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COSMETIC DENTISTRY: Treatment Planning for Success in the Esthetic Practice

April 1, 2001
by Edward Narcisi, DMD


The title “Treatment Planning for Success in the Esthetic Practice” can easily be broken down into three parts, The Esthetic Practice, Success, and Treatment Planning. No Doubt today’s practices have to be focused on delivering esthetically pleasing dentistry. Materials, techniques and laboratory support, coupled with the expertise of the supporting team of dental specialists, allow for the most attractive dental results the profession has ever been capable of delivering. Success is then the product of providing patients with the dentistry they need, exceeding their expectations esthetically, and ultimately being financially compensated for one’s time, skill and judgement. Once the clinical skills have been acquired the key variable in success is in letting patients know what they need or to help them understand what they want– a plan for treatment. For years experts in practice and clinical management have strongly advocated comprehensive diagnosis and treatment planning as the lifeline for practice success. Without them the practice flounders and the level of expertise stagnates. The demands of a successful esthetic practice exemplify these principles.

The phrase “treatment planning” when presented to dentist’s can elicit numerous responses. Most appreciate the need, but dread the exercise or more the perceived lack of production for time spent. Some confuse diagnosis for treatment planning. Others shy away from presenting complete treatment plans for fear of overwhelming patients. On occasion, however, a certain patient with a special-need will rekindle the spirit. The dentist will endeavor in the process, deliver the treatment, and experience the patient’s satisfaction and savor the professional fulfillment. That is the spark that needs to ignite the fire for a thriving esthetic practice.

Several practice experiences need to occur prior to the treatment-planning phase. First and for most, the patient needs to present themselves to the practice. This occurs subsequent to either a referral (patient referred or professionally referred) or a stimulated external marketing effort (phonebook or advertising piece etc…). Once contact has been made the patient is typically scheduled for a consultation appointment. Please do not under-estimate the importance of this visit. The introduction to the practice and the consultation are essential foundation builders for the up coming diagnosis and treatment planning components. It is not the intent of this article to explore the fine details of the consultation process; however, certain principles should be referenced to understand the dynamics that are responsible in building the momentum of patient management in the esthetic practice. The consultation is intended to introduce the patient to the practice and vice verse. The dental professional “gets to know the patient” at this appointment. Through simple conversation and listening skills the dentist gains insight to the patient’s personality and background, call it a basic personal profile. This conversation easily allows for the segue into the patient’s dental interests– chief complaints, esthetic concerns, previous experiences, expectations, perceptions, attitudes and degree of motivation. Equally important, and so often underestimated, is the process of the patient “getting to know the dentist”. The patient starts to generate an impression as early as the first telephone conversation. The consultation process, however, is when the patient starts to critically evaluate the practice and in particular the doctor. The facility, staff and doctor are all critiqued on appearance and personality. The mood has to be warm, friendly, and efficient. The doctor has to exude confidence and enthusiasm. The confidence and enthusiasm will begin to positively impact the patient, allowing the patient to relax and be more able to assimilate and comprehend the subject of their visit.

The doctor conversationally elevates the patient’s awareness and visually reinforces with aids such as before and after photos. The intention is to continue to build momentum toward exciting the patient to embrace the reason they are there. Now is a great time to compliment the patient for their interest in pursuing treatment and to emphasis its importance. A brief dialog explains the clinical process of a complete and comprehensive examination and how this will be the solid foundation in formulating a specific treatment plan for the patient. Ultimately, at the end of the consultation the doctor asks permission from the patient to continue the diagnostic process. Volumes can be written on the process and management of the consultation. It is encouraged that the doctor and staff continually study and assess the consultation process.

Subsequent to the consultation experience is the comprehensive examination and diagnosis appointment. A thorough examination supplies the clinician with the bank of information critical to create the important treatment planning options. The more detailed and thorough the exam the more detailed and thorough the treatment planning can be. It is beyond the scope of this article to cover in detail the process of the examination. It will be assumed that the reader has a systematic process of gathering the pertinent clinical data. It is important that the doctor, as well as, the patient realize that it is premature to present a comprehensive treatment plan for an involved esthetic case without taking the time to study all diagnostic findings. The patient is informed that in a specific amount of time (determined by the doctor, based on the complexity of the case, as well as, the doctor’s schedule) that a detailed treatment plan will be presented for review. The plan will present viable options, time requirements, and approximate costs.

