Patient-Centered Treatment Planning: Part 1

As part of our formal training to become dentists we are taught to diagnose, treatment plan, and present dentistry to our patients. Part of the presentation phase is educating patients about the conditions, consequences if treatment is not performed, and the benefits and risks of treatment. All of these elements are critical, but after years in clinical practice, it is clear to me that some things are missing.
As a profession, we have learned we must educate our patients. Does education lead to treatment acceptance? In order to better motivate our patients to receive the dentistry they need, I believe we need to move to another level of communication. With regard to procedures that enhance or improve appearance, if a patient has an idea of what he or she wants as an end result, it is imperative we discover what that idea is. It is important to have patients involved in selecting the treatment they’ll receive and, when possible, in planning the sequence of treatment. This, of course, presupposes that their desires create no harm and fit within the doctor’s overall treatment plan.
The most effective way I know of creating a patient-centered treatment plan is to have a detailed conversation with the patient prior to case presentation. This interactive conversational approach for gathering information puts more emphasis on listening to the patient and asking open-ended questions, rather than questions that can be answered by “yes” or “no.” The key is listening rather than speaking. An important part of this technique is engaging the patient on an emotional level. This can only be done by clarifying the person’s answers with additional open-ended questions. When a treatment plan is finally presented, the patient has basically told the doctor how he or she wants to proceed.
It is the doctor’s responsibility to see that whatever dentistry should be done first is included as part of satisfying the patient’s overall desires. As an example, if a patient needs periodontal treatment, but his or her stated goal is smile improvement, the doctor must say something like, “Mr. (or Ms.) Smith, we’ll gladly help you improve your smile, and as part of doing this we also need to get your gums healthier.” The key word in this statement is and. Too often practitioners use the word but to indicate the procedure that must come first. This patient-centered approach differs from the more typical presentation in which a doctor says, “Mr. (or Ms.) Smith, you need…” By using a more interactive approach and making the patient’s goals the focus of the presentation, we are invoking the Premack principle (commonly known as “Grandma’s Law”). The principle states that one activity can act as a reward for another activity.¹ From a behavioral perspective, people usually don’t do what you want them to do until you give them what they want. Essentially, you get something you want after you do something else, such as getting ice cream if you eat your Brussels sprouts.
Coaching programs and books exist that enable a doctor and his or her team to learn and refine these communication skills. I participated, and still do, in such a program through Coaching Solutions, located in Cinnaminson, NJ (previously associated with Blatchford Solutions). The program taught me how to become a better listener. By the very nature of our dental school training, we are taught to find solutions to problems. Therefore, when a patient says, “I don’t like my smile,” it is natural for us to think how we can improve it and to suggest solutions too quickly. If we immediately respond without knowing what really bothers the patient and without reaching an emotional level with our patient, we are missing the boat. After realizing the importance of multiple open-ended questions that target the emotional side of the brain, I began to expand my thinking about case presentation. In searching for better ways of communicating, I came upon work done by Roger Sperry, a psychobiologist and Nobel Prize winner in physiology (1981).

LEFT BRAIN/RIGHT BRAIN

Figure 1. Differences between brain hemispheres.	Figure 2. How people make decisions.

