In a modern era like the one we are living in a patient has access to heaps of information regarding any disease. Consumers watch YouTube videos of treatment and their protocols and are up to date with the latest information. If the patient finds something online that we have not mentioned it might be a little embarrassing. This is something that all of us as dentists should be careful about. The patient might judge our competency if we fail to educate properly. They might know way more than what they are told and that will result in them judging the doctor.
We know most of the problems in the mouth are all preventable by routine checkups and better hygiene at home. Most of the population does not realize the benefits of oral health. As time passes more people will know and talk about it. You too should be a part of this movement, and help create that awareness so we can all grow together. This will help save a lot of lives, improve lifestyles and reduce cost of overall health care.
As a dentist our ultimate goal really needs to be to get rid of infections. It can be gingivitis, periodontists or even an asymptomatic failing root canal which has pericardial abscess.
We educate our patients on importance of getting rid of any infection and explain to them the possible consequences if not treated. We come from a complete health context and also describe the oral systemic connection they will be more likely to accept the treatment plan. If they don’t, at least they understand the importance of this and might go home and do more research on it or talk to other family members about it. If they are surrounded by people who have chronic illnesses they might consider it more seriously.
It will take some time to create that impact. Like always, there are people who pick on things fast, and they are the ones who will always be skeptical. You should never leave yourself exposed to being judged by someone who already understands the importance of no infection in the mouth when you don’t practice complete health.
GINGIVAL (Gums) HEALTH
The standard of care is to treat chief complaints, educate about dental issues with a complete oral evaluation and explain the consequences if not treated. Always start from gingival (gums) health; that is, scaling if gingivitis and root planing if periodontal disease. The ultimate goal is to have no gingival inflammation and no bleeding on probing. Doing cleaning just for the sake of charging the patient and doing cleaning with an intention of getting gums healthy are two entirely different things. They require different time duration and effort. Conclude with oral hygiene instructions and emphasize on recare follow-ups.
CARIOUS LESIONS
Once we have restored health of the gums next phase needs to be any restorative work like fillings, root canals and crowns. When there is decay in the tooth which is detectable with an explorer, it needs to be addressed right away as it will only keep spreading and end up in indirect or direct exposure of the pulp and require root canal treatment. It is a great service to the patient to educate and identify any carious lesions and explain to them the consequences of not getting treatment. The patient then knows what is happening and what can happen if not treated.
When we do a filling it is imperative that we remove all the decay and any unsupported enamel. In a place where bitewings are not taken we need to be very intentional in our diagnosis, as proximal cavities can be difficult to diagnose at times. Any residual decay or untreated decay can lead to pulpitis and therefore the need for a root canal. If explained properly to the patient they will be very likely to take care of these at early stages, especially when they are aware of consequences if not treated. Ensuring the complete removal of soft dentin, establishment of proximal contacts, marginal integrity and proper occlusion are important while doing a filling. At Ideal Smile we warranty our fillings for 1 year and will replace any filling that gets dislodged free of cost. The sooner those cavities are done the better it is for the patients, and by bringing in comprehensive approach we increase our productivity.
INDIRECT RESTORATIONS
Crowns are needed when we have gross damage of the tooth structure, a broken cusp or wall or a cavity involving more than 2/3 of the occlusal surface or a root canal treated tooth. It is again very important to have good gingival health to be able to do a crown. We need to make sure there are no deep pockets and gums don’t bleed before we prepare any tooth for the crown as the integrity of the coronal margin cannot be achieved. When we place a crown we need to make sure that we have a long term prognosis and the tooth does not get rotten after a few years. It is unfortunate that 78% of the crowns I have come across here during my first year at IDEAL SMILE had open margins, root decay, overhangs, residual decay, compromised anatomy and most of those were just a few years old crowns. Here normally crowns just last for 2-3 years and by then majority of the crowned teeth end up in extractions. I have done thousands of crowns each year in my practices in California and the only teeth I extracted were because of failed endodontic therapy.
Standard of care is that when we do a crown we should not ever end up in loss of tooth because of the problems mentioned above. There is a minimum of 5 years time frame where a dentist has to be responsible for any failures in the crown work. When we know we can’t have luxury of losing tooth and also we have to warranty our restorations for 5 years we will be more intentional in our treatment planning and will not be using weak teeth for abutments and make sure any endo work that has already been done on those is within standard of care. When we look for a longer prognosis we will be more intentional with our preps and lab selection as well. I warranty our crowns at Ideal Smile for 4 years and will replace any failed crowns with no charge to patient and also I let them know that they should not end up losing those teeth, the most we might have to do is to replace those crowns after few years. We do come across at times with compromised situations and best thing in that case is to inform the patient upfront about the poor prognosis of the tooth and give them different options and let them decide what they want to do in that case.