The time and process between the examination appointment and the presentation of the treatment plan is the principle subject of this article. The treatment planning exercise is initiated by a preliminary opinion for the case. In other words the “initial feel” for the case is considered. That “initial feel” comes from the doctor’s clinical experience and is as subjective as there are doctors. That “initial feel” then has to withstand the rigors of a systematic investigation and then be efficiently put into a practical and logical sequence of clinical events to achieve the proposed outcome. The systematic investigation has to defend, repair or correct the examination findings and ultimately achieve the patient’s expectations.

The initial concern with any treatment plan has to be to the acute condition. Any active and progressing pathology needs to initiate the plan. Any active infections (periapical or periodontal), fractured teeth, failing restorations, hopeless teeth, or any condition which is or typically would, if left untreated, cause the patient pain or complication. Every patient should be educated to understand the urgency of this phase. The importance in treatment planning however is to allow this initial therapy to flow easily into subsequent phases of treatment.

The subsequent phases of therapy must respect the attention of each of the dental disciplines. How will the intended treatment plan phase, correct and respect the periodontal condition? How will endodontics impact the case? What degree of surgical intervention will be necessary? Will there be simple exodontia, orthognathic, preprosthetic, or implant procedures involved? What benefit would orthodontics bring to the case and how much time would be involved? Would simple direct placed restorations be applicable or should laboratory processed restorations be considered? Is fixed prosthetics an option or does the dental condition warrant removable prosthetics or would a combination of both best suite the patient? How will the proposed treatment impact the occlusal health and function of the patient? Does the case present with occlusal instability? How will the patient be managed pharmacologically- anesthesia, premedication, anxiety control, saliva control etc…? This partial list of questions is intended to emphasis the responsibility the dentist has in investigating and coordinating the treatment plan. Every case that presents will have its own unique plan and every dentist will have his or her own clinical disposition. It is the responsibility of the dentist to systematically design each treatment plan or treatment option with these thoughts in mind.

Every dentist should give intent thought in treatment planning to maximize the esthetic outcome of the case. Smile design plays a significant role in the planning process. Each element of smile design should be carefully evaluated and included in the planning process. Modality selection as well as material selection is paramount to achieving the best esthetic outcome. When should all-ceramic and resin materials be used, or would more traditional porcelain fused to metal or gold modalities serve the case better? Laboratory selection, cost and time need to enter the treatment equation. Will the case warrant a diagnostic wax-up, surgical stents, lab processed provisionals, occlusal splints, implant parts, attachments, or treatment partial dentures. Realizing that each of these tools impacts the cost of the case. Scheduling efficiency becomes a serious process in both patient management as well as practice financial management. The patient needs to understand clearly the time involved in treatment whether it’s two visits or two years. The clinician has to realistically, and as carefully as possible, determine the intended goals for each clinical session. If the case takes a significantly greater amount of clinical time the economics of the practice will suffer.

The most important aspect to treatment planning a case is for the clinician to assume ownership of the plan. The clinician should approach the case as if he or she where designing it for themselves. What treatment options are possible, which are most practical. Present a good, better, best list of options, with each option having the potential to be phased in a practical and healthful sequence. Each plan should possess a time frame for completion, as well as, a cost of delivery. The patient is also given the guidelines of the practices financial policies and their impact on each of the proposed treatment plans. The practice should maintain a treatment plan database of all purposed treatment, as well as, all accepted and completed treatment. The database serves as a percentage measure of the efficiency of treatment purposed against treatment accepted. The practice can then use that percentage measure to evaluate the success of the treatment planning process, striving to get as close to 100% acceptance as possible.

Comprehensive treatment planning provides one of the most valuable building blocks for success in an esthetic dental practice. Unfortunately, its emphasis is overshadowed in education by procedural competency. To ultimately be successful one has to possess both clinical competency and the ability to diagnose and treatment plan. If either one is lacking the resultant success will be compromised. Possession of both allows the patient to receive the best care possible and empowers the dentist to maximize professional and economic fulfillment.OH

Dr. Edward M. Narcisi lectures extensively on esthetic and reconstructive dentistry. He is an active member of the American Academy of Cosmetic Dentistry. He is principle of The Centre for Dental Excellence and maintains private practice in Monroeville, PA.

Oral Health welcomes this original article.