Dr. Sperry was a professor at Harvard University and the California Institute of Technology. He studied the relationship of the brain’s right and left hemispheres. The chart in Figure 1 details some of the differences between the hemispheres. The main theme to emerge from Sperry’s work is that “there appear to be two modes of thinking, verbal and nonverbal, represented rather separately in left and right hemispheres respectively and that our education system, as well as science in general, tends to neglect the nonverbal form of intellect. What it comes down to is that modern society discriminates against the right hemisphere.” -Roger Sperry² (1973) (Figure 1).
The significance of Sperry’s work is that in case presentation, to be more effective in motivating patients to want the dentistry they need, we must reach an emotional level with them. People make most decisions unconsciously on an emotional level in the right brain, and then without being aware of it, the rational left brain finds a way to justify that decision. This concept is well-documented in neuroscience and illustrated in Figure 2.
A Web site devoted to how the brain works states, “People don’t choose rationally to listen to your message and then have a feeling about it. They choose to listen to your message because they have a feeling about it. If you’re basing your communications solely on logical, rational, reasoned facts… the brain is not your friend. Emotions are the gatekeeper… if you want in, you gotta talk to the amygdala. You make a decision emotionally, but part of that decision is based on using logic to figure out how you’ll feel in the future about your decision.”³
Further research confirms this. A research paper published in 2004 states, “people make judgments… by evaluating the consequences and their probability of occurring…also primarily at a gut or emotional level.”⁴
All of the above neuroscience research leads to the conclusion that to be most effective in motivating our patients, it is important to reach an emotional level in communicating with them. The standard “Mr. (or Ms.) Patient…..you need….” ap-proach does not accomplish that. Using the interactive open-ended questioning approach described above, I find I am more successful in having patients accept my recommendations and bringing patients to a higher level of health, appearance, or both, while simultaneously satisfying their goals.
In this 2-part series, I will describe several patients and their clinical cases. I will include the patients’ expressed treatment desires and the approach I used for case presentation. It should become clear that the patients’ goals were respected, and this was essential in developing treatment plans for each case.

CASE 1: DON

Figure 3. The patient wanted his smile to look like this smile that appeared on the cover of Sports Illustrated.	Figure 4. Don, after treatment, retracted view.

Figure 5. After treatment, full face.

A man was referred to me by another dentist specifically for aesthetic treatment. Don came to my office with a Sports Illustrated magazine cover he had saved for a long time. At the initial interview, Don told me he was not happy with his smile. After a series of open-ended questions, I understood more specifically that the color of his teeth was not objectionable, but he did not like the shapes and arrangement of his teeth. In fact, he was so clear as to what he wanted that when he pulled out the Sports Illustrated magazine cover with a picture of Mark McGwire, the professional baseball player who had hit a record number of home runs (Figure 3), I wasn’t surprised. Interestingly, Don was a softball player himself. I thought, if I was to hit a home run with this patient, I really had to listen to everything he was telling me.
Since I was being asked to deal only with appearance issues, one could argue that I did not have to do a comprehensive, total oral exam. However, I feel strongly that I owe every patient that option. I suggested to Don that we check his overall oral condition, including tissues, teeth, and periodontal status, and he agreed. There was nothing in Don’s examination findings that contraindicated performing the aesthetic treatment he desired.
After careful analysis of Don’s smile, I saw that his bicuspids were tilting inward and creating very wide buccal corridors. His central incisors could have used lengthening in relation to his lateral incisors. Don was very clear about what he wanted. Since this patient came specifically for aesthetic purposes, case presentation was limited to what we could do for his smile. I felt I had the responsibility to show Don what possibilities existed for his smile and to do it in a way that would not make him uncomfortable with his preconceived idea about what he wanted. I showed him many images in order to make him aware of different smile designs. I wanted to be sure that he understood all that was possible with aesthetic treatment. I showed him what could be achieved by making the centrals slightly longer than the lateral incisors and veneering the bicuspids to fill in the buccal corridors. In the end, Don decided to do just what he came in for, namely his 6 front teeth, and of course, you know they looked just like Mark McGwire’s.
After treatment, the wide buccal corridors remained and the central and lateral incisors were very similar in their incisal edge position (Figure 4). And of course, when we finished, Don’s veneers were shaped just like Mark McGwire’s teeth. After completing his aesthetic treatment, I referred Don back to the dentist who was kind enough to send him in the first place, along with a summary of what I had done and any other conditions needing further treatment. In the end, we did exactly what this patient asked for. We created veneers that gave him the look that matched his vision for himself (Figure 5). He was thrilled! While his new look did not impact his batting average, it did give him a much better feeling about his appearance.

CASE 2: SAUL

Figure 6. Saul, pretreatment study model.	Figure 7. Pretreatment, right lateral view.
Figure 8. Pretreatment, left lateral view.	Figure 9. Pretreatment, occlusal view.

Figure 10. Preoperative photo of  lower anteriors.

