Patient-Centered Treatment Planning: Part 2

In Part 1 of this series, I discussed many issues related to communicating with our patients prior to case presentation (Dentistry Today, January 2007). Some of the key points in making this communication effective are conducting an initial interview using open-ended questions, discovering the patients’ goals for their mouth and their smile, and incorporating the satisfaction of their goals in the case presentation. I mentioned that coaching programs (eg, Coaching Solutions, Cinnaminson, NJ) are available for dentists to learn more effective ways of communicating and better ways to achieve success in case presentation. In Part 2 of this series, I will describe a patient, our initial conversation, and the treatment options I presented to her. I will describe her choice and how we accomplished her treatment as well as the ethical issues surrounding this very interesting case.
How do we develop a treatment plan when the patient wants to accomplish something that can be done easily and with minimal invasion but prefers another method that is far more invasive? When the patient desires treatment not for disease-based but rather for strictly appearance-based concerns, what does one do? Should a practitioner choose not to treat the patient? Would this type of situation present an ethical dilemma for some doctors? The purpose of this article is to show how effective communication led to the patient choosing a treatment option that satisfied her goal for improved aesthetics. I realize some practitioners would hold that if a less invasive way is available to produce the results the patient desires, we must use that less invasive way, and it would be unethical to do otherwise. Is there an absolute right or wrong answer, or is it a personal choice the doctor must make? Many questions surround this scenario.

ETHICS AND COSMETIC DENTISTRY

Without digressing from the main purpose of this article, a short discussion of ethics related to cosmetic dentistry is required. In the British Dental Journal, DL Hussey writes, “Where the treatment is noninvasive and effective, such as bleaching, there should be no argument against its use as long as relevant health concerns have been addressed.”¹ Hussey also says, “In what I have termed cosmetic dentistry, restorations such as veneers or crowns make a valuable contribution to the treatment of patients with severely discoloured or malformed teeth. However, such treatments have also been placed in an attempt to overcome minor irregularities that could be amenable to more traditional approaches, such as orthodontics, which has proven successful in adult as well as adolescent cases.”¹
In the case described in this article, a more “traditional” approach would have given us the final result the patient desired; however, the patient was unwilling to accept this more traditional and less invasive approach.
As background and a very brief review of the issue of ethics, I thought it prudent to research what the ADA has to say. The ADA Code has 3 main components: The Principles of Ethics, the Code of Professional Conduct, and the Advisory Opinions. The Principles of Ethics are the aspirational goals of the profession. They provide guidance and offer justification for the Code of Professional Conduct and the Advisory Opinions. There are several fundamental principles that form the foundation of the ADA Code: patient autonomy, nonmaleficence, beneficence, justice, and veracity. Principles can overlap each other as well as compete with each other for priority. More than one principle can justify a given element of the Code of Professional Conduct. “Principles may at times need to be balanced against each other, but, otherwise, they are the profession’s firm guideposts.”²

Section 1
Principle: Patient Autonomy (“self-governance”). This expresses the concept that professionals have a duty to treat the patient according to the patient’s desires, within the bounds of accepted treatment. Under this principle, the dentist’s primary obligations include involving patients in treatment decisions in a meaningful way, with due consideration being given to the patient’s needs, desires, and abilities.
Code of Professional Conduct 1.A. Patient Involvement. The dentist should inform the patient of the proposed treatment, and any reasonable alternatives, in a manner that allows the patient to become involved in treatment decisions.

Section 2
Principle: Nonmaleficence (“do no harm”). Under this principle, the dentist’s primary obligations include keeping knowledge and skills current, and knowing one’s own limitations and when to refer to a specialist or other professional.

Section 3
Principle: Beneficence (“do good”). The dentist has a duty to promote the patient’s welfare. Under this principle, the dentist’s primary obligation is service to the patient and the public at large. The most important aspect of this obligation is the competent and timely delivery of dental care within the bounds of clinical circumstances presented by the patient, with due consideration being given to the needs, desires, and values of the patient.

