Andrew Cobb, DDS
Imagine you had a patient walk in Monday morning with extreme wear, and you were able to diagnose the underlying cause of the patient’s issue. There was no confusion of how to correctly sequence treatment, and the patient trusted you enough to accept your plan. For many dentists across the world, this is an unfamiliar scenario. But when dentists have a thorough understanding of the masticatory system, utilize a codiagnostic technique with patients, and implement a treatment planning protocol, this scenario can be their norm.
The end result of these processes and techniques makes for successful treatment and a happy patient. What’s more, those who have applied these treatment planning protocols have reported a rediscovered enjoyment of dentistry because they are able to eliminate guesswork, which in turn eliminates remakes, failures, and frustration.
Understand how the system works
Eliminating guesswork requires an understanding of the entire masticatory system, how it functions in harmony, and what happens if it is not in harmony. This understanding is essential to correctly diagnose problems and provide complete dental solutions. Many dentists are not provided a clear understanding of the masticatory system. However, the concepts are not complicated.
Four steps to predictable success
Predictable success with the treatment planning process is as easy as applying the four-step protocol taught by The Dawson Academy. This process can be applied to every patient, regardless of case complexity, and provides quality control throughout the process.
Each of the following steps must be completed in order to predictably and accurately treat a patient:
1. Completely evaluate the gnathostomatic system to identify the system’s weakness and to connect with the wants of the patient.
2. Plan treatment two-dimensionally and three-dimensionally in order to determine appropriate treatment options and sequencing.
3. Test provisional prototypes in the patient’s mouth and adjust for phonetics, esthetics, and function.
4. Deliver definitive restorations based on the adjusted prototypes.
These four steps create a simple roadmap to follow during the treatment planning process. However, it is imperative to understand the amount of restorative work needed and the patient’s commitment level before creating an actual treatment plan.
Codiagnose with your patient
The complete exam provides an elevated level of comfort between the patient and the dentist. It is also an educational opportunity where the dentist talks through (and shows) what is “normal” versus what is “not normal,” leading to codiagnosing. This occurs throughout the complete exam and is key to case acceptance. Gathering all the necessary records is crucial for dentists to properly diagnose instability within the masticatory system, as well as predictably treat any case and provide clear steps to improve the patient’s oral health.
The following are the elements of a complete exam as outlined by The Dawson Academy:
1. Preclinical exam—Before the examination begins, it is important that the dentist or team member conducts a preclinical exam to understand why the patient is there, past experiences, desired changes, any problems occurring, and more.
2. Restorative charting, periodontal exam, and oral cancer exam—After the preclinical exam, the dentist should identify any signs of disease within the masticatory system. To do so, the dentist should perform a restorative charting and periodontal exam to identify microorganism-induced breakdown, such as caries and periodontal disease. Additionally, the dentist should always screen for oral cancer.
3. TMJ occlusal exam—In order to fully identify signs of disease and instability in the masticatory system, dentists must also perform a TMJ occlusal exam. This exam records patient history, range of motion, centric relation load test, TMJ Doppler auscultation, muscle palpation, and an evaluation of dentition for wear, mobility, and migration.
4. Airway evaluation—Diagnosing and addressing potential airway issues is a key component in this process, as breathing issues usually need to be treated to get the patient comfortable before other treatment. Never begin building a treatment plan without understanding the patient’s airway.
Throughout the examination process, the dentist should ask leading questions as signs of disease or instability are noticed. Leading questions might be phrased in the following ways:
- Has anyone ever told you why this tooth fractured?
- Has anyone explained to you that your issues are caused by how your teeth function?
- Has anyone shared the consequences of not treating this issue?
Once the examination is complete, the dentist will know if the patient requires more complex treatment or if this is a general practice patient. It’s OK for some patients needing advanced treatment not to be immediately ready for restorative dentistry, but addressing periodontal and bacterial issues, along with their understanding of how to achieve their goals, is vitally important.
For specialty patients who are ready to tackle the issues, dentists should map out the process to restore the patient’s oral health. Additional records are required for the treatment planning process, including centric relation facebow mounted models on an articulator and a series of photographs. During this time, the dentist or team member can elicit any time or financial concerns the patient may have that would prevent them from obtaining the care they deserve. This allows for the treatment plan to be developed within the patient’s constraints.
Easy-to-follow treatment planning process
The treatment planning protocols taught by The Dawson Academy include an easy-to-use checklist. This process can be applied to every patient, regardless of case complexity, and provides quality control throughout the process.
First, the dentist will complete a two-dimensional functional-esthetic analysis checklist. This checklist helps the dentist address occlusal stability, global esthetics, and macro esthetics.
The next step is to apply the treatment plan three-dimensionally on models. Prototypes can be created from the 3-D wax-up, placed in the patient’s mouth, and adjusted for phonetics, esthetics, and function. The lab utilizes these approved prototypes to predictably create the definitive restorations.
By following this treatment planning process, dentists can be confident restorations will look beautiful, function well, and improve the patient’s oral health for the long term.
Proper and ethical treatment planning
Approaching each patient case as a collaborative process between the patient and dentist for the treatment planning processes will provide long-lasting and predictable dental work regardless of case complexity. By following the simple checklist and creating a collaborative process, the dentist can feel confident that the best care was provided to the patient.
Additionally, with the proper type of leading questions and shared understanding that occurs throughout the exam, every bit of information needed to achieve patient acceptance of the treatment plan will have been communicated. The presentation of the treatment plan and associated costs should not be a shocking moment, but rather a confirmation of completing the type of work the patient is committed to.
The Dawson Academy’s philosophy on the concept of complete care is to create the most conservative treatment plan available to deliver long-term oral health. Treatment plans can span months or years to properly fit a patient’s budget or time constraints, which should not be a deterrent when creating the correct treatment plan.
Dentists who implement these protocols often enjoy a reputation for solving even the most challenging issues, plus confidence in knowing that no case is too difficult. This can lead to a more enjoyable and profitable career.
Andrew Cobb, DDS, is a senior faculty member at The Dawson Academy and maintains a private practice in the Washington, DC, area that focuses on restorative and esthetic dentistry. Dr. Cobb is also involved with a number of dental organizations, including the American Academy of Cosmetic Dentistry and the American Equilibration Society. He is a fellow in the International College of Dentists and the American College of Dentists.