When Saul came to my office, during our initial conversation when I asked what his goals were, he said “I’d like to experience an implant where I’m missing a tooth.” I had no idea if this treatment was appropriate for him, no idea about the general condition of his mouth, and no idea what I’d present to him. But I did hear his request and replied by saying, “If an implant is appropriate, you’ll have it.” Starting off on a positive note brings the patient closer and develops rapport, which is essential to creating the emotional trust needed for the patient to accept treatment plan recommendations. If I had said, “We have to wait and see. Let’s examine you and then we’ll talk,” then this might have created a negative feeling. While the net result of the 2 different communications would be the same technically, the emotional impact on the patient would have probably been different. As the title of a book by Joan Detz says, It’s Not What You Say, It’s How You Say It (St. Martin’s Press, New York, NY).
With his permission, I asked Saul many questions about his long-term dental health goals, his feeling about his smile, and what else he thought he needed done. Only by listening and asking more specific questions could I begin to understand his desires. It was critical for me to understand why he wanted to “experience an implant.” What did he know about implant dentistry? Why an implant as opposed to other treatment options? I also explained the need to evaluate his entire mouth. He consented, and in a very positive manner remarked, “No one ever asked me all these questions before.”
After doing a comprehensive exam including soft tissues, oral cancer screening, teeth, x-rays, and periodontal probing, it was clear that Saul was in need of much more than an implant. There were open edges and recurrent caries around existing bonding and veneers on many teeth. Open margins can easily be seen on his study models on teeth Nos. 6, 11, and 12 (Figure 6). Recurrent caries can be seen in preoperative views of the upper canines (Figures 7 and 8). As you can see in the overall preoperative condition of his maxilla shown in Figure 9, there was much more to do than an implant. His mouth was breaking down, and he needed a complete rehabilitation. The maxillary treatment plan included extraction of tooth No. 2, implants to replace the roots of teeth Nos. 2 and 3, root canal therapy as needed, posts, cores, and crowns. His mandibular reconstruction would include several composite restorations, root canal therapy as needed, posts, cores, and 2 posterior fixed bridges. The crowding of his lower anterior teeth as seen in the retracted preoperative view (Figure 10) did not bother him aesthetically, and he wanted to leave these teeth as they were.
My case presentation to Saul included all the information about what was going on in his mouth, my suggestions, and how he would benefit from the care being suggested. However, the very first thing I said to him was, “I’m happy to tell you, we can help you experience an implant.” I then added that there was a lot more I was concerned about, and we talked about the rest of his conditions. He was happy to listen, because his primary goal would be satisfied. We discussed what else needed to be done in order to bring him back to optimal health and appearance. Saul was excited about getting his implant and eager to start. He accepted my recommendations for everything else he needed, and we began a long and gratifying course of treatment.

CHAIRSIDE TREATMENT

Figure 11. Tooth No. 8, old veneer peeled off.	Figure 12. Caries found under veneer.
Figure 13. Preparations with retraction cord packed.	Figure 14. Temporary restorations, incisal-occlusal view.
Figure 15. Aesthetic wax-up.	Figure 16. Cleaning crown preparations with ICB Brushes and Consepsis Scrub.
Figure 17. Veneer Nos. 6 and 11 and crown Nos. 7 to 10 immediately after cementation.	Figure 18. Post-treatment smile.

