probe your thoughts on the current state of professional publications. What appears to me is that hacking occurs on both sides of the aisle. There are clinicians whose clinical interpretations of their findings are commonly subject to misattribution, and the professional researcher/academician commonly hides his/her work under the veil of statistical significance (p- hacking) which has little or no clinical relevance. What do you think about this theory?

Yes, and may I also add that an overlooked peril of statistics in an article is that for every formula in an article, you lose one-half of the readers. It only requires about three formulas, and a writer has almost no audience. Clearly, researchers need some statistics to justify conclusions, and I understand that. That said, researchers need to make certain with their statistics that they are not simply suffering from physics envy. Also, we forget to our peril that wherever statisticians thrive, freedom and individuality diminish.

Do you believe that if our professional culture were more accepting of failure, we would be more transparent, and as a result, cultivate a generative rather than pathological environment of learning?

That is absolutely true. The airline industry offers the example par excellence because the features of every flying accident are re-created in flight simulators where pilots rehearse the accident and learn to prevent a dangerous outcome. We have no big data collection of failures in orthodontics, resulting in generation after generation continuing to make the same mistakes. I would suggest that our institutions of learning worldwide pool data on clinical failures along with the written narratives and see if they can reach some helpful conclusions. That could be a highly useful NIH grant that could provide needed and interesting information to improve orthodontic processes.

Dr. Larry White with Drs. Nikhil and Bhuma Vashi from Bombay, India

In the “real world,” how constrained is an editor in fulfilling this role?

I feel editors probably have more constraints by publishers and committees than we imagine.

As a seasoned clinician who decided to join the “academic ivory tower,” what were you unprepared for?

I was unprepared for all of the political correctness that permeates academia and for the entitlements students seem to expect. In my view, administrators have lost the courage to confront nonsense, and this of course, goes to the very top of our institutions. Our faulty jurisprudence system encourages this to our detriment.

And what advice can you share with those who are contemplating switching gears from a private practice to that of a full-time faculty member?

Make sure you have the temperament to deal with the features I have mentioned and many more that I haven’t but which you will confront. You will no longer call the shots as in your private practice, and be prepared to accept unfulfilled promises. I finally realized that though I enjoy sharing ideas and experiences with others that is only a small part of an academic life. Thus, I remain a clinician, not an academician. I salute those who have the personality to do this full time, but I realize I am not among them.

You are constantly refreshing your personal skills to better care for patients. How have you managed to create a care team that is resilient to change?

You must have your staff buy into any vision you have for your practice. Without that, you will experience frustration, so explain why you want to improve a technique, and help them know they will experience a learning curve as they try to implement the necessary changes.

In the practice of clinical ortho-dontics, we continually strive to revise our mental models. Having practiced orthodontics for well over 50 years, can you share with us specific examples of “mind shifts” that you have personally encountered in the way you provide patient care?

I was trained to diagnose and treatment plan with the Tweed Triangle and Steiner Technique. These were based on using the mandibular incisor as the key to diagnosis. Dr. Reed Holdaway was the first to make me realize the maxillary incisors, and not the mandibular, were the key, and he taught me how to perform and implement the Visual Treatment Objective, whereas Burstone and Marcotte taught me to use occlusograms. These remain fundamental in my diagnosis and treatment-planning regimen.

The term illusionary truth refers to the tendency to believe information to be correct (even if not) after repeated exposure. Have you personally been subject to this effect, and if so, can you share some examples?

I think that just about every dentist at one time or another experiences this. We are pretty much blank slates when we enter our professional training and accept completely what we are told. It takes years of experience to understand that much of what passes as “dental gospel” is simply wrong or at best incomplete. If something is done wrong often enough, it becomes right; that is, volume is a defense against error.

And how do clinicians guard themselves and, more importantly, their patients in a world that abounds with misinformation?

Bertrand Russell once said that there is an unbridgeable gap between knowledge by description and knowledge by acquaintance and no way of going from one to the other. That is, there is no substitute for experience. Professionals need to have the willingness to change when their experience indicates improvements are available.

Many clinicians to this day are reluctant to adopt practices such as occlusograms or the Virtual Treatment Objective (VTO) because they believe they add to their tasks and provide little value in patient care. How do these decision aids help you, and how have you incorporated these into your clinical work processes?

In my previous New Mexico practice, I had a rather large staff, and we took records of new patients on a half-day or sometimes a full day. So I had trained people to do the occlusograms, and after making a few important points on a cephalometric film, another would do the tracing with the lines I used. Now, I have a much smaller practice and staff, so I now do all of the tracings and occlusograms myself, and it takes almost 1 hour to complete a diagnosis and treatment plan. I don’t mind doing them because they give me reasonable expectations and a final destination to aim for. I would hate to start any treatment without knowing where I am going, and how I will arrive. I personally believe that initiating orthodontic therapy without closely considering the records is like playing poker without ever looking at your cards.