Section 4
Principle: Justice (“fairness”). The dentist has a duty to treat people fairly. This principle expresses the concept that professionals have a duty to be fair in their dealings with patients, colleagues, and society. Under this principle, the dentist’s primary obligations include dealing with people justly and delivering dental care without prejudice. In its broadest sense, this principle expresses the concept that the dental profession should actively seek allies throughout society on specific activities that will help improve access to care for all.

Section 5
Principle: Veracity (“truthfulness”). The dentist has a duty to communicate truthfully. This principle expresses the concept that professionals have a duty to be honest and trustworthy in their dealings with people. Under this principle, the dentist’s primary obligations include respecting the position of trust inherent in the dentist-patient relationship, communicating truthfully and without deception, and maintaining intellectual integrity.”² When we look at the ADA Principles and Code, it is easy to say, “Well…this is subject to interpretation.” The fact is that any document is subject to interpretation.

CLINICAL CASE

Let us now look at the clinical case and see how my initial conversations with the patient led to the case presentation and finally to what the patient chose to do to accomplish her goals. I will discuss the patient, her chief concerns, and the treatment performed.

Background and Initial Interview

Figure 1. Preoperative smile after BriteSmile in-office whitening.

The patient is a psychology professor at Columbia University in New York City. She presented with the complaints that the color of her teeth was objectionable and she hated the crowding of her lower front teeth. Using an interactive and open-ended question approach, I asked her to “tell me more” about the color issue. She replied, “I want my teeth whiter.” I asked what she knew about whitening teeth, and our discussion covered in-office and home whitening as well as whitening maintenance issues and dietary factors (ie, color of food and drink she ingests). Rather than providing all the information in “lecture” format, I guided the conversation so that it was a question-and-answer session, with the patient being led to ask the questions that needed to be answered. She made it clear she wanted to use the in-office method because she didn’t want to “use those trays.” The preoperative smile after in-office BriteSmile treatment of both arches (Discus Dental) was used to whiten her teeth is shown in Figure 1.
When we talked about the crowding of her lower front teeth, I asked her what specifically bothered her. She said, “they’re crooked, and it looks like I’m missing a tooth.” I also asked her how she thought it would feel if her teeth were straight and it didn’t look as if she was missing a tooth. She said, “It would feel great,” and she remarked she often watched the television show Extreme Make-over. The show made her realize how much her bottom teeth really bothered her and helped her to finally decide “to get them fixed.” In order to reach the emotional basis of her desire, I asked other open-ended questions to find out why “getting them fixed” was important. She told me as a professor she does a lot of public speaking and is very self-conscious about her bottom teeth. Additional questions led to her revealing the feeling of being very embarrassed about these teeth.
In addition to finding out why our patients want appearance-related changes, it is very important for us to understand what outcomes they expect from treatment and how they perceive treatment will make them feel. Reaching this emotional plane makes the tasks of treatment planning and case presentation go more smoothly, and ultimately helps our patients make decisions about the options we present.³
Further conversation revealed that the patient already had bridges and crowns, and she wanted to “ignore my back teeth for now.” She indicated she wanted to keep the rest of her natural teeth. She also said she wanted to straighten her lower front teeth, but was unwilling to sacrifice her natural teeth to get a great smile. I asked her how she felt about wearing braces if that were appropriate, and she said emphatically, “Absolutely not!” I then asked, “What if wearing braces is the best way to accomplish your goal and preserve your teeth in the most natural and healthy state?” Again, she replied, “Absolutely not!” It would have been easy to move on at this point, but I wanted to be sure that I understood her completely.
An interactive approach requires clarification of a patient’s answers so that you truly understand what the patient is saying. This can only be achieved with further questioning. This time I stuck my neck out a little and asked, “How would you feel if wearing braces meant using a device you could remove if you had to, and the time of treatment was only a few months?” I wasn’t sure what she’d say, and the answer rang loud and clear: “I’m not going to wear braces of any kind no matter how short the time is.”
I was faced with a true dilemma. On one hand she wanted to straighten her mal-posed teeth and not sacrifice her natural teeth in any way. On the other hand, she was not willing to wear braces to straighten her teeth. I had not yet examined this patient, but red warning flags were already going up.

Examination, Findings, and Initial Treatment

Figure 2. Preoperative view with SeeMore PLUS retractor.	Figure 3. Occlusal view of lower incisor region.