All this improves the quality of work and motivates patients to do more work. This will eliminate the perspective of public that they will lose teeth after a few years of getting crowns in any case so why bother getting crowns in the first place. Crowns and bridges are bound to fail if the patient has poor oral hygiene.
ENDODONTICS
47% failure rate of the root canals i have come across in Ideal Smile is pretty alarming. I have seen underfilled roots, periapical lesions and even canals which are not filled at all. It is acceptable to have 4-5% failure in root canal but doing endo on teeth which are not restorable and under filling are things which shouldn’t be acceptable. Proper diagnosis and long term prognosis are important factors before starting treatment. Also, our skills need to be up to mark in endo. Endo is a simple and straightforward procedure if we follow proper protocols and avoid complicated endo. It was easier to refer complicated cases to endodontists in America, but as there are no endodontists here I inform the patients of possibility of failures in such cases. It’s better to let them know in advance than break the news later.
In America it is required to inform patient of any separated instrument. If we fail to do it, patients can sue us. By informing them we just earn more respect.
COSMETIC DENTISTRY
Cosmetic dentistry is a speciality just like ortho and maxillofacial surgery. A general dentist who knows good crown prep is not necessarily be able to be a good cosmetic dentist. When we talk about changing smiles or cosmetic dentistry it does not mean we are doing multiple crowns on teeth or doing PFMs in anterior region. Cosmetic dentistry needs complete training. To start off with, perfect crown preps are required. Highest possible skill level along with the ability to visualize the end effects is required when it comes to cosmetic dentistry. Different cases require different approach.
Main objective in cosmetic dentistry is to enhance a smile in a way that is not noticeable. New smile makeovers need to blend in with face and rest of the teeth in a way that no one can tell if something is on those teeth.
Knowledge of basic principles of smile makeover is a must and so is the ability to observe minute details because that is the difference between a natural looking smile makeover and a failed case. Obviously an open margin and overhang is a big no but also shape, color, line angles, black triangles, buccal corridor, gum line, lip line, contact areas, embrasures, phonetics, golden proportion ratios, long term prognosis, occlusion, function, TMD, bruxism, clenching etc. These are some of the important things which need to be thoroughly planned and considered before starting a case.
A well planned and well executed smile makeover can change a life of the person for good in a positive way.
PEDIATRIC DENTISTRY
Deciduous teeth are not taken seriously in our society and people think they will be replaced by permanent teeth. We as a dental community have failed to create that awareness in the public about good oral health in kids and the importance of keeping deciduous teeth. Health of deciduous teeth is important for not only function and maintaining space for permanent teeth, but also kids who lose their deciduous teeth early in the age will have low confidence and self-esteem. So every time a kid has pain in a tooth it should not be extracted if natural time for shedding is anytime soon as it will lead to the space closure for the permanent tooth.
ORTHODONTIC TREATMENT
When it comes to orthodontics, getting teeth straight is not the goal. The goal needs to be not only having aesthetically pleasing teeth arrangement but also ideal occlusion. Long term prognosis and function are important. Many people think if they did few month courses they can start orthodontic treatment in their practices. What that leads to is root resorptions, TMD, worn down teeth, compromised function and relapse of the treatment.
We can’t grow as a dental community unless we create awareness about good oral hygiene and instill in our patients the trend of follow-ups as a recare should provide. This creates a solid foundation for any good dental practice and it will allow us sustenance and pay our bills too. The added benefit is that patient sees how important oral health is and will start becoming proactive instead of being reactive. They will schedule for all types of preventive treatment and when they see value of improved oral health they will want to do more work and respect your treatment plans.
When we do fail in delivering the best care we should make it up somehow to the patient for their loss. It would be ethical to replace any tooth at no charge if patient lost the tooth due to our negligence. Acknowledgement and taking care of the issue will help us grow, as the patient will appreciate the honesty and efforts to make up or fix. Also when we know we have to follow standard of the care we will raise our bar in clinical skills and be more intentional with our work.