Treatment began with the posterior segments on both the maxilla and mandible. While most of the time I begin with the anterior teeth, this patient had no anterior coupling. Saul’s existing occlusal scheme had his bicuspids guiding closure in chewing, and he had no signs or symptoms of temporoman-dibular joint pain, occlusal dysfunction, or myofacial pain. Trying to change his very functional and comfortable occlusion and make it conform to some textbook ideal of occlusion may have set up iatrogenic occlusal disease, with its many ramifications.
Root canal therapy was accomplished as needed using the Root ZX apex locator (J. Morita USA) for canal length measurement, FlexoFiles (DENTSPLY Maillefer) coated with RC-Prep (Premier) for instrumentation, and obturation with DENTSPLY Maillefer gutta-percha points and Ketac Endo sealer (3M ESPE). IntegraPosts (Premier) were cemented with IntegraCem (Premier) after post spaces were etched, washed, dried, and coated with Clear-fil Photo Bond (Kuraray). Where insufficient coronal structure remained, core build-ups using Luxacore Dual (Zenith/DMG) and Clearfil Photo Core (Kuraray) were placed. The teeth were prepared for crowns using a KaVo high-speed air-driven handpiece (KaVo America) and round-end tapered chamfer diamonds (Axis Dental). Posterior segments were restored with porcelain-fused-to-gold crowns and fixed bridges cemented with the resin-reinforced glass ionom-er cement Fuji Plus (GC America). After the posterior treatment was completed, I began restoring the upper anteriors.
The old anterior veneers and bonding were stripped off with fine, flame-shaped diamonds (Axis Dental) under magnification with Dimension-3 Galilean loupes (Ora-scoptic). It is important to perform this procedure without water spray because the water makes it impossible to distinguish between tooth structure and restorative material. Figure 11 shows this step in progress. Many carious areas such as the one seen in Figure 12 were found under the old restorations. These areas were restored using the antibacterial self-etching system Clearfil Protect Bond (Kuraray), an adhesive system with the antibacterial monomer MDPB, which helps ensure the toilet of a cavity and imparts a bactericidal effect along cavity walls when the adhesive is light-cured. Venus, a microhybrid composite (Heraeus Kulzer) with the ability to blend easily with surrounding tooth structure, was used to restore the carious areas. The upper incisors were prepared for all-ceramic crowns using Great White Ultra burs (SS White Burs). The canines were prepared for feldspathic ceramic veneers using the LVS kit (Brasseler). Pre-impression hemostasis and retraction were achieved with ViscoStat Plus, which was applied with a Dento-Infusor and Ultra-pak retraction cord moistened with Astringedent (all Ultradent Products, Figure 13). A full-arch COE perforated disposable plastic tray (GC America) was used for making the impression with Impregum Penta Soft Medium Body (3M ESPE) mixed in a dynamic mixer, Pentamix 2 (3M ESPE). A low-viscosity wash of Permadyne Garant (3M ESPE) was injected into the sulci after the retraction cords were removed and the area washed thoroughly and dried, and before the tray was seated. A bite registration was made with Zenith/DMG O-BITE(Zenith/DMG), and temporaray restorations were created using Luxatemp Fluorescence (Zenith/DMG), reinforced with Connect (Kerr Lab), a high-strength reinforcement ribbon. The temporary restorations (Figure 14) were based on the design of the aesthetic wax-up (Figure 15). Interestingly, we altered the contours of the temporaries to give Saul the tooth shapes and overall appearance he liked best. By having a patient wear and evaluate the interim restorations, there is a far better chance the final aesthetic result will be what the patient wants.
All-ceramic crowns were created for teeth Nos. 7 to 10 inclusive and feldspathic veneers for teeth Nos. 6 and 11. At the insertion visit, after removal of the temporary restorations, aesthetics and fit of the final restorations were confirmed. The inner surfaces of the restorations were cleaned with phosphoric acid, washed, dried thoroughly, and silanated with RelyX Ceramic Primer (3M ESPE). The insides of the veneers for teeth Nos. 6 and 11 were prepared for cementation with an air-thinned layer of OptiBond Solo Plus (Kerr Dental), and the appropriate shade of Insure resin cement (Cosmedent) was  then placed in a ResinKeeper (Cosmedent). Teeth Nos. 6 and 11 were etched with Caulk 34% Tooth Conditioner Gel (DENTSPLY Caulk),  washed and dried, but not dessicated. OptiBond Solo Plus was applied to the teeth, air-thinned, and cured using a Demetron Optilux 501 (Kerr Dental) halogen curing light with a 13-mm light guide (Kerr Dental). The pre-loaded veneers were seated, tacked down, and most excess cement removed. Final curing was accomplished for 40 seconds after placing a thin layer of De-Ox (Ultradent Products) around the margins and contact areas. This glycerin product ensures that the outermost layer of resin cement is fully cured, because the usual air-inhibited layer of composite is not allowed to form in the absence of oxygen. The 4 incisor preparations were then cleaned using ICB Brushes (Ultradent Products) and Consepsis Scrub (Ultradent Products, Figure 16), and the all-ceramic crowns were cemented with the self-adhesive cement RelyX Unicem Self-Adhesive Universal Resin Cement (3M ESPE). Using curettes and scalers (Premier Dental), all excess cement was removed facially and palatally. Removing any stubborn, residual interproximal cement was accomplished with NTI Ser-rated Diamond Strips (Axis Dental).
The completed upper anterior veneers and crowns are seen immediately after placement in Figure 17. A week later, the patient returned for a post-placement evaluation (Figure 18) and reported that he was very comfortable and very happy with the result.