A comprehensive oral exam including oral cancer screening, evaluation of her existing restorations, caries screening, digital images, and periodontal pocket charting was performed. A full set of x-rays was taken,  and impressions for diagnostic models were made using Directed Flow Impression Trays (3M ESPE) and Position Penta Quick (3M ESPE). The SeeMore PLUS 4-way retractor (Discus Dental) allows you to see the nature of the problem with the patient’s lower anterior teeth (Figure 2). An occlusal view (Figure 3) demonstrates the severity of crowding and malpositions.
In order to satisfy one of the patient’s goals—whiter teeth—an in-office Brite-Smile whitening was performed on upper and lower arches. At that visit, we talked more about what might be done to make her lower anterior teeth look straight. I told the patient that in order to look at treatment possibilities other than orthodontics, I would have to create a wax model, which could serve as an aesthetic blueprint. I also mentioned that in order to make the room we needed to realign these teeth, the tooth that was in linguo-version would need to be removed, and it was possible that we would have to do a lot of treatment on the tooth farthest to the front in order to make it look as if it was in line with the other teeth. These “trial balloons” were sent up to let her know I heard her “no braces” theme and to either confirm or negate her earlier statements about not wanting to sacrifice any natural teeth. This dialogue was essential if I was to present an alternative other than orthodontics. Her response was, “I’d like to see what else can be done.”

Treatment Planning

I sent the diagnostic models to my technician and we discussed the challenges we faced with the lower anterior teeth. Clearly, extraction of lingually malposed tooth No. 24 was required in order to create space in which to realign the other lower incisors. Since orthodontics was not in the cards, what other options did we have? Could we place veneers on teeth Nos. 23, 25, and 26 and create the illusion of straight teeth? If so, would we be able to prepare tooth No. 25 for a veneer without encroaching on the pulp? What if veneers weren’t the answer? Would crowns be a solution? Many questions arose, and it began to look as if we’d have to do elective endodontics on tooth No. 25 in order to prepare it sufficiently. A veneer did not look like the answer for tooth No. 25, but for teeth Nos. 23 and 26 it seemed as if veneers would work. The aesthetic wax-up in Figures 4 and 5 shows how 3 slightly oversized incisors could be created to give the appearance of straight teeth in the area in question. After further conversations with my technician, we decided that an all-ceramic crown on tooth No. 25 was best, and porcelain veneers would be best on the other incisors. Finally, gingival recontouring as seen on the preparation model (Figure 6) would also be necessary to create aesthetic gingival contours.

Case Presentation

The time came to present what could be done. Remembering the initial conversation and subsequent conversations, I felt I had prepared well for this day. I knew what could be done easily with removal of one incisor and short-term orthodontics. I also knew what was involved to achieve her goals without orthodontics, and it was clear to me that I had an ethical responsibility to discuss all of the options even though the patient had already said “No braces.” If the mere mention of braces set her off and she decided to leave, so be it. I would have been fine with the knowledge that I did what was right. If by chance I moved her into orthodontic treatment after extracting No. 24, then I would have been happy to guide her into a tooth-conservative approach to satisfying her goal.
At the time of case presentation, I reiterated that she could accomplish what she wanted with a short-term removable orthodontic appliance after removing the tooth that was in back of the others. When I approached the issue of extraction of one tooth, she said she understood that there wasn’t enough room for all the others to line up. It was apparent that she had accepted the sacrifice of one natural tooth in order to make room. This was all done prior to showing her the aesthetic wax-up. I wanted to be absolutely sure that orthodontics was off the table before showing her what else could be done. When I revisited the issue of braces, she had not changed her mind; orthodontic treatment of any sort was out of the question.

Figure 4. Aesthetic wax-up.

Figure 5. Occlusal view of aesthetic wax-up.	Figure 6. Preparation model note: tissue trim needed.

