Why comprehensive diagnosis and treatment planning?

Comprehensive diagnosis involves subjective and objective evaluation of patient characteristics, including periodontal health, remaining teeth, tooth structure, pulpal health, temporomandibular joints, esthetic concerns, oral hygiene compliance, availability of restorative space, and medical history [1]. It includes evaluating all the factors that are relevant to formulating a diagnosis and treatment plan [1]. Integrated treatment planning involves developing a comprehensive treatment plan that collaboratively integrates various disciplines [2, 3]. The intent is to find optimal ways to treat patients, factoring in all the disciplines. When working with dental specialists, a collaborative approach with a common goal is vital to treatment success. There are two perspectives regarding comprehensive diagnosis and integrated treatment planning. The first one involves the patient, and the second one is relevant to the clinician; however, both have some common undertones.

Patient perspective

Many dental practitioners are concerned about the fact that some of the fastest-growing “dental practices” in North America do not have dental professionals practicing in them [4]. An individual can go online, order a do-it-yourself (DIY) impression kit, and start orthodontic aligner therapy without ever meeting with a qualified dentist [5, 6]! Some of the DIY orthodontic companies say they have clinicians evaluating the process prior to sending out the aligners. But what if the case would be better treated with conventional orthodontic brackets and wires? What if the patient also requires periodontal, endodontic and/or surgical procedures? Patients must understand the risks and compromises of forgoing those consultations and the lack of integrated care.

Why is it that an individual can walk into a mall or tanning salon and have random people perform teeth whitening with no dental training [7]? It is because most patients feel that dental treatment is a commodity and not a true healthcare procedure [8]. Would they be able to go to the mall for medical treatments such as a biopsy, knee injury, or cancer treatment without seeing a physician or healthcare provider? What is it about dentistry that has led dental practitioners down the path of being a commodity, based on price rather than expertise? Did they do this to themselves or did the market do it to them? It probably is a combination of the two.

How often does a dental receptionist receive calls from patients asking the following questions?

 “How much is a crown?”

 “How much for a root canal?”

 “How much do veneers cost?”

 “How much is a cleaning?”

Most of the time, these calls are answered by quoting a price without even thinking about what the caller’s (patient’s) requirements/diagnosis would be. Would an orthopedic surgeon quote a fee for a knee replacement without knowing the condition of the knee and what treatment might actually be required? The more these types of behaviors are encouraged, the more they perpetuate the notion that all our training, knowledge, and skill boil down to very little. Most dental practitioners fear losing a patient to another office, which is the most likely reason for discussing pricing over the phone even though most practitioners understand that each procedure requires their expertise in diagnosing and treatment planning and may be associated with different clinical and patient-related factors [9]. Not all veneer restorations are the same, nor are all direct restorations. Some patients are happy with a restoration that looks “white” even if we use only one shade. Others want something natural and inconspicuous, which may require artistically blending three to four shades. The time required to complete each restoration is different, and therefore treatment costs and time will vary from one restoration to another.

Dental insurance companies further endorse patients’ perception of dental procedures as a “commodity” rather than a healthcare service. Although these companies allow patients to defray some expenses, all procedures are distilled down to a dollar value based on statistics and the proposed norms in the industry, with little to no regard for clinical judgment, expertise, and complexity of treatment [10]. Thus, many patients assume that the value of a procedure is based on the compensation they receive from the insurance provider.

Dental professionals in many ways have “lost” their way in connecting and communicating value for what they can provide as healthcare practitioners. They are so focused on wanting to do every treatment that they get lost as to what they are truly there for. For efficient time management, many dental practitioners appoint “treatment coordinators” for explaining and discussing the treatment plan with the patients [11]. The treatment coordinators often commoditize the treatment procedures during patient consultation appointments. Their lack of training precludes them from efficiently discussing oral health problems and their possible solutions. Dental practitioners should minimize delegating these tasks as they are in the best position to help patients understand their problems and the available treatment options. If a treatment coordinator is appointed, the dental practitioner should discuss details of the treatment plan with the coordinator before it is presented to the patient.

Dental practitioners are in a healthcare profession, and for that reason, they should not compromise on the “care” part. Care ideally pertains to clinicians being involved in the treatment from start to finish and beyond. It is important to educate patients and make them understand the value of comprehensive dentistry in creating a more stable and long-lasting result as opposed to being reactive to a single problem. This can help change the perception of dentistry in the minds of their patients.

Dentist perspective

How can dental practitioners change the perception of dentistry from a commodity to value-based profession? This can be accomplished by using their minds, evidence, and expertise to create value in everything they do. Treatment planning is an integral part of any practice, but there are varying interpretations of what that might look like when you speak to different clinicians [1]. Often, there is a “disconnect” between what is seen and the actual “bigger picture” [12]. A dental school setting may present challenges in teaching students how to perform a comprehensive diagnosis and formulate an integrated treatment plan for patients [13]. There are so many disciplines to learn and requirements to complete that it is difficult for dental students to comprehend the benefits of comprehensive diagnosis and treatment planning [13]. The situation is further complicated by the presence of a variety of full-time and part-time instructors, each with his/her experience and biases [14]. Dental students are trained to fix teeth by treating caries, inflammation, and fractures. When a dental student sees a patient with a history of repeated fracture of a Class IV composite restoration, instead of thinking about the cause of the repeated fracture, the student most likely starts working on redoing the composite restoration. Most dental students are too focused on “what they can do” and not “why the condition arose” or “how it could be further prevented.” As a result, most young dentists are trained to provide adequate “single-tooth” dentistry for the average patient but not comprehensive care [15]. Their dentistry becomes mechanical as they are more focused on the reactive or reparative approaches rather than a preventive approach.

There is an increased incidence of periodontal disease, caries, wear, crowding, drifting, fractured or missing teeth, temporomandibular joint (TMJ), and muscle dysfunction in today’s patient population due to longer life expectancy [16-20]. Furthermore, people continue to want to look and feel younger, eat properly, and have a beautiful smile. Missing teeth, loose dentures, and worn teeth are no longer acceptable to most patients. Part of the daily challenge is differentiating the “forest from the trees.” Dental practitioners often have blinders on and focus on what they recognize easily instead of looking at the bigger picture or asking, “Why did this condition arise?” Patients’ problems vary from missing teeth (Fig. 1.1) to lack of tooth display when they smile, excessive tooth wear (Fig. 1.2), and dissatisfaction with their smile (Fig. 1.3) [16, 19]. Most of these conditions cannot be treated with a “tooth by tooth” approach as it would force the practitioner to ignore the underlying problems that may have led to the current condition [12].

To understand the value of comprehensive diagnosis and integrated treatment planning, it is important to understand the terms unidisciplinary, multidisciplinary and interdisciplinary dentistry (Fig. 1.4) [21].

Unidisciplinary Dentistry

 Unintegrated Dx and Tx planning

 Ignorance of other disciplines

 Minimal collaboration

Multidisciplinary Dentistry

 Awareness of benefits of other disciplines

 Unstructured collaboration

 Separate goals

Interdisciplinary Dentistry

 Working common knowledge (“think alike”)

 Structured collaboration

 Common goals

Adapted from R. Roblee, DMD