CONCLUSION

In both of the cases presented above, the patient’s goals were satisfied. Although more could be done to improve Don’s smile, the treatment provided matched Don’s very specific goals for his smile. By satisfying Saul’s desire to “experience an implant,” I was able to move him into comprehensive care and provide him with greatly improved oral health and a smile he loves. One of the things most gratifying to me after we completed Saul’s case was his comment. He said, “You gave me hope. I don’t feel like an old man anymore, and I expect to keep my teeth.” In fact, when I met one of his sons, he reiterated what his father had said, and with great emotion, thanked me for helping his dad.
After speaking with many doctors who attend the lecture and hands-on continuing education courses I teach, it is my belief that the traditional model for case presentation still prevails. In fact, the typical business model of examination, x-rays, prophylaxis, and presentation of a need-based treatment plan leaves much to be desired. It has become clear to me that there is a much better way to motivate patients to accept the treatment they need. In addition to these issues, the question of ethical responsibility arises when a patient requests treatment that might not be the doctor’s choice. Next month, in Part 2 of this series, I’ll discuss how we can deal with this challenge and still fulfill our ethical obligation.
I once read a book called The Goal: A Process of Ongoing Improvement, by Eliyahu Goldratt.⁵ As the title suggests, the theme of this book is that a business can thrive when it maintains the goal of ongoing improvement. It has been my goal in the first part of this 2-part series to introduce a better understanding of what makes a patient say “yes,” and to show how a more interactive approach helps us to understand what a patient really wants. When we take the time and make the effort to truly understand what our patients’ goals and expectations are, it becomes much easier to have our patients accept treatment plans for comprehensive dentistry. Ultimately, we serve these patients better and help them achieve a higher level of health. And as I’ve come to learn, it is far more enjoyable to practice dentistry when the doctor and patient are in harmony about the treatment being performed.

References

1. Hibbs SE. To help you finish what you start. Consider It Done Newsletter. Vol 12. Dr. Hibbs – Consider It Done Web site. Available at: http://www.drhibbs.com/volume12.htm. Accessed October 11, 2006.
2. Eden D. Left brain:right brain. ViewZone magazine Web site. Available at: http://www.viewzone.com/bicam.html. Accessed May 6, 2006.
3. Sierra K. You’re emotional. Deal with it. Creating passionate users Web site. Available at: http://headrush.typepad.com/creating_passionate_users/2005/07/youre_emotional.html. Accessed May 6, 2006.
4. Bechara A. The role of emotion in decision-making: evidence from neurological patients with orbitofrontal damage. Brain Cogn. 2004;55:30-40.
5. Goldratt EM, Jeff Cox. The Goal: A Process of Ongoing Improvement. 2nd rev ed. Great Barrington, Mass: North River Press; 1992.

Acknowledgment

Thanks to Dr. Peter Rosenstein (Suffern, NY) for his assistance in placing the implants in Case 2. Thanks to daVinci Dental Studio and Killian Dental Ceramics for their technical expertise and artistry. Images produced with Canon G5 Digital Dental Camera System from Photo-Med International.

Dr. Fier is a full-time practicing clinician and lectures in the United States and internationally on aesthetic and restorative dentistry. He is the executive vice president of the American Society for Dental Aesthetics and coordinates its annual International Conference on aesthetic dentistry. He is a Fellow of the American Society for Dental Aesthetics, a Diplomate of the American Board of Aesthetic Den-tistry, a Fellow of the American College of Dentists, a Fellow of the Academy for Dental-Facial Esthetics, and a Fellow of the Academy of Dentistry International. He is a contributing editor for REALITY and for Dentistry Today, and for the past 4 years has been listed in Dentistry Today’s annual list of leaders in continuing education. He can be reached at (845) 354-4300 or docmarv@optonline.net.

Disclosure: From time to time, the author receives material and lecture support from many of the companies mentioned herein.