I showed her the wax model (Figure 4) and let her look at it and absorb what she was seeing. I did not begin to describe how we would achieve this. Had I started to talk, the opportunity for her to ask me, “How would we do this?” would have passed. I simply gave her the model and sat quietly. An interactive approach to patient-centered treatment planning must have properly placed silences in the conversations. As dentists, we tend to avoid silences and work hard at educating our patients. While patient education is important, the traditional explanatory approach neglects to address the right hemisphere of the brain, where decisions begin.4 Without being patient-centered in our approach, we often miss opportunities to present treatment options in a more effective manner. When this patient said, “That’s what I want,” then, and only then, was it time for me to speak.
I began to let the dimension of what we’d have to do unfold. I explained why we would probably have to do endodontics on one tooth and why we would have to veneer the others after removing the lingually malposed tooth. I also told her we would have to do a gingivoplasty (No, I did not use these words with her!) in order to make all the teeth appear to have the same length. Using the aesthetic wax-up, I showed her how the restored teeth would be slightly wider than her natural teeth, and she said she was fine with that. At various intervals I asked if I had made things clear, so that if something wasn’t clear, the onus of responsibility was on me as the sender rather than on her as the receiver of information. It is much easier for a patient to seek clarification in this way rather than by replying to the question, “Do you understand?”
The patient chose to have her dentistry done using the nonorthodontic, more invasive option. It should be apparent that all ethical considerations had been satisfied. Reasonable alternatives that allowed the patient to become involved in treatment decisions were presented. Due consideration was given to the needs, desires, and values of the patient. A truthful dialogue took place in which I stated that, “If this were my mouth, I would choose the orthodontic solution.” While I wasn’t happy with her choice, I respected her right to make that choice. I fulfilled my ethical obligation to the patient, and since I have the necessary knowledge and skills to perform the treatment this patient desired, she was appointed to begin treatment.

Treatment

Figure 7. Tissue trimming with Bident.

Figure 8. Preparations completed.	Figure 9. Extraction of tooth No. 24 completed.

Prior to extracting tooth No. 24, the planned gingivoplasty was performed (Figure 7) using the Bident bipolar electrosurgery unit (Synergetics-Valley Forge Scientific). Removal of the display of excess gingiva created aesthetic soft-tissue contours to surround the restorations we would place. After teeth Nos. 23, 25, and 26 were prepared (Figure 8) using a GENTLEforce LUX 6000B air-driven high-speed hand-piece (KaVo Dental) and the LVS diamond preparation kit (Brasseler USA), tooth No. 24 was extracted (Figure 9).

Figure 10. One-piece temporary cemented in place.

A one-piece temporary splint of Protemp 3 Garant (3M ESPE) was created from an impression of the aesthetic wax-up and cemented with a mixture of GC TEMP Advantage (GC America) and petroleum jelly to facilitate easy removal (Figure 10). The reason the cement was not used alone is that the insertion paths for the veneers are different from the insertion path for the crown. If endodontic treatment became necessary, then I wanted to be able to easily remove the temporary without destroying it. I decided to wait and see how tooth No. 25 reacted to the necessary heavy preparation in order to determine if the need for endodontic treatment followed. Within a few days, it was clear that, based on the patient’s clinical symptoms, root canal therapy had to be done.
After achieving adequate anesthesia and removing the one-piece temporary, root canal therapy was completed using the Root ZX apex locator (J. Morita USA) for canal measurement and K-Files (Premier USA) coated with RC-Prep (Premier USA) for instrumentation. Sodium hypochlorite was used for irrigation. The canal space was dried and filled with gutta-percha points (DENTSPLY Maillefer) and Ketac-Endo sealer (3M ESPE), and the temporary was recemented with the GC TEMP Advantage and petroleum jelly mixture.

Figure 11. Ultrapak Cord retraction cords placed.	Figure 12. Impregum Penta Soft impression in a Triple Tray.

Figure 13. Prepared tooth undershade with A1 tab as reference.

