It really shouldn’t come as any surprise- but it still  catches me off guard at courses. I see the reaction from attendees but I also catch myself having the same reaction even after 20 years of clinical practice and over 12 years of teaching. We attend courses to be inspired, increase our knowledge base and help our patients. Our goals of improving and learning seem pretty clear. Yet it still happens.

What is it that I’m referring to? It’s that moment at a course when we feel so overwhelmed by what we don’t know and guilty for a level of care that we have not provided to our patients in the past, even though we are just learning of it. Even though that knowledge was the reason that we signed up for the course to begin with.

I’ve seen the reactions. I have felt the reactions myself. I felt inadequate. I have felt depressed. I have felt guilty. That tightness in my chest creeps up as the overwhelming feeling of inadequacy beats my ego down into a quivering, bloody, pulp. I have seen that overwhelmed look on attendees faces as well.  I’ve seen the looks of  depression and of despair. I have even seen people walk into another room, out into the hallway or outside the building and even cry.

It doesn’t have to be like that and there are some tips and tricks that we can use to help avoid falling into that rabbit hole of self-deprecation. There’s a quote that sticks with me that was shared by Christian Saeger, the former CEO of The Pankey Institute,  when I attended my first  Continuum on Key Biscayne some 15 years ago.

Chris shared with the class: “Cadillac never apologized for last year’s model.”

We attend CE courses to improve ourselves, provide better for our patients, make our practices more successful and in general to improve the depths and width of our knowledge base. It is not only what we expect of ourselves but what our patients expect of us as well. We are better dentists today than we were yesterday and we will be better dentists tomorrow. Revel in that!

At your next course, when you feel that anxiety swelling up in your chest-just recognize it. Say “Hello! Isn’t that interesting.” (Thank you Joan Unterschuetz!) Recognize that feeling as a sign that you have chosen your course wisely and will be learning something new and exciting that will help you be that better dentist.

As always-we would love to hear your comments & please feel free to share using the link buttons below!

Decisions

Some of the most frequent questions that I hear before, during & even after courses has to be “So-when do we mount?”… “Why do we mount??”… “Which patients should we be mounting??” I know-because I have asked and continue to ask myself the same questions even after over 20 years of clinical practice & 12 years of teaching the subject. I think that I will continue to pursue the answers to these questions for another 12 and 20 years.

My own pendulum on application has swung from one extreme to the other in my 20+ years of clinical practice. There was a time, when every case that I did was done with the triple tray-whether it be quadrant or full arch.  Then I began my commitment to occlusal studies and the pendulum swung quite hard to the others-so extreme. I mounted every case with full arch models, a face bow, a CR recording  and programmed condyle or inclination. It did not matter if I was restoring a single maxillary lateral incisor on a class 2 patient with a half a meter of over jet that would never contact another tooth. Looking back, I laugh at my own fanaticism.

Each of their approaches have their time and place to be appropriate. The question remain-which, when, why and for whom.   I will go over the  which,when & for whom, but first I would like to share the why.

Regardless of the clinical application or the chosen method of mounting- be it triple tray  or fully adjustable articulation, my decision and choice of modality will come down to efficiency and economics, as long as I can achieve the same excellent outcome. When I look at decisions between instrumentation choices, I need to consider how long it will take me for the initial restorative records  & balance that with the time and frustration savings of intraoral adjustments.   If I try to save time by using a quick set PVS  with a triple tray, but it takes me 20 minutes of introral adjustments and ends with a compromised outcome, was there any benefit to the approach?  On the other side of the pendulum,  if we have a single unit posterior restoration with sufficient anterior guidance or anatomy that can be matched off of the adjacent teeth, is there any advantage of going through full arch models  & face bow recording? If we can achieve the same excellent outcome, what advantage is it to spend more time taking the records then it would take for minor, if any intraoral adjustments and polishing?

So-when do I mount?  I do so when it will help me achieve a goal. Will it help me do something more efficiently? Will it help me see something that I cannot see or figure out yet?  I know that this may seem oversimplified,  but they are my guiding questions when making my decisions.

My current preferences are:

Restoratively..

For single posterior units, with an otherwise intact dentition that can support the occlusion I use a triple tray. Even for second molars you ask?? Yes-even for second molars. I do leaf gauge screen then-which is the subject of another blog and article.

Anytime I am doing two posterior units, with few exceptions, or any anterior unit, I am doing face bow mounted, programmed full arch models. These may or may not be mounted in a seated/CR position. In many cases, I find MIP or the patients natural bite to be just fine.

So-when do I use “CR.” First of all-I am not a huge fan of the term. I really prefer the criteria that define it-comfortable…stable…repeatable. I guess I would rather call it “CSR” but that is a whole other story.

Mounted, programmed models with a mounting that is done in a seated position is something that I use, when indicated or allowed in the diagnostic phase. I use this when I cannot “see it” or need to figure out how things do fit, what changes are possible and which options make the most sense to me.

From a restorative standpoint, I will ‘always’ be using a seated position when doing full arch or full month rehabilitation.  For other circumstances, my decision tree is in flux based on my evolving experience, application and the uniqueness of each case. What I would like to do is present a variety of cases and decision tree discussions on how I make these decisions and why. My rationale may be different tomorrow. As Dr. Peter Dawson said “if you quote me, please date me.” I am learning along with the rest of the profession

All of that being said,  there is another powerful and frequently overriding factor that can completely override or come in conflict with our well-thought-out plans and decision tree processes. That of course is the patient. Even in situations that present the possibility for more complex, comprehensive records and treatment planning there are simply some patients that are either not ready for a more involved approach were simply do not desire to do so.

