Important issues to consider in the provision of good dental care (Part 2)

Following on from Part 1 of this post, when dealing with difficult cases in could be prudent to refer to an appropriate specialist.  I find that many times, patients are not initially referred because the dentist feels economic pressure to do complex work because, if they refer to others, there is a loss of cash flow. This is especially during times of economic downturn or when a dentist is establishing a practice and consequently would rather keep the payments within their own practice. However, I emphasise that you should consider the economic loss if something goes wrong and you face medico-legal issues, not to mention the risk to your dental registration or license.

It is also wise to find a mentor (or more than one). Most senior specialists will be prepared to offer you advice on how to treat certain situations – particularly if you utilise their services from time to time. It is not unbecoming to ask for advice – rather it is sensible and important for good patient care. After 50 years of practicing dentistry (40 as a specialist) – I still have many colleagues I ask for advice in areas outside my specialty. In some cases, I also talk to colleagues within my specialty because it is always sensible to seek alternative points of view. Of course the old joke applies: “If you put 100 dentists in a room – you will get 100 different opinions”, but sensible dentists will endeavour to get advice, consider different feedback and then formulate a clinical plan that seems to be the best or most practical option and (most importantly) gains acceptance from the patient (after being fully informed about the various alternatives). Overriding all is to remember that at all times to “do no harm”.

However, the most practical advice I can offer to any dentist who is formulating a treatment plan, is to divide an extensive treatment plan into two and create “Phase 1” and “Phase 2” plans.

Phase 1 treatment

Phase 1 involves an initial examination to assess the clinical situation and problems. This should include any appropriate radiographs and tests. Then record all pathology and consider what corrective action needs to be taken.

For Phase 1 treatment, I aim to generate a “disease free” state or baseline. As such, I aim to treat (or get treated – by referring to others) all problems concerning: hygiene issues, perio, endo, caries, fractured teeth and fillings, abscesses/cysts, extractions, etc. The primary objective is to get a disease free, stable base line. Depending on the situation (eg geographic location, time availability, economics, what the patient wants) this might take weeks, months or years to accomplish. The aim is to “buy time” so that disease issues are controlled and therefore unscheduled emergency treatment is minimised. It is also a lower cost phase, so that patients can more easily structure their budget and payments.

Sometimes, some aspects of Phase 1 need to be carried out urgently, but other times it can be spread out over a longer period. Usually all teeth are restored in resin and initially any OVD problems are not corrected. When required, patients need to be warned that Phase 2 treatment will need to be carried out at a later time (over an appropriate time frame - eg 1 to 10 years). Once all obvious issues are fixed, opening the OVD can be easily carried out by overlaying resin on the occlusal surfaces of appropriate teeth – in either the upper or lower arch, or both. This will generally be a temporary solution, but it allows the clinician to gain information about any consequences of opening the OVD (eg speech, eating, TMJ).

Once Phase 1 is completed, an assessment period is required. If the OVD has been altered, you need to be sure the changes are well tolerated. If endo has been carried out, then you need to be sure resolution of any pathology occurs. If hygiene, perio or caries are issues – you need to know this has been resolved.

Before Phase 1 is commenced, you should take time (30-60 minutes) to carefully explain what the problems are, what the consequences of non treatment are, what the various options are and what the associated time and costs are. Then ask the patient what they want and aim to steer them to a sensible decision. If Phase 2 treatment is going to be required at a later date, then this needs to be mentioned (including an outline of time frame and costs).

A hint to help you is that I almost always say (after the initial examination): “My objective is to keep my patients with the existing teeth they have – for a life time. While this is not always possible, that is my primary objective. Does this interest you?” If the answer is “Yes”, then effectively you have their permission to outline ways this can be achieved. If they answer “No”, then you can discuss what they want, what is viable, and what you are prepared to do for them.

The objective with Phase 1 treatment is to achieve to a reasonable, stable, satisfactory conclusion and then (at a mutually agreeable time) commence the elective and complex Phase 2 treatment plan. Occasionally patients might have come in for expensive treatment (eg implant and crown), but there are multiple other problems that need to be fixed. Often economic issues are involved. I always explain that it is better to save multiple teeth (eg 10-15 teeth) rather than spending the same amount of money (or more) on one implant and crown; because it is economically more sensible to save many teeth rather than replacing one. From a professional point of view, while it might be tempting to take the “easy” money first, it is poor management to go for glory to start with, before fundamental dental care is properly provided. I also add that failing to properly attend to obvious pathology before doing implants or other expensive restorative work has the potential to create significant medico-legal issues.

Phase 2 treatment

Once Phase 1 has been successfully carried out, you will often be able to delay the commencement of the complex Phase 2 treatment for 6-12 months (sometimes more if financially necessary).

Phase 2 is the elective phase where complex and/or expensive treatment is required. This might be orthodontics, implants, crown and bridge work, general occlusal rehabilitation, orthognathic surgery, etc. It may involve opening the OVD or reproducing it if you have previously opened the OVD with occlusal/incisal resin build up.

In most cases, I usually do Phase 2 crown, bridge and implant work over several years (as the patient can afford). However, occasionally the patient is in a position to have all Phase 2 work done relatively quickly, but even so, I will usually do posterior quadrant by quadrant unless there is a complete arch dimensional change required. I usually do the anterior restorations lastly - after I have established a good occlusal relationship with posterior rehabilitation. There is a subtle logic to proceeding this way. Most patients will want anterior rehabilitation done first (for aesthetic reasons), but many times such work will be jeopardised by an unstable posterior support situation. Therefore I always insist on restoring the posterior occlusion first, then the anterior teeth. Since the patient generally wants the anterior teeth restored, they almost always continue to finish the entire recommended treatment plan.

In Phase 2 rehabilitation cases spread over a reasonably lengthy time (years), I usually decide, at a review examination, which teeth need to be crowned in the respective year, since the priority may change if tooth, restoration or periodontal issues become more apparent since the preceding last review/treatment. Interestingly, in cases where this type of slow rehabilitation is being carried out, the patient will often ask as they sit down for an exam, “What crowns are you going to do this year?” My reply is usually: “I don’t know until I have examined all your teeth and see which ones are most urgent at this time.”

I have found that by following the principles of Phase 1 and Phase 2 treatment plans, it becomes easier and less overwhelming for the dentist and your patients. It allows the patient time to plan for the cost, but at the same time, provides good dental care and reduces the chance of catastrophic dental events that might cause pain and the loss of teeth. However, the key to such a successful approach requires the dentist to carefully explain what they are aiming to achieve and gaining patient acceptance. Further, the dentists needs to realise that they will make less money initially because the treatment is not extreme. However, the trade off is that almost always, a patient who is committed to such a long term program will continue with the dentist for many years (indeed - even if they move to a new geographic location - they will travel very long distances to continue treatment on a yearly basis).