Within a few days, a core buildup was placed in tooth No. 25 using LuxaCore Dual (Zenith/DMG) bonded with Clearfil Photo Bond (Kuraray Dental). Ultrapak Cord retraction cords (Ultradent Products) impregnated with Astringedent (Ultradent Products) were placed (Figure 11). An impression with Impregum Penta Soft (3M ESPE) in a Triple Tray (Premier USA) was made (Figure 12) and sent to the laboratory for fabrication of the definitive restorations. Digital images of the shades of the prepared teeth (stump shades; Figure 13) were made with the Kodak DX-7590 Dental Digital Camera and sent to the lab to show the tooth shades underneath the restorations. A shade tab must be included in the image as a reference for the technician. In order to achieve excellent shade results, the undershades must be sent to the lab. If multiple teeth are being restored, then I send undershade images of several teeth, especially if the prepared teeth vary in color. This time the temporary was inserted with GC TEMP Advantage alone. I wanted the temporary restoration to stay on securely while the case was being fabricated in the laboratory. GC TEMP Advantage is an eugenol-free zinc oxide temporary cement containing fluoride, potassium nitrate, and chlorhexidine. It provides an excellent seal and maintains low sensitivity for the patient.

Insertion Visit

Figure 14. Restorations. Note internal surfaces etched for bonding.	Figure 15. Temporaries prior to removal.
Figure 16. Resecting temporaries.	Figure 17. Removal of temporaries.
Figure 18. Cleaning preparations with Consepsis scrub.	Figure 19. Immediate postoperative view.

When the definitive restorations were returned, they were examined for contour, shade, and adequate etching of the internal surfaces of the porcelain (Figure 14). When feldspathic porcelain restorations are to be bonded, it is crucial the inner surfaces are prepared properly to ensure an effective bond to tooth structure. Before trying in the restorations, the temporary splint needed to be removed (Figure 15). It did not lift off easily due to the differing paths of insertion and the secure cement seal. The decision was made to resect the one-piece temporary into 3 sections for easy removal. Using a very thin, fine, flame-shaped diamond, No. 392-016 (Axis Dental), the temporary was cut at the joints (Figure 16), and the individual sections were readied for removal (Figure 17).
The prepared teeth were cleaned with Consepsis Scrub (Ultradent Products), a chlorhexidine cleanser, to remove all traces of the temporary cement, and ultrathin retraction cords were placed very gently into the sulci (Figure 18). Although the preparations were supra-gingival and equigingival, cords were used to ensure clear visibility of the margins during seating of the restorations. Using a total-etch technique, all teeth were etched for 15 seconds, washed, and dried. Opti-Bond Solo Plus (Kerr Dental) was applied to the restorations, air-thinned according to the instructions, then cured with an Optilux 501 halogen light (Kerr Dental). The restorations, which were previously prepared with RelyX Ceramic Primer (3M ESPE), Opti-Bond Solo Plus, and Insure resin cement (Cosmedent), were seated and cured with the curing light. After spot-curing each restoration for 5 seconds, excess cement was removed and final curing of 40 seconds per restoration was done. Clean-up of excess cement was accomplished and contact areas checked. The immediate postoperative view is seen in Figure 19.

CONCLUSION

While the clinical aspects of this case are interesting, the main purpose of this article has been to discuss the treatment planning and presentation of this case. Most of the time we can examine, diagnose, treatment plan from our clinical and radiographic findings, and present needed dentistry to our patients. However, this approach does not involve the patient on an emotional level, and can lead to resistance to accepting recommendations for necessary dentistry, especially when it is extensive. The words “needed” or “necessary” take on new meanings when we find out what patients’ goals are for their mouths and their health. What a clinician perceives as necessary may differ greatly from the patient’s perception of what is necessary. If we include the concept of self-esteem in a patient’s overall health and well being, then there will be occasions when necessary dentistry includes that which is done specifically to improve appearance.
In the case of appearance-related dentistry, it becomes even more important to involve the patient in a dialogue because he or she may have preconceived ideas about treatment outcomes. Understanding a patient’s expectations is an essential component of good communication. In addition, if a patient is requesting an aesthetic change that can be accomplished in more than one way, it is critical and ethically necessary for the doctor to present the various options fairly and inform the patient of the risks and benefits of each option. Doing this satisfies our obligations and also tells our patients we took the time to consider how we can help them achieve what they want. After going through the process described in this article, when a patient makes his or her decision about treatment, it will be with full information. When we approach treatment planning with our patients being involved from the beginning, we can better serve the people for whom we care.

References

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, is a Diplomate of the American Board of Aes