March 1, 2006
by Ira Schecter, DDS
A combination of modern medicine, increased patient awareness, and proven, evidence-based solutions has resulted in a population whose median age is older than ever before in history. This in turn has created a challenge for the dental profession. The dental needs of our patients are often complex and demanding, and dental practitioners need to be equipped with multiple skill sets in order to be able to provide thoughtful, high-quality care for the problems presented.1
The challenge for dentists today is to be as skilled at diagnosis, treatment planning, and offering prognoses for long-term success as they are at creating dental restorations. They must understand the medical and/or systemic implications of the recommended treatment, including both surgical and non-surgical therapies. Merely identifying the presenting problem is not sufficient. Being able to delineate the underlying basis for the situation at hand is also essential. Dentists must be able to compare the advantages and disadvantages of various modes of therapy when making treatment recommendations. It is also incumbent upon us as health-care professionals to be able to critically assess the clinical research available and then relate that information to various treatment recommendations.
In all these areas, critical thinking skills are crucial. In the absence of critical thinking and reasoning, patients will not be directed to the optimal treatment solutions. In fact, having the right thought process is as important as arriving at the concluding diagnosis and recommended treatment.2
The following cases illustrate the need for critical thinking and reasoning when treatment-planning our patients’ various clinical situations. In the first instance, an insufficient amount of critical reasoning led to unhappy consequences. In the second, when a treatment plan was adequately planned, explained to the patient, and executed, the result included excellent aesthetic results and a high level of patient satisfaction.
Figures 1-3 illustrate the radiographic appearance of the deteriorating problem in this patient’s lower right quadrant. This patient had presented to the general dentist complaining of pain in that region. The general dentist referred the patient to an endodontist for root-canal treatment on the molar abutment tooth. The patient then presented at my office for a restoration of the recently treated tooth. Upon examination it was readily seen that the tooth in question was completely decayed under the existing crown down the distal root aspect. A complicating periodontal defect with a “through and through” furcation communication was also evident, along with looseness of the rear portion of the bridge. The patient also was continuing to experience discomfort while chewing.
It was the opinion of this practitioner that the molar abutment tooth was not predictably restorable and that the proper and more correct treatment plan would be to section the existing bridge distal to the anterior abutment, place two dental implants in the edentulous space, and extract the terminal molar tooth. After much time was spent explaining this recommendation to the patient, he understood that the rationale for the treatment plan was the long-term predictably successful resolution to the problem. The endodontist, when contacted, claimed he was merely following the prescribed treatment from the referring dentist. The patient was referred back to the original dentist for a follow-up review of the original diagnosis.
The patient’s new concern and complaint was that he had undergone root-canal treatment when the tooth could not be salvaged. This had required a considerable expenditure of time and money. It also confronted the patient with differing professional opinions and caused him to feel somewhat disillusioned with our profession, creating unnecessary anguish for everyone involved.
In this case, the upper anterior bridge was failing due to deteriorating periodontal support and resorption of the central incisor abutment tooth (Figs. 4-6). Upon examination of the rest of the mouth, it was readily observed that the patient had difficulty with his plaque control, no matter how much effort he put into it, and he required frequent intervention by a dental hygienist. It was thus decided that the best treatment for long-term success would be to remove the existing bridge, extract the left central incisor, and place two dental implants in the edentulous space to support single-crown restorations, also restoring the canine tooth with a new crown.
Figures 7-10 illustrate the initial phase of treatment. This included extracting the left central incisor and filling the socket with Dynagraft bone grafting material (Citagenix Inc., Laval, Quebec) to preserve the fragile buccal plate and the socket site for a future implant placement. A Replace Tapered Implant with the Ti-Unite surface (Nobel Biocare, Yorba Linda, CA) was placed in the lateral incisor space at the same time as the extraction. It was immediately loaded with an acrylic temporary restoration that was attached to the adjacent re-prepared canine tooth.3 Once the soft tissue at the lateral incisor site had healed sufficiently, a permanent custom Procera zirconia abutment was made, utilizing the 3D computer-assisted design system, and connected to the implant. The acrylic temporary restoration was then re-inserted (Figs. 11 & 12). When the bone in the central incisor area had regenerated sufficiently, a second implant of similar design was placed there, and a second custom zirconia abutment was fabricated (Figs. 13 & 14). The final restoration included three individual all-ceramic Procera crowns that restored this area of the mouth to proper function and aesthetic form (Fig. 15).
The challenge for every dental professional is to constantly nurture his or her critical thinking and reasoning skills. During the average life span of every dentist, information relevant to certain practice techniques will develop significantly. Dentists thus must explore, question, and discriminate among the ever-abundant information available on the Internet and from other continuing-education avenues. We must always be open to expanding our knowledge base so that we can best serve our patients’ needs.4
Those who are screening prospective dental school candidates must also have these critical thinking and reasoning skills so that they will know what to recognize when interviewing and selecting applicants. Educators, too, have an equal responsibility to help dental students refine their critical thinking and reasoning skills. New graduates must develop the ability to convert the information accumulated from textbooks and lecturers through self assessment and reflection and inferential decision making as they confront new problems and developments in practice.5-8
The ability to critically think is essential to the development of critical reasoning for clinical decision making.9
Dr. Schecter has been in private practice in Toronto since 1980 and has been practicing implant dentistry for more than 20 years. He has extensive surgical and prosthetic training in the Nobel Biocare implant systems and has been an innovative user of the Procera custom technology. For the past 10 years, he has lectured extensively in the field of implantology and comprehensive restorative dentistry.
Oral Health welcomes this original article.
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3.Schecter I. Immediate loading and custom abutments to create and assure predictable aesthetic implant dentistry. J Oral Health 2005;95(4)
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9.Behar-Horenstein IS, Dolan TA, Courts FJ, Mitchell GS. Cultivating critical thinking in the clinical learning environment. J Dent Educ 2000;64:610-615.
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