How curiosity can improve treatment planning
Dr Elaine Halley explains how to become a better treatment planner by learning how to develop a systematic approach to analysing cases before the start of the process, thus leading to more predictable outcomes.
One of the most interesting things about general practice is that we never know what type of patient will walk through the door and the type of dentistry they will need until they are examined. The continuous evolvement of dental specialties in terms of knowledge, clinical skills and the options available to us has resulted in diagnosis and treatment planning becoming more complicated, and often we don’t give ourselves enough time to really be able to analyse and diagnose our cases.
Having already identified the five common treatment planning mistakes in the previous article, this article will go into more detail about how to organise and review clinical examination findings, how to ask questions in a systemic way and how to maximise the use of digital technology for greater patient communication.
Diagnosis and risk assessment
When discussing and showing patients the problems with their teeth, using an intraoral scanner (IOS) cannot be underestimated in supporting this communication. I recommend adhering to a simple 4-step process:
- Calculus – showing the calculus in a HD (3D or 5D) format can be eye-opening to the patient to see the state of their oral hygiene and discuss recommendations to improve.
- Colour scan – A digital tour of the mouth allows you to show patients their natural healthy teeth before focusing on the fractured or broken dentition. caries, cracked teeth, failing amalgams.
- Occlusogram -Wear of any kind, particularly in younger patients. When canines wear down, they lose canine guidance and buccal cusps with large fillings will start breaking and lose protective function. If there is wear through to dentine in anyone younger than 80 then this may be an issue worth analysing.
- Stone model – The ‘Colour Off’ stone model feature of the IOS scanner helps to identify wear facet and tooth surface loss and visually communicate this to the patient.
At this stage we should not be listing out the solutions or treatment options. I recommend systematically looking at everything before you come up with the treatment options. I like to give patients a bit of reassurance that we don’t necessarily have to fix everything, but we need to at least have seen it.
Risk assessment is central to the practice of individualised patient-centric care – so how do we implement that in practice on a day-to-day basis? Ideally, we want our patients to understand their own individual risk status, how they may be able to improve their risk status, and how those risk factors will affect the need for dental intervention in the future. For example, a patient could have destroyed her upper central incisor enamel through to the dentin by continuing to grind her teeth at night and we can’t switch that off for her. So, regardless of the type of dentistry we do in those high-risk individuals, they need to understand that there is a risk of chipping and a risk of future dental requirements.
We need a system that helps us identify the risks for individual patients and helps us communicate that with them so that they truly understand what they are facing in the future of their dentistry. I think if we can do that consistently, it can make our lives less stressful, because treatment should become more predictable, but when things do require maintenance, our patients are aware of that right from the beginning.
Systematic, co-diagnosis approach
It is imperative to have a systemic, co-diagnosis approach. Essentially, patients don’t have context when it comes to their oral health – they don’t know what is and isn’t normal. By using photography or using intraoral scanner screenshots, we can show patients what normal is and how they are deviating from normal. The patients might not think it is relevant to their situation but with screenshots from our scanners we can educate them.
Consider it like a map, getting from A to B – what is the end goal? Essentially the smile design is the primary principle or a restorative treatment plan, that factors in aesthetics, function, structure and biology. In using the treatment planning funnel below, we can guide our observations, identify the challenges and brainstorm our treatment options.
- Macro observations – Global diagnoses, skeletal, medical, soft tissue, perio classification
- Mid observations – Smile analysis, tooth structure, arch form, guidance, occlusion
- Micro observations – Tooth by tooth, radiology, vitality, endo, tooth surface loss
- Challenge list – The main challenges to overcome to achieve the design
- Treatment plan options – Brainstorm of possible ideas, tools, inter and multi-disciplinary
We should always have a definitive treatment plan with informed consent and financial discussions and co-diagnosis. This means that the patient is involved in the entire process of developing their customised treatment plan. The dentist is not telling the patient what needs to be done, instead we are sitting side-by-side, showing their conditions, and mutually formulating their options and ultimate treatment plan.
Storyboard for increased patient acceptance.
To enhance the treatment planning process I have developed a ‘Storyboard’ system for organising the diagnostic information, collating photographs and relevant imagery into a presentation format to communicate between dentist and patient. I create a storyboard for every patient which acts as a storage for the photographs for the patient and a risk assessment form. This can then be shown to the patient to discuss the treatment plan and goals. When procedures are explained this way to a patient, they can sometimes opt for treatment plans which differ to their original ideas.
The lessons I have learnt with treatment planning is that we should ask questions and make sure that we listen and not take things at face value. The list of questions that we can ask ourselves gives us a structure to analyse the case. Having a system like a ‘Storyboard’ allows us to organise our visual tools that we can then use to motivate the patient. But most of all, we want to work with our patients in the spirit of co-diagnosis. So, I would encourage dentists to stay curious and keep an open mind. You’ll then really be able to deliver a fantastic service for your patients and give them the ability to say yes to comprehensive dentistry.