I know that this answers some questions & may create many others. Most of all I hope it can help start or continue some excellent discussions.

As always-we would love to hear your comments & please feel free to share using the link buttons below!

Again and again, I see, read and hear treatment discussions between dentists. Some study models-perhaps some photos or x-rays are shared at a study club, online or at the end of a course.

• “What do you think we should do?”
• “Do you think ortho would help this be ideal??”
• “Should I refer the patient to a _________ (name the specialist)?”

This goes on for a while. The models are held together and scrupulously examined.

• “We need to mount the case…”
• “We need to get a wax up.”
• “What is the patients diet like? Do they floss a lot? They probably dont…”

This goes on & on. The models are passed, exchanged…re-examined.  At some point I would hope that it gets asked-or I might interject-“What does the patient want? What are their goals?”

We may be met with blank stares or “What do you mean?”

Well they dont want__________. You can fill in the blank. Braces, surgery, to spend a lot of money. The patient is turning down or placing barriers to a ˜dental destination that has not even been clarified. The dentists begin looking at procedures and processes when they are not even sure what the end point is The patient may not even be aware of what is possible. Without goals, the dentists do not know how to proceed. It becomes somewhat the blind leading the blind. Everyone gets frustrated.

When treatment planning begins without an outcome or goal in mind, it becomes inefficient at best. It can be a lot closer to blind guesswork. It does not need to be though. Looking at what can sometimes be a daunting or intimidating clinical presentation, we need introduce some ˜knows, some goals. This begins by trying to better understand the patient and also by helping the patient understand and realize what is possible.

Shared by Dr. Frank Spear, these can be organized into 4 basic groups: Esthetics, Function, Structure & Biology. I would also add pain & budget. Pain almost always comes first as an emergent treatment. Budget can show up at many different times during the process. Certainly always at the end, but budget can also be a guiding factor early on in case planning. Without a goal or outcome, a budget can also just be a price tag that is attached to nothing but a monetary amount without consideration of what it means to the patient.

Purpose

Esthetics: Are looks important to the patient? In which way? Color? Shape? Display? Gum tissue? Arrangement/straight./crooked/canted? Or-maybe they dont care about looks at all. Lets move on to the next area then.

Function: Now dont go dental! Ask about their expectations of what they expect to eat. My favorite examples are always corn on the cob & steak. They are taxing meals. A patient on a ˜limited budget may want dentures but are they aware of the limitations? Will their functional goals dictate either saving teeth or bringing in implants? Slowly, the processes begin to present themselves as more obvious options, driven by the purpose.

Structure: Are things broken? Are they going to break? That seems obvious-but also structure can be looked at as the foundation upon which the esthetics and function can be built. That may include bone or tissue grafting. It may include implants. It may be teeth upon which the chewing or smiling goals are accomplished. Again-driven by the patient goals-the purpose that we clarify together

Biology: That is the disease stuff. The stuff we always talk about The place we always start treatment planning from. While I am not saying dont address disease, I am suggesting to not let it monopolize your focus too early in treatment or case planning. Believe it or not, when you have goals that we examined above, the biology/disease will largely take care of itself as a process of the treatment plan to help us achieve the purposes or goals of the treatment plan. If not, we can always treatment plan to address disease.

The days of treating for textbooks or podium perfection is passing. But please dont get me wrong-it is not that we cannot and will not still achieve those levels of care. A time has come for that care & outcome to be driven by the patient and their goals-their purpose. We are here to be facilitators in explaining what is possible, the benefits & considerations of care and the process with which patient can achieve it. This can be best summed up in a phrase a friend and mentor, Dr. Gary DeWood shared with me “Based on your goals, as i understand them, what I would recommend is….”

A clarifying perspective is that the purpose IS the treatment plan. The technical steps, the referrals, the crowns, the implants, the wax ups, the diagnostics…the process simply becomes a way to help us achieve it.

I hope that that helps you as much as it did me in my own treatment planning journey. I hope for you that this is where possible begins.

As always-we would love to hear your comments & please feel free to share using the link buttons below!

I wasn’t sure what I should start off with for my 1st On the Cusp blog, so I decided to start with what I thought could be the most impactful, relevant and easy to achieve: case acceptance.

WHAT?!!? EASY?!?!

It comes up time & time again-how can we best get our patients to accept treatment? We are met with blank stares…broken eye contact…and the dreaded “I’ll think about it.” We take courses on occlusion & advanced treatment planning. We buy articulators, digital cameras…imaging software….and they “think about it.”

I have heard countless dentists talking, asking, sometimes grumbling about case acceptance, insurance…and a lot of frustrations about patient interactions. We are looking for that magic formula, phrase, solution, course… We talk about how our patient’s don’t understand the value…They don’t understand the treatment… They don’t understand what we are explaining… But-how much do we understand them? How much do we understand our patients’ goals & desires?

So-here is the 30 Day Challenge:
For the next 30 days, when you recommend that a patient do some sort of treatment use the phrase:

“Based on your goals, as I understand them, what I would recommend is ______________ to best meet your goals.”
That’s it. No course. No need to memorize any complex scripts. No need to purchase any fancy new equipment. What it will mean though, is that you will need to understand your patients. You will need to ask questions about what is important to them. You will need to listen and connect their desires to the conditions that you see. You will need to commit to this for the next 30 days. Things will change…and your patients will benefit.

I look forward to hearing your successes, your challenges and your stories-because, based on your goals of achieving greater case acceptance, this is a great place to begin.

*I would like to give a very special thanks to Dr. Gary DeWood for sharing this phrase with me. It has made all of the difference.

As always-we would love to hear your comments & please feel free to share using the link buttons below!