One of the greatest challenges we face as general dentists is the myriad of dental problems that walk through our front door: esthetic problems, occlusal problems, patients who desire the replacement of multiple missing teeth, structural problems with teeth, periodontal disease, and caries. To solve these varying problems predictably, it important that we start with all of the data necessary to make a complete diagnosis, and then have a systematic protocol to create a complete, properly sequenced treatment plan.
Treatment planning workflows can be reliable tools to predictably solve the specific problems of each individual patient. All too often, dentists become focused on the execution of the treatment without having treatment goals in place that are specific enough and, therefore, no clear end point. Treatment plans without a clear end point lead to incomplete treatment, which then leads to unpredictable results and unmet patient expectations.
Always begin with complete data
Every patient who enters a dental practice should be evaluated for any dental disease that could break down the dentition or threaten the patient’s overall health. One must determine if caries, periodontal disease, TMJ problems, occlusal disease, sleep apnea, and oral cancer are present. If the screening evaluation turns up a positive response for any of these problems, additional information needs to be gathered. If the patient desires to have elective cosmetic procedures or wants to replace missing teeth with dental implants, additional information will need to be gathered to make a complete diagnosis and treatment plan. The key is to create a protocol for each type of patient in your practice to ensure that all necessary data is obtained. When we combine complete, accurate data with a programmed approach to treatment planning, the results we obtain will be predictable, optimal, and consistent. In this article, I will discuss five areas we can focus on.
General dental problems
In dental school, we were taught how to treat general dental problems caused by microorganisms and structural problems with individual teeth so that patients can achieve optimal oral health. The key to successfully treating these general problems is having time to do a thorough tooth-by-tooth examination, looking at a full set of properly taken x-rays, and probing six points around each tooth. Optimal oral health includes creating a mouth that is healthy to maintain. That means patients should be able to clean every surface of every tooth, and they should know how to properly clean those teeth. To that end, we must address any pockets 4 mm and larger, carious lesions, open margins on crowns or fillings, as well as plaque that is not adequately removed by our patients.
A general dental examination should include a full series of radiographs, oral cancer screening, sleep apnea screening, TMJ/occlusal evaluation, full periodontal probing, and a tooth-by-tooth restorative examination. Biologic problems and structural problems with individual teeth can be diagnosed and treatment planned at the same appointment. More complex issues will require that additional data be collected, which can be obtained at the initial visit or at a separate “advanced records appointment,” which will be discussed later in this article.
Esthetic problems beyond changing color
Patients who desire to change their smile should have the same screening as general dental patients, plus a full series of photographs and an occlusal analysis. In our training at The Dawson Academy, we take 21 photographs, 12 of which are used by the American Academy of Cosmetic Dentistry. Properly taken photographs are critical to assess current tooth position and determine the options that would be best to improve the patient’s smile. Occlusal analysis will include a facebow transfer, diagnostic impressions, and a centric jaw relation record so the models can be mounted on an articulator. It is critical that the dental team has a protocol in place to determine how the patient’s esthetic changes will affect occlusion. Complete dentistry that has an esthetic component to it will always optimize the occlusion and be done in a biologically stable environment.
When patients are found to have occlusal problems, additional time will be needed for a thorough assessment. Close documentation of tooth wear, mobility, migration, masticator muscles that are tender to palpation, and any TMJ instability will be noted. During the treatment planning phase, time will be required to determine if the occlusion can be altered to improve the forces on the teeth. To do so, models will need to be accurately mounted on an articulator in centric relation (occlusal analysis). Additionally, a full photographic series (21 photos) will be done to assess current tooth position and plan for appropriate changes. These things are in addition to the standard data collected during the general dental examination.
Multiple missing teeth (patients considering dental implants)
Patients considering dental implants require the same workup as patients with occlusal or esthetic issues, plus a CBCT scan. Special emphasis must be placed on relating the optimum tooth and contour position back to the proposed implant position. This allows us to determine the mesiodistal/buccolingual position of each implant as well as the depth. Grafting procedures, as needed, and the correct sequence of care can then be planned. It cannot be overemphasized that implant dentistry is a prosthetically driven discipline, where beginning with the end in mind prior to implant surgery is necessary.
TMJ dysfunction/facial pain
Patients presenting with TMJ issues and/or facial pain should be examined with the same procedure as patients with general dental problems. In addition, expand the examination to look at the areas of pain and take a more detailed history. Having a CBCT scan with interpretation can also be very helpful. A maxillofacial radiologist can read the CBCT image and tell you about the condition of the joint—whether it is stable, actively remodeling, or in a state of degeneration. If you want a further level of visualization, an MRI will show the position and condition of the disc, as well as inflammatory levels inside the joint. Doctors who successfully diagnose and treat patients with facial pain spend time putting a specified protocol into place to gather all data necessary to reach a correct diagnosis. Then and only then can a customized treatment plan be recommended.
The advanced records appointment
The breakthrough for many doctors is the creation of an “advanced records appointment.” This is an appointment created for a patient with issues that go beyond what is usual and customary. For example, if a patient is being seen for a routine dental evaluation (general dental problems) and the team discovers that the patient wants to explore another level of dentistry involving esthetics, occlusal disease, implant dentistry, or the resolution of a TMJ/facial pain problem, it is time to schedule an advanced records appointment. If a new patient calls the practice and can be identified as a person with one of these problems, schedule the patient for an advanced records appointment right from the start.
The advanced records appointment protocol establishes each team member’s responsibilities in the records-taking process and ensures that all the necessary records are obtained for each type of patient. This will increase efficiency, allow for the gathering of complete and accurate data, as well as provide the necessary time to address any question the patient may have regarding his or her dental problem. It is important to recognize that a treatment plan is not created at this appointment. Once the additional information is gathered, time is spent educating the patient on the problem. Only after the patient understands the problem and desires a solution is he or she rescheduled for a separate consultation to review the treatment plan. This gives the dental team time do the lab work and develop an optimum plan that is properly sequenced.
Even in the best of circumstances, dental practices are doing their best to manage chaos. The key is to separate the patients who have general dental problems from those who will need more advanced care. By doing so, we can create customized workflows depending on the wants and needs of each individual patient. This will allow the team to maintain a healthy general dental practice and also have tremendous success tackling more advanced, specialized problems.
John C. Cranham, DDS, is an associate clinical professor at the Medical College of Virginia, where he graduated with honors in 1988. An internationally recognized speaker on the esthetic principles of dentistry and contemporary occlusal concepts, among other topics, he is the clinical director of the Dawson Academy, where he oversees the international lecture and hands-on courses. Dr. Cranham has an esthetic-oriented practice in Chesapeake, Virginia.