You are proponent of simplicity in managing patient care. Obviously, the road to simplicity is a long and arduous one. Can you guide us through the journey map of any particular facet in the clinical management of your patients that you have simplified substantially over the years?

Rather than use a computer to record treatment notes, I still prefer to use a paper chart with the photos, panograph, and scanned mouth records inside. On the front side of the chart is a miniaturized diagnosis and treatment plan along with space to record procedures that are done. On this chart, I can record any interproximal enamel reduction with a line between ideograms of the teeth, and I can immediately see the VTO and refer to the occlusograms for remembering if there is a tooth size discrepancy. I cannot get this information immediately from any computer program that I am currently aware of. So I strongly believe a picture is worth a thousand words. In my experience, for some things analog is better than digital.

We are both considered “agers” in orthodontics since we have crossed the age of 60. What is the greatest gift bestowed to one who is fortunate enough to cross this chronological threshold?

I crossed that line almost 25 years ago, and the greatest gift I have received is the friendship and camaraderie that I continue to build in this profession even at this late date.

Family celebration of his wife, Lue’s 80th birthday

Larry and Lue in New Zealand | Larry and Lue in Taiwan

You recently opened up a solo practice in Dallas at age 85. This would be considered unthinkable and untenable for one to do at this stage in life. And yet, you have accomplished the impossible and are running a successful practice. So what provoked you to do so?

I was replaced by a younger person in my nonprofit dental clinic and at the school where I served one-half day a week. I didn’t think I was finished professionally and felt I still had some good years left, and there remained so many things I still didn’t understand about orthodontics. I wanted to continue pursuing the knowledge I didn’t yet have.

Website for Dr. White’s new practice

What were the mental boundaries that you had to overcome to achieve this goal?

I didn’t have any doubts that patients would eventually respond to my practice’s appeal because I intended to use a strategy I had successfully used in New Mexico. I would require a rather small monthly payment with nothing down. I just didn’t know how quickly they would respond. Fortunately, they responded a little quicker than I expected.

What is different about this practice than the first one you started?

This one has started faster because I knew exactly the audience I intended to appeal to and how they might respond. My 59 years of experience does confer some advantages.

You have been the witness of many “eras in orthodontics.” Each era is associated with the belief system and cultural values of a particular generation. Could you elaborate on the changes you have observed?

Unfortunately, I find people less likely to spend time diagnosing and treatment planning now than before, and I feel that causes patients to stay in treatment longer and probably receive less definitive care.

You have been keen student of the late Peter Drucker. What is the most important management lesson you learned from his writings?

Drucker was an amazing writer with a vast historical knowledge along with unparalleled management expertise. To choose just one invaluable lesson I would offer his remark, “Efficiency is doing things right; effectiveness is doing the right things.”

The music industry was among the first to adopt digital technologies, and as we all recognize, it was disruptive, painful, and transformational. And today, “vinyl is back.” Deloitte Global forecast the sales of physical records in 2017 and has witnessed vinyl’s 7th straight year of double-digit growth with sales of over 40 million new records with a revenue of over $900 million. Do you believe a reversal in tide may occur in orthodontics that is from digital to analog, and if so, in what particular aspects of the care ecosystem, and why?

There are many things that cannot be done effectively by digital means such as effective and sincere patient relations or even professional relations. Regarding analog music now being revived – digital never gave the quality of analog, but it did give mobility that analog cannot. So much of the digital solutions now offered in dentistry improve our quality of care but at a much greater price, and I think that clinicians will eventually understand that a fundamental understanding of diagnosis, treatment planning, and a thorough knowledge of biomechanics can obviate many of the digital solutions now available and also in the future.

I am not going to ask you to predict the future of our profession; however, if you did have a magic wand, how might you reframe it?

Not just for dentistry but for society, I would like to see a return to common sense and commonly held values that have enriched mankind for centuries. Holy Writ admonishes us to “forget not the ancient landmarks.” Those landmarks of behavior developed over centuries, and it disturbs me to see people cavalierly set them aside as though they have no value in the “modern world.”

I know that you have lectured worldwide and still continue to do so very actively. In your interaction with our international colleagues, I am sure there have been instances of “moments of learning” that have enriched you professionally. Are there any such “aha” moments that you can share with us?

The biggest “aha” moment I ever received was from Dr. Clarence Bryk, who taught me about the usual futility of removing mandibular premolars in Class II malocclusions. That came after 30 years of struggling with those decisions. Dr. Janson from Brazil further corroborated Dr. Bryk’s experience in several studies. Another aha moment came from Dr. Carlos Coelho in Brazil when he showed me his Mandibular Protraction Appliance (MPA) that could be fitted chairside with a minimum of investment and time.

You are an “unsung hero” of our profession. My thanks and eternal gratitude to you for being my mentor, my guardian angel, colleague, and friend. In parting, what would be the first lines of the lyrics you would compose for a song to be sung by the next generation of budding orthodontists?

I would plagiarize a song and title from Marvin Hamlisch’s A Chorus Line — “